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

(Revised 8/1/13 ML #3373)

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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.

 

  1. 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.

 

  1. 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.

 

  1. 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 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 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 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.

  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).

 

  1. The Public Assistance Reporting Information System (PARIS) is a computer data matching and information exchange system administered by the Department of Health and Human Services (DHHS) and Administration for Children and Families (ACF). This system provides States with a tool to improve program integrity in administering Public Assistance and Medicaid programs. PARIS is designed to match State enrollment data from TANF, SNAP and Medicaid Programs with data from other participating States and from a selected group of Federal databases. See also “Public Assistance Reporting Information System (PARIS) at 448-01-50-40.

 

Effective May 1, 2013, processing of PARIS hits has been incorporated into the TECS eligibility system. The first hits that will appear will be for the benefit month of August, 2012. Thereafter, you will receive PARIS hits on a quarterly basis in: