Iowa Admin. Code r. 481-73.1

Current through Regsiter Vol. 46, No. 26, June 12, 2024

Rule 481-73.1 - Definitions

"Abuse " or"neglect" means any act that constitutes abuse or neglect of a patient or resident under applicable state law and includes, but is not limited to, incidents involving physical harm inflicted as a result of an intentional act or negligence, consensual or nonconsensual sexual contact, misappropriation of money or property, theft of medications, or degradation of personal dignity. The victim is a patient or resident receiving health care services in a health care facility that receives Medicaid funds or in a board and care facility at the time of the abuse or neglect.

"Board and care facility " means a residential setting where two or more unrelated adults reside and receive one or both of the following:

1. Nursing care services provided by, or under the supervision of, a registered nurse, licensed practical nurse, or licensed nursing assistant.

2. A substantial amount of personal care services that assist residents with activities of daily living, including personal hygiene, dressing, bathing, eating, personal sanitation, ambulation, transfer, positioning, self-medication, body care, travel to medical services, essential shopping, meal preparation, laundry, and housework.

"Department" means the department of inspections and appeals.

"Director" means the director of the department of inspections and appeals.

"Fraud" means an intentional deception or misrepresentation made by an individual or entity with the knowledge that the deception or misrepresentation could result in an unauthorized benefit to the individual or entity, or another individual or entity, and includes any act that constitutes fraud under applicable federal or state law, including but not limited to Iowa Code chapters 249A and 685.

"Medicaid provider" means:

1. Any individual, agency, institution, or organization enrolled with the department of human services, Iowa Medicaid enterprise, or contracted managed care organizations (MCOs), and approved to provide goods or services to Iowa Medicaid beneficiaries and be paid by Iowa Medicaid enterprise, or contracted MCOs, for the provided goods or services; or

2. Any third party acting on behalf of or under the authority or direction of a Medicaid provider as defined in "1" to prepare or submit necessary documentation to Iowa Medicaid enterprise, or contracted MCOs