Improper Payments and Suspected Fraud 510-03-10-25

(Revised 5/1/2017 ML #3498)

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IM 5313

IM 5313 Attachment

 

 

Improper payments can result from agency errors, recipient errors, and provider errors. All reasonable and practical steps must be taken on all errors to prevent further overpayments, waste, or abuse.

 

1. Agency caused errors do not result in an overpayment that the recipient is responsible to repay. However, the error must be corrected to prevent further overpayments from occurring.

Suspected provider related errors must be reported to the Surveillance Utilization Review (SURS) Unit in the Medical Services Division using SFN 20, “SURS Referral Form” with a copy to the Medicaid eligibility unit. SFN 20 may be sent to SURS as described in the 'Determining Amount of Overpayments' section below. The SURS unit will be responsible for recoupment from any provider.

2. Recipient errors may occur as a result of:
   1. Health Care Coverage granted pending a fair hearing decision subsequently made in favor of the county agency;

1. Decrease or end eligibility effective the end of the month the decision is received.

• Any amount paid during the period the individual was granted Health Care Coverage pending the fair hearing is considered an overpayment.

2. Payment that was provided as a result of a medical expense or increased medical need for a given time period (i.e. medical care payments);

1. The months in which the payments are intended for must be reworked in the system utilizing the monthly payment amount.

Note: Eligibility Staff must contact State Medicaid Policy to approve authorization to increase the ‘client share’. Send all requests to the State Medicaid Policy Group Mailbox at -Info-DHS Medicaid Policy hccpolicy@nd.gov.

3. Failure to report a change in circumstance:

1. If the change does not result in a change in eligibility for any individual in the household, document the findings and nothing further needs to be done.

2. When a household fails to report a change that results in an increase or decrease in coverage:

1. If the change results in an INCREASE in coverage, the change will be made for the future benefit month based on the date the verification/information is received. An increase in coverage results when:

• An individual was eligible for Medicaid Expansion Coverage and should have been eligible for Traditional Medicaid Coverage with or without a client share.

  Note: If an individual fails to report a change and the change would have resulted in eligibility for the individual under another coverage:

  • An overpayment will not be established for the coverage and
  • A referral should not be made to the Surveillance Utilization Review (SURS) Unit and
  • Document the reason the overpayment was NOT completed and a referral to SURS was NOT made.

   

2. If the change results in a DECREASE in coverage, the change will be made prospectively following the 10-10-10 rules, based on the date the change is reported. Document the findings in the narrative.

• If the individual was eligible for Traditional Medicaid coverage with no client share and should have been Medicaid eligible with a ‘client share’, the amount of the overpayment is the difference between the correct amount of ‘client share’ (using actual income) and the amount of the client share met by the ACA Medicaid Household.
• If the individual was eligible for Traditional Medicaid coverage with or without a client share, and should have been eligible for Medicaid Expansion, no overpayment will result. However, the individual must be changed to Medicaid Expansion Coverage based on 10-10-10 rules.

3. If the individual was eligible for Traditional Medicaid coverage or Medicaid Expansion and based on the change, the individual is no longer eligible for any coverage, the change will be made prospectively following the 10-10-10 rule, based on the date the change was reported.

1. If the individual was eligible under Traditional Medicaid coverage, the amount of the overpayment is the amount paid in error for all months the individual should not have been eligible under Traditional Medicaid Coverage.

2. If the individual was eligible under Medicaid Expansion, the amount of the overpayment is equal to the total amount of all premiums paid in error for all months the individual should not have been eligible under Medicaid Expansion.

4. An individual attains age 65, or if under age 65, becomes Medicare eligible:

1. When an individual attains age 65 and eligibility continued under Medicaid Expansion, Medicaid Expansion coverage must be ended at the end of the month prior to the month the individual attains age 65. Any premiums paid for the month the individual attained age 65 or after must be recouped from the insurance vendor.

• Eligibility for the individual MUST be pursued under Non-ACA Medicaid policy:

• If the individual is determined eligible for Non-ACA Medicaid coverage, the individual must be determined eligible beginning with the month the individual attains age 65.

• If the individual is determined not eligible for Non-ACA Medicaid coverage, contact the State Medicaid Policy Unit for assistance to process Non-ACA Medicaid Coverage for the months the premiums were recouped. Send all requests to the State Medicaid Policy Group Mailbox at -Info-DHS Medicaid Policy <hccpolicy@nd.gov>.

2. When an individual under age 65 became Medicare eligible but continued eligible under Medicaid Expansion, Medicaid Expansion coverage must be ended at the end of the month prior to the month the individual became Medicare eligible. Any premiums paid for the month(s) the individual received coverage under Medicaid Expansion while Medicare eligible, must be recouped.

