Improper Payments and Suspected Recipient Fraud 510-05-10-25

(Revised 2/04 ML #2900)

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Any currently discovered overpayment, whether resulting from a recipient error, from assistance granted pending a fair hearing decision subsequently made in favor of the county agency, or from payment that was provided as a result of a medical expense or increased medical need for a given time period, is subject to recovery. No distinction is made between willful and nonwillful withholding of or failure to report information that affects eligibility.

 

The amount of a recipient error is determined as follows:

 

  1. For ineligible cases resulting from excess assets, the amount of the overpayment is the lesser of:

  1. The amount of Medicaid payments paid in error on behalf of the Medicaid unit; or
  2. The difference between the actual amount of excess assets and the Medicaid asset limit.

  1. For overpayments resulting from errors related to incorrect recipient liability, the amount of the overpayment is the lesser of:

  1. The amount of Medicaid payments paid in error on behalf of the Medicaid unit; or
  2. The difference between the correct amount of recipient liability and the amount of the recipient liability met by the Medicaid unit.
  3. For overpayments resulting from any other error, the amount of the overpayment is the amount of Medicaid payments paid in error on behalf of the Medicaid unit.

 

The county agency must promptly take all reasonable and practical steps to correct the overpayment. All recipient errors must be referred to the states attorney’s office with copies to the regional representative and the Estate Recovery Unit at the Department. Refer to Service Chapter 449-07 for the proper procedure to follow regarding suspected fraud.

 

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