42 C.F.R. §§ 455.13–455.23

§455.13. Methods for identification, investigation, and referral.

42 C.F.R. § 455.13

The Medicaid agency must have—

(a)

Methods and criteria for identifying suspected fraud cases;

(b)

Methods for investigating these cases that—

(1)

Do not infringe on the legal rights of persons involved; and

(2)

Afford due process of law; and

(c)

Procedures, developed in cooperation with State legal authorities, for referring suspected fraud cases to law enforcement officials.

Notes, amendments, and revision history

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3755, Jan. 27, 1983]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3755, Jan. 27, 1983]

§455.14. Preliminary investigation.

42 C.F.R. § 455.14

If the agency receives a complaint of Medicaid fraud or abuse from any source or identifies any questionable practices, it must conduct a preliminary investigation to determine whether there is sufficient basis to warrant a full investigation.

Notes, amendments, and revision history

Amendments

[48 FR 3756, Jan. 27, 1983]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[48 FR 3756, Jan. 27, 1983]

§455.15. Full investigation.

42 C.F.R. § 455.15

If the findings of a preliminary investigation give the agency reason to believe that an incident of fraud or abuse has occurred in the Medicaid program, the agency must take the following action, as appropriate:

(a)

If a provider is suspected of fraud or abuse, the agency must—

(1)

In States with a State Medicaid fraud control unit certified under subpart C of part 1002 of this title, refer the case to the unit under the terms of its agreement with the unit entered into under § 1002.309 of this title; or

(2)

In States with no certified Medicaid fraud control unit, or in cases where no referral to the State Medicaid fraud control unit is required under paragraph (a)(1) of this section, conduct a full investigation or refer the case to the appropriate law enforcement agency.

(b)

If there is reason to believe that a beneficiary has defrauded the Medicaid program, the agency must refer the case to an appropriate law enforcement agency.

(c)

If there is reason to believe that a beneficiary has abused the Medicaid program, the agency must conduct a full investigation of the abuse.

Notes, amendments, and revision history

Amendments

[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]

§455.16. Resolution of full investigation.

42 C.F.R. § 455.16

A full investigation must continue until—

(a)

Appropriate legal action is initiated;

(b)

The case is closed or dropped because of insufficient evidence to support the allegations of fraud or abuse; or

(c)

The matter is resolved between the agency and the provider or beneficiary. This resolution may include but is not limited to—

(1)

Sending a warning letter to the provider or beneficiary, giving notice that continuation of the activity in question will result in further action;

(2)

Suspending or terminating the provider from participation in the Medicaid program;

(3)

Seeking recovery of payments made to the provider; or

(4)

Imposing other sanctions provided under the State plan.

Notes, amendments, and revision history

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3756, Jan. 27, 1983]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3756, Jan. 27, 1983]

§455.17. Reporting requirements.

42 C.F.R. § 455.17

The agency must report the following fraud or abuse information to the appropriate Department officials at intervals prescribed in instructions.

(a)

The number of complaints of fraud and abuse made to the agency that warrant preliminary investigation.

(b)

For each case of suspected provider fraud and abuse that warrants a full investigation—

(1)

The provider's name and number;

(2)

The source of the complaint;

(3)

The type of provider;

(4)

The nature of the complaint;

(5)

The approximate range of dollars involved; and

(6)

The legal and administrative disposition of the case, including actions taken by law enforcement officials to whom the case has been referred.

Notes, amendments, and revision history

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3756, Jan. 27, 1983]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3756, Jan. 27, 1983]

§455.18. Provider's statements on claims forms.

42 C.F.R. § 455.18

(a)

Except as provided in § 455.19, the agency must provide that all provider claims forms be imprinted in boldface type with the following statements, or with alternate wording that is approved by the Regional CMS Administrator:

(1)

“This is to certify that the foregoing information is true, accurate, and complete.”

(2)

“I understand that payment of this claim will be from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.”

(b)

The statements may be printed above the claimant's signature or, if they are printed on the reverse of the form, a reference to the statements must appear immediately preceding the claimant's signature.

Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

§455.19. Provider's statement on check.

42 C.F.R. § 455.19

As an alternative to the statements required in § 455.18, the agency may print the following wording above the claimant's endorsement on the reverse of checks or warrants payable to each provider: “I understand in endorsing or depositing this check that payment will be from Federal and State funds and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.”

Notes, amendments, and revision history

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

§455.20. Beneficiary verification procedure.

42 C.F.R. § 455.20

(a)

The agency must have a method for verifying with beneficiaries whether services billed by providers were received.

(b)

In States receiving Federal matching funds for a mechanized claims processing and information retrieval system under part 433, subpart C, of this subchapter, the agency must provide prompt written notice as required by § 433.116 (e) and (f).