• Eligibility for the individual MUST be pursued under Non-ACA Medicaid policy:

• If the individual is determined eligible for Non-ACA Medicaid coverage, the individual must be determined eligible beginning with the month the individual becomes Medicare eligible.

• If the individual is determined not eligible for Non-ACA Medicaid coverage, contact the State Medicaid Policy Unit for assistance to process Non-ACA Medicaid Coverage for the months the premiums were recouped. Send all requests to the State Medicaid Policy Group Mailbox at -Info-DHS Medicaid Policy <hccpolicy@nd.gov>

5. An individual moves out of State/loses State Residency:

1. Close the individual’s coverage the end of month it becomes known the individual has moved out of State (10 day notice not required).

• If the individual moved out of state prior to the month it became known they moved, an overpayment equal to the amount of Medicaid benefits/premiums paid beginning the month following the month the individual actually moved out of state and the date the case closed would result. Also, refer the case to SURS if Medicaid benefits/premiums were paid out.

• If the individual moved out of state in the month equal to the month the case was closed, no overpayment results. No referral needs to be made to SURS.

6. Individuals request coverage be terminated and premiums recouped for the entire period of time they were eligible.

1. If the individual contacts the county within 30 days from the date the notice was sent, all premiums must be recouped. (Refer to the ACA Processing Guide for the Mini-App Recoupment Process).

2. If the individual contacts the county after 30 days from the date the notice was sent, close the individual’s coverage at the end of the month of the request and no recoupments are made. Since the client requests their case closed, adequate notice is sufficient.

7. Error made when FFM determined an individual was eligible and the individual was not eligible:

1. Since the determination was made by the FFM, the change will be made prospectively following the 10-10-10 rules, based on the date the change is reported.

• Document the findings, no overpayment will result and nothing further needs to be done.

8. For any month(s) an individual received coverage under Medicaid Expansion through the insurance vendor, and meets all three of the following criteria:

1. Is determined eligible for Social Security Disability or SSI; AND

2. Meets the asset requirements for Non-ACA Medicaid coverage; AND

3. Has medical bills for the month(s) which are not being covered by Medicaid Expansion through the insurance vendor but could be paid under Traditional Medicaid coverage.

• Premiums for those months the individual meets all three of the above criteria must be recouped from the insurance vendor.

• Due to notice requirements, Non-ACA Medicaid coverage must be approved for those months the premiums were recouped.

Note: If the individual has been residing in a LTC facility and the Level of Care does not equal the date of entry, contact the State Medicaid Policy Unit. Send all requests to the State Medicaid Policy Group Mailbox at -Info-DHS Medicaid Policy <hccpolicy@nd.gov>.

 

9. Medically Frail individuals who chose to be covered under Traditional Medicaid coverage, who are in receipt of nursing care services and fail to report a Disqualifying Transfer(s):

1. Any amount paid for nursing care services during the Disqualifying Transfer penalty period is the amount of the overpayment.

10. Sharing Medicaid ID’s:

1. When an individual shared their Medicaid ID card with another individual who utilized it to receive services, and it becomes known, a referral to the SURS Unit must be made immediately. There is no overpayment applied to the Medicaid recipient.

Determining Amount of Overpayments

Any overpayment resulting from a recipient error is subject to recovery. Overpayments are established on recipient errors in which Medicaid funds were misspent regardless of the reason the error occurred.

 

To determine the amount of the overpayment for Traditional Medicaid Coverage and Medicaid Expansion through the insurance vendor:

1. For Traditional Medicaid overpayments not related to incorrect client share (recipient liability), the amount of the overpayment is the amount of Medicaid payments paid in error on behalf of the ACA Medicaid eligible individual.

2. For Traditional Medicaid overpayments related to incorrect client share (recipient liability), the amount of the overpayment is the lesser of:

   1. The amount of Medicaid payments paid in error on behalf of the ACA Medicaid Unit; or

   2. The difference between the correct amount of client share (using actual income) and the amount of the client share met by the ACA Medicaid Unit.

3. For Medicaid Expansion overpayments, the amount of the overpayment is equal to the total amount of all premiums paid in error.

 

All recipient errors in which there is an overpayment or suspected fraud (regardless of overpayment) must be referred to the Surveillance Utilization Review (SURS) Unit in the Medical Services Division using SFN 20, “SURS Referral Form” with a copy to the Medicaid eligibility unit. SFN 20 may be sent to SURS by:

• Mail: SURS, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505;
• Fax: 701-328-1544; or
• Email: medicaidfraud@nd.gov.

 

Copies may be sent to the Medicaid Eligibility Unit as follows:

• Mail: Medicaid Eligibility Unit, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505;
• Fax: 701-328-5406; or
• Email: -Info-DHS Medicaid Policy.

 

Repayment of Overpayments

Any repayment of an overpayment received at the county agency must be submitted to the Fiscal Administration unit using SFN 828, "Credit Form".