23 Miss. Code. R. 305-1.2 - Fraud, Waste, and Abuse

A. The Division of Medicaid investigates suspected cases of fraud, waste, and abuse using methods that:

1. Do not infringe on the legal rights of persons involved, and

2. Afford due process of law to individuals under investigations.

B. The Division of Medicaid must make a formal, written fraud referral to the Medicaid Fraud Control Unit (MFCU) for each credible allegation of fraud or an allegation that leads to the initiation of a payment suspension, in whole or in part. If the Division of Medicaid determines that good cause exists to remove a payment suspension, in whole or in part, or to discontinue a payment suspension previously imposed, the Division of Medicaid is not relieved of its obligation to make a referral to MFCU.

C. The Division of Medicaid must suspend all payments to a provider when the Division of Medicaid determines there is a credible allegation of fraud for which an investigation is pending unless the Division of Medicaid determines that good cause exists not to suspend or partially suspend such payments or not to continue a payment suspension previously imposed including, but not limited to:

1. Law enforcement:

a) Specifically requesting payments not be suspended, or

b) Declining to cooperate in certifying that a matter continues to be under investigation.

2. The Division of Medicaid determining:

a) Other available remedies exist that could be implemented by the Division of Medicaid to more effectively or quickly protect Medicaid funds,

b) A payment suspension is not in the best interest of the Medicaid program, or

c) A payment suspension would have an adverse effect on beneficiary access to necessary items or services because either of the following is true:

1) An individual or entity is the sole community physician or the sole source of essential specialized services in a community, or

2) The individual or entity serves a large number of beneficiaries within a Health Resources and Services Administration (HRSA) designated medically underserved area.

d) A payment suspension should be removed based upon the submission of written evidence by the individual or entity that is the subject of the payment suspension.

D. The Division of Medicaid will notify providers of suspension of payments within five (5) days of the suspension unless requested in writing by a law enforcement agency to temporarily withhold such notice.

E. The Division of Medicaid may grant an administrative hearing, if requested by the provider, as described in Miss. Admin. Code Part 300, to determine whether or not good cause exists to remove a payment suspension or suspend payment only in part.

F. Suspension of payments will continue until:

1. The Division of Medicaid or the prosecuting authorities determine that there is insufficient evidence of fraud by the provider, or

2. Legal proceedings related to the provider's alleged fraud are completed.

G. The Division of Medicaid will:

1. Make a referral to the appropriate law enforcement agency if there is reason to believe that a beneficiary has defrauded the Medicaid program.

2. Conduct a full investigation if there is reason to believe that a beneficiary has abused the Medicaid program or if an applicant made a false statement or failed to disclose a material fact in his/her Medicaid application.

Notes

23 Miss. Code. R. 305-1.2

42 C.F.R. Part 455; Miss. Code Ann. §§ 43-13-121, 43-13-129.

Adopted 11/11/2016