Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Department
investigation.
The department shall investigate vendors or recipients to
monitor compliance with program requirements for the purposes of identifying
fraud, theft, abuse, or error in the administration of the programs.
Subp. 2.
Contacts to obtain
information.
The department may contact any person, agency, organization,
or other entity that is necessary to an investigation under subpart
1. Among those who may be
contacted are:
A. government
agencies;
B. third-party payers,
including Medicare;
C. professional
review organizations as defined in Minnesota Statutes, section
145.61, subdivision
5, or their representatives;
D.
consultants under contract in part
9505.0185;
E. recipients and their responsible
relatives;
F. vendors and persons
employed by or under contract to vendors;
G. professional associations of vendors and
their peers;
H. recipients and
recipient advocacy organizations; and
I. members of the public.
Subp. 3.
Activities included
in department's investigation.
The department's authority to investigate extends to the
examination of any person, document, or thing which is likely to lead to
information relevant to the expenditure of funds, provision of services, or
purchase of items, provided that the information sought is not privileged
against such an investigation by operation of any state or federal law. Among
the activities which the department's investigation may include are as
follows:
A. examination of health
service and financial records;
B.
examination of equipment, materials, prescribed drugs, or other items used in
or for a recipient's health service under a program;
C. examination of prescriptions for
recipients;
D. interviews of
contacts specified in subpart
2;
E. verification of the professional
credentials of a vendor, the vendor's employees, and entities under contract
with the vendor to provide health services or maintain health service and
financial records related to a program;
F. consultation with the department's peer
review mechanisms; and
G.
determination of whether a health service provided to a recipient meets the
criteria of parts
9505.0210 and
9505.0215.
Subp. 4.
Determination of
investigation.
After completing its investigation under subparts
1 to
3, the department shall
determine whether:
A. the vendor or
the recipient is in compliance with the requirements of a program and program
payments were properly made;
B.
insufficient evidence exists that fraud, theft, abuse, or error has occurred;
or
C. the evidence of fraud, theft,
abuse, or error supports administrative, civil, or criminal action.
Subp. 5.
Postinvestigation
actions.
A. After completing the
determination required under subpart
4, the department shall take
one or more of the actions specified in subitems (1) to (8):
(1) close the investigation when no further
action is warranted;
(2) impose
administrative sanctions according to part
9505.2210;
(3) seek monetary recovery according to part
9505.2215;
(4) refer the investigation to the
appropriate state regulatory agency, peer review mechanism, or licensing
board;
(5) refer the investigation
to the attorney general or, if appropriate, to a county attorney for possible
civil or criminal legal action;
(6)
issue a warning that states the practices are potentially in violation of
program laws or regulations;
(7)
refer the investigation to the appropriate child or adult protection agency;
or
(8) place the recipient in the
restricted recipient program.
B. After completing the determination
required under subpart
4, the department may seek
recovery of investigative costs from a vendor under Minnesota Statutes, section
256B.064,
subdivision 1d.
Statutory Authority: MS s
256B.04;
256D.03
