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

(Revised 1/1/18 ML #3508)

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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 5 below. The SURS unit will be responsible for recoupment from any provider.
   
   
3. 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.
   
   For overpayments resulting from recipient errors, the amount of the overpayment is the amount of Medicaid payments paid in error on behalf of the Medicaid unit.

4. 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. Medical Care Payment received by a member of the Medicaid Unit that was provided as a result of a medical expense or increased medical need for a given time period
   1. The months in which the payments are incurred 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. Indicate in the subject line “request for increase in RL because of rework”

3. Failure to report income or other changes that affect eligibility or benefits, such as a change in household member composition, etc;
   
   1. If the change does not result in a change in eligibility for any individual in the household the Medicaid Unit , document the findings and nothing further needs to be done.

   2. If the change results in an INCREASE in coverage, the change will be made for the future benefit month following the month in which the verification/information is received.

      Note: If an individual fails to report a change and the change would have resulted in equal or better 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.
        
        

        Exception: Reductions to ‘Client Share’ can be made retroactively, upon receipt of actual verified information for the month the ‘Client Share’ is being reduced.

   3. 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 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.
     
     
   • If the individual should have been eligible with a larger client share the amount of the overpayment is the difference between the incorrect amount of ‘client share’ (using actual income) and the correct amount of the client share that was met.

   
   

   4. If the individual was eligible for Medicaid coverage 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.
      
      
   • The amount of the overpayment is the amount paid in error for all months the individual should not have been eligible.
     
     
4. Failure to disclose assets
   
   1. If the undisclosed assets results in ineligibility, 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.

   2. If the undisclosed assets did not result in a change in eligibility for any individual in the Medicaid Unit, document the findings and nothing further needs to be done.

5. An individual moves out of State/loses State residency:
   i. Close the individual’s coverage the end of month it becomes known the individual has moved out of State/loses State residency (10 day notice is 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 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 incurred.
     
     
   • 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. An individual fails to report a Disqualifying transfers;
   
   1. If the disqualifying transfer period has not yet expired, send a notice informing the Medicaid Unit they are no longer eligible for nursing care services.
      1. The amount of the overpayment will be the lessor of:
         • The amount of the disqualifying transfer; or
           
           
         • The amount of Medicaid payments paid in error on behalf of the individual, for nursing care services;
           
           

   2. If the disqualify transfer has expired

      • The amount of the overpayment will be the lessor of:

        • The amount of the disqualifying transfer; or

        • The amount of Medicaid payments paid in error on behalf of the individual, for nursing care services;

7. Sharing Medicaid ID card.
   
   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. The Eligibility Worker is not required to establish an overpayment; however, the SURS investigation may result in an overpayment.
      
      

An SFN 20 “SURS Referral Form” must be completed for all recipient errors where there is a suspicion of fraud. If a suspicion of fraud does not exist, the SFN 20 “SURS Referral Form” is not to be completed.

To assist with determining what constitutes a suspicion of fraud, the following items should be considered:

• Was information listed on the application(s) false? —meaning they were employed or had other assets or household members, etc., that were not disclosed at the time of application.
  
  
• Were false statements made by the Medicaid Unit member – meaning denying (specifically indicated no) assets or income on a certain date when there really were assets or income.
  
  
• Recipient admitted they knew they should have reported.
  
  
• Other proof or evidence there was false information given in order to receive benefits.

For questions regarding determining a suspicion of fraud, contact the Fraud, Waste, and Abuse Administrator at 701-328-4024 or via email medicaidfraud@nd.gov.

1. If it has been determined there is a suspicion of fraud, review the information with a lead worker/supervisor and complete the SFN 20 “SURS Referral Form”

• The lead worker/supervisor must sign the SFN 20 “SURS Referral Form” to acknowledge their review of the referral and agreement with the suspicion of fraud determination.

Note: The SFN 20 “SURS Referral Form” will be returned if a lead worker or supervisor’s signature is missing.

• If an SFN 20 “SURS Referral Form” has been submitted to the SURS Unit, DO NOT send a Letter of Overpayment as defined in #2 below.

• When completing the SFN 20, “SURS Referral Form”, if you include programs other than Medicaid in the referral, it must be clearly stated.

2. If it has been determined that there is NOT a suspicion of fraud, the Eligibility Worker must send a Letter of Overpayment (510-03-110-15 Letter of Overpayment) to the Medicaid Unit , regardless of the amount of the overpayment.

Note: Any SFN 20 “SURS Referral Form” received at the state which lacks proof for of suspected fraud, it will be returned to the county to send the Letter of Overpayment.

Once a Letter of Overpayment has been sent to the Medicaid Unit , immediately email a copy of the Letter of Overpayment to SURS at medicaidfraud@nd.gov. This information is needed for tracking of the overpayment, repayment plans, and other collection efforts.

When the overpayment amount includes the Medicaid Expansion premium payment(s), Eligibility Workers will need to send a request for this information to the Medicaid Eligibility Policy Group Box(in the email subject line indicate “overpayment-Medicaid Expansion premium payment amounts needed” at hccpolicy@nd.gov, or you can call (701) 328-1015 or toll free 1-844-854-4825.

6. 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).