Notes, amendments, and revision history

Amendments

[48 FR 3756, Jan. 27, 1983, as amended at 56 FR 8854, Mar. 1, 1991]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[48 FR 3756, Jan. 27, 1983, as amended at 56 FR 8854, Mar. 1, 1991]

§455.21. Cooperation with State Medicaid fraud control units.

42 C.F.R. § 455.21

In a State with a Medicaid fraud control unit established and certified under subpart C of this part,

(a)

The agency must—

(1)

Refer all cases of suspected provider fraud to the unit;

(2)

If the unit determines that it may be useful in carrying out the unit's responsibilities, promptly comply with a request from the unit for—

(i)

Access to, and free copies of, any records or information kept by the agency or its contractors;

(ii)

Computerized data stored by the agency or its contractors. These data must be supplied without charge and in the form requested by the unit; and

(iii)

Access to any information kept by providers to which the agency is authorized access by section 1902(a)(27) of the Act and § 431.107 of this subchapter. In using this information, the unit must protect the privacy rights of beneficiaries; and

(3)

On referral from the unit, initiate any available administrative or judicial action to recover improper payments to a provider.

(b)

The agency need not comply with specific requirements under this subpart that are the same as the responsibilities placed on the unit under subpart D of this part.

(c)

The agency must enter into a written agreement with the unit under which:

(1)

The agency will agree to comply with all requirements of § 455.21(a);

(2)

The unit will agree to comply with the requirements of § 1007.11(c) of this title; and

(3)

The agency and the unit will agree to—

(i)

Establish a practice of regular meetings or communication between the two entities;

(ii)

Establish procedures for how they will coordinate their efforts;

(iii)

Establish procedures for §§ 1007.9(e) through 1007.9(h) of this title;

(iv)

Establish procedures by which the unit will receive referrals of potential fraud from managed care organizations, if applicable, either directly or through the agency, as required at § 438.608(a)(7) of this title; and

(v)

Review and, as necessary, update the agreement no less frequently than every five (5) years to ensure that the agreement reflects current law and practice.

Notes, amendments, and revision history

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 84 FR 10713, Mar. 22, 2019]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[43 FR 45262, Sept. 29, 1978, as amended at 84 FR 10713, Mar. 22, 2019]

§455.23. Suspension of payments in cases of fraud.

42 C.F.R. § 455.23

(a)

Basis for suspension.

(1)

The State Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual or entity unless the agency has good cause to not suspend payments or to suspend payment only in part.

(2)

The State Medicaid agency may suspend payments without first notifying the provider of its intention to suspend such payments.

(3)

A provider may request, and must be granted, administrative review where State law so requires.

(b)

Notice of suspension.

(1)

The State agency must send notice of its suspension of program payments within the following timeframes:

(i)

Five days of taking such action unless requested in writing by a law enforcement agency to temporarily withhold such notice.

(ii)

Thirty days if requested by law enforcement in writing to delay sending such notice, which request for delay may be renewed in writing up to twice and in no event may exceed 90 days.

(2)

The notice must include or address all of the following:

(i)

State that payments are being suspended in accordance with this provision.

(ii)

Set forth the general allegations as to the nature of the suspension action, but need not disclose any specific information concerning an ongoing investigation.

(iii)

State that the suspension is for a temporary period, as stated in paragraph (c) of this section, and cite the circumstances under which the suspension will be terminated.

(iv)

Specify, when applicable, to which type or types of Medicaid claims or business units of a provider suspension is effective.

(v)

Inform the provider of the right to submit written evidence for consideration by State Medicaid Agency.

(vi)

Set forth the applicable State administrative appeals process and corresponding citations to State law.

(c)

Duration of suspension.

(1)

All suspension of payment actions under this section will be temporary and will not continue after either of the following:

(i)

The agency or the prosecuting authorities determine that there is insufficient evidence of fraud by the provider.

(ii)

Legal proceedings related to the provider's alleged fraud are completed.

(2)

A State must document in writing the termination of a suspension including, where applicable and appropriate, any appeal rights available to a provider.

(d)

Referrals to the Medicaid fraud control unit.

(1)

Whenever a State Medicaid agency investigation leads to the initiation of a payment suspension in whole or part, the State Medicaid Agency must make a fraud referral to either of the following:

(i)

To a Medicaid fraud control unit established and certified under part 1007 of this title; or

(ii)

In States with no certified Medicaid fraud control unit, to an appropriate law enforcement agency.

(2)

The fraud referral made under paragraph (d)(1) of this section must meet all of the following requirements:

(i)

Be made in writing and provided to the Medicaid fraud control unit not later than the next business day after the suspension is enacted.

(ii)

Conform to fraud referral performance standards issued by the Secretary.

(3)

(i)

If the Medicaid fraud control unit or other law enforcement agency accepts the fraud referral for investigation, the payment suspension may be continued until such time as the investigation and any associated enforcement proceedings are completed.

(ii)

On a quarterly basis, the State must request a certification from the Medicaid fraud control unit or other law enforcement agency that any matter accepted on the basis of a referral continues to be under investigation thus warranting continuation of the suspension.

(4)

If the Medicaid fraud control unit or other law enforcement agency declines to accept the fraud referral for investigation the payment suspension must be discontinued unless the State Medicaid agency has alternative Federal or State authority by which it may impose a suspension or makes a fraud referral to another law enforcement agency. In that situation, the provisions of paragraph (d)(3) of this section apply equally to that referral as well.

(5)

A State's decision to exercise the good cause exceptions in paragraphs (e) or (f) of this section not to suspend payments or to suspend payments only in part does not relieve the State of the obligation to refer any credible allegation of fraud as provided in paragraph (d)(1) of this section.

(e)

Good cause not to suspend payments. A State may find that good cause exists not to suspend payments, or not to continue a payment suspension previously imposed, to an individual or entity against which there is an investigation of a credible allegation of fraud if any of the following are applicable:

(1)

Law enforcement officials have specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation.

(2)

Other available remedies implemented by the State more effectively or quickly protect Medicaid funds.

(3)

The State determines, based upon the submission of written evidence by the individual or entity that is the subject of the payment suspension, that the suspension should be removed.

(4)

beneficiary access to items or services would be jeopardized by a payment suspension because of either of the following:

(i)

An individual or entity is the sole community physician or the sole source of essential specialized services in a community.

(ii)

The individual or entity serves a large number of beneficiaries within a HRSA-designated medically underserved area.

(5)

Law enforcement declines to certify that a matter continues to be under investigation per the requirements of paragraph (d)(3) of this section.

(6)

The State determines that payment suspension is not in the best interests of the Medicaid program.

(f)

Good cause to suspend payment only in part. A State may find that good cause exists to suspend payments in part, or to convert a payment suspension previously imposed in whole to one only in part, to an individual or entity against which there is an investigation of a credible allegation of fraud if any of the following are applicable:

(1)

beneficiary access to items or services would be jeopardized by a payment suspension in whole or part because of either of the following:

(i)

An individual or entity is the sole community physician or the sole source of essential specialized services in a community.

(ii)

The individual or entity serves a large number of beneficiaries within a HRSA-designated medically underserved area.

(2)

The State determines, based upon the submission of written evidence by the individual or entity that is the subject of a whole payment suspension, that such suspension should be imposed only in part.

(3)

(i)

The credible allegation focuses solely and definitively on only a specific type of claim or arises from only a specific business unit of a provider; and

(ii)

The State determines and documents in writing that a payment suspension in part would effectively ensure that potentially fraudulent claims were not continuing to be paid.

(4)

Law enforcement declines to certify that a matter continues to be under investigation per the requirements of paragraph (d)(3) of this section.

(5)

The State determines that payment suspension only in part is in the best interests of the Medicaid program.

(g)

Documentation and record retention. State Medicaid agencies must meet the following requirements:

(1)

Maintain for a minimum of 5 years from the date of issuance all materials documenting the life cycle of a payment suspension that was imposed in whole or part, including the following:

(i)

All notices of suspension of payment in whole or part.

(ii)

All fraud referrals to the Medicaid fraud control unit or other law enforcement agency.

(iii)

All quarterly certifications of continuing investigation status by law enforcement.

(iv)

All notices documenting the termination of a suspension.

(2)

(i)

Maintain for a minimum of 5 years from the date of issuance all materials documenting each instance where a payment suspension was not imposed, imposed only in part, or discontinued for good cause.

(ii)

This type of documentation must include, at a minimum, detailed information on the basis for the existence of the good cause not to suspend payments, to suspend payments only in part, or to discontinue a payment suspension and, where applicable, must specify how long the State anticipates such good cause will exist.

(3)

Annually report to the Secretary summary information on each of following—

(i)

Suspension of payment, including the nature of the suspected fraud, the basis for suspension, and the outcome of the suspension.

(ii)

Situation in which the State determined good cause existed to not suspend payments, to suspend payments only in part, or to discontinue a payment suspension as described in this section, including describing the nature of the suspected fraud and the nature of the good cause.

Notes, amendments, and revision history

Amendments

[76 FR 5966, Feb. 2, 2011]

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.

Amendments

[76 FR 5966, Feb. 2, 2011]