N.D. Admin Code 75-02-05-06 - Reporting of violations and investigation

1. Information from any source indicating that a provider has failed or is failing to fulfill the provider's responsibilities, as set forth in section 75-02-05-04; or that a provider has acted in a manner which forms a ground for sanction as set forth in section 75-02-05-05 must be transmitted to the department.

2. The department shall investigate the matter and, if the report is substantiated, shall take whatever action or impose whatever sanction is most appropriate. The taking of any action or the imposition of any sanction does not preclude subsequent or simultaneous civil or criminal court action.

3.

a. The department may investigate suspected fraud or abuse. The department may conduct an investigation to determine whether:

(1) Fraud or abuse exists and can be substantiated;

(2) Sufficient evident exists to support the recovery of overpayments or the imposition of sanctions; or

(3) The matter should be referred for action by another agency, including a law enforcement agency, to determine whether sufficient evidence exists to pursue any other civil or criminal action permitted by law.

b. The department may undertake an investigation to:

(1) Examine a provider's medical, financial, or patient records;

(2) Interview a provider and a provider's associates, agents, or employees;

(3) Verify a provider's professional credentials and the credentials of the provider's associates, agents, and employees;

(4) Interview recipients;

(5) Examine equipment, prescriptions, supplies, or other items used in a recipient's treatment;

(6) Sample a random mix of paid claims, prior authorizations, and medical records;

(7) Determine whether services provided to a recipient were medically necessary;

(8) Examine insurance claims or records or records of any other source of payment, including recipient payments; or

(9) The department may refer the case to the appropriate authority for further investigation and prosecution.

4. The department may contract with specialists outside the department as part of the investigation.

Notes

N.D. Admin Code 75-02-05-06

Amended by Administrative Rules Supplement 2014-352, April 2014, effective April 1, 2014. . Amended by Administrative Rules Supplement 368, April 2018, effective 4/1/2018.

General Authority: NDCC 50-24.1-04

Law Implemented: 42 CFR 455.14; 42 CFR 455.15; 42 CFR 455.16