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

(Revised 9/1/11 ML #3280)

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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.
  2. 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.” SFN 20 may be sent to SURS as described in 6 below.  The SURS unit will be responsible for recoupment from any provider.
  3. Recipient errors may occur as a result of:
  1. Assistance granted pending a fair hearing decision subsequently made in favor of the county agency;
  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);
  3. Failure to report income or disclose assets;
  4. Failure to report other changes that affect eligibility or benefits, such as a change in household member composition, etc;
  5. Recipient misunderstanding;
  6. Disqualifying transfers; and
  7. Medicaid ID card sharing.
  1. 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.
  2. 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 (using actual income) and the amount of the recipient liability met by the Medicaid unit.
  1. 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.
  1. 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.” SFN 20 may be sent to SURS by:
  1. Mail: SURS, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505;
  2. Fax: 701-328-1544; or
  3. Email: medicaidfraud@nd.gov.  

A copy of SFN 20 must also be sent to the Estate Recovery Unit when the error includes an overpayment. SFN 20 may be sent to the Estate Recovery Unit by:

  1. Mail: Estate Recovery Unit, 600 East Boulevard Avenue, Department 325, Bismarck, ND 58505;
  2. Fax: 701-328-1060; or
  3. Email: dhseap@nd.gov.  
  1. Any repayment of an overpayment received at the county agency must be submitted to the Fiscal Administration unit using SFN 828, "Credit Form" (05-100-55).