Current through Reg. 49, No. 38; September 20, 2024
(a) Overpayments
involving possible fraud are referred to the Attorney General's Fraud Control
Unit. If intent to defraud is not determined or cannot be proven, the
department or its agents may take an administrative sanction to recoup
overpayments. Recovery of the overpayments from a provider who made a false
statement or misrepresentation, or who omitted pertinent facts may include the
cumulative dollar amount due. The following situations are not intended to be
all inclusive.
(1) An ordering provider
causes an overpayment to be made to himself or to another provider as a result
of a false statement, misrepresentation, or omission of pertinent facts on a
claim, attachments to a claim, medical records, or any other documentation used
to adjudicate a claim for payment; any documentation submitted or maintained by
the provider to support payment on individual claims or to support
representations made on cost reports; or other documents used to establish
fees, daily payment rates, or vendor payments.
(2) A provider makes a false statement, a
misrepresentation, or omits pertinent facts on a provider agreement or any
documents required as a prerequisite for Medicaid participation.
(b) Medicaid Fraud Control Unit is
primarily responsible for obtaining and reporting restitution in fraud court
cases. If a particular case involves both judicial and administrative
processes, the judicial process takes precedence. The unit is responsible for
arranging repayment terms in fraud cases of court-ordered restitution. The
department may take any other administrative sanction or action pertinent to
the violation.
(c) The department
may recover funds when no actual overpayment was made. The following instances
are not intended to be all inclusive:
(1)
recover of a patient's trust fund money for distribution to appropriate
recipients or their responsible parties if those funds were misapplied,
misused, or embezzled; or the provider is required to make this
distribution;
(2) recovery of funds
previously collected by the provider from recipients if collection is not
allowed by contract, statute, regulation, rules, provider policy or procedure
manuals, published Medicaid bulletins, policy notification letters, or
interpretations previously sent to the provider;
(3) recovery of the cost of a contract
appeals hearing from the provider if the department's action is upheld by the
final decision of the contract appeals committee. For the purpose of this
paragraph, cost of a contract appeals hearing is defined as the total cost for
the court reporter and any transcripts and copies developed in preparation for,
during, or after the hearing; and
(4) recovery of an unpaid debt plus interest,
if any, owed to any state Medicaid or Medicare program as the result of
fraudulent or abusive actions by the provider. The department distributes the
balance of the recovered amount to the state Medicaid or Medicare program after
recovering any administrative costs associated with the recovery. Any appeal by
the provider is based solely upon whether there is or is not an unpaid balance
owed to the state Medicaid or Medicare program in question.
