DATE: July 31, 2012
SUBJECT: REFERRAL OF RECIPIENT FRAUD TO LAW ENFORCEMENT
DISTRIBUTION: COUNTY DIRECTORS OF SOCIAL SERVICES
PROGRAM INTEGRITY SUPERVISORS AND INVESTIGATORS
INCOME MAINTENANCE SUPERVISORS AND CASEWORKERS
The Centers for Medicare and Medicaid Services has determined that the North Carolina Medicaid Program is not in full compliance with Federal Regulations 42 CFR 455.15 (b) and (c) regarding the process of referral of recipient fraud to law enforcement. In order to be in full compliance with 42 CFR 455.15(b) and (c), a correction is being made to the policy regarding the process of referring individuals suspected of fraud or abuse of the Medicaid program to the appropriate law enforcement agency.
A part of this process correction is a change in the procedures used by the counties to report information to the Division of Medical Assistance regarding cases of suspected recipient fraud or abuse of the Medicaid program that they have referred to law enforcement. Referral to law enforcement includes either referral to the district attorney or referral to a law enforcement agency.
When the county department of social services determines from an investigation that
an individual has defrauded Medicaid or North Carolina Health Choice the director or
his designee must:
Division of Medical Assistance, Quality Assurance Section,
2501 Mail Service,
Raleigh, NC 27699-2501
The schedule for these reports is as follows:
If you have questions about this policy, please contact Quality Assurance at 919-814-0000.
Michael Watson, Director
Division of Medical Assistance
(This material was researched and written by Shara Britt, Quality Assurance Section)
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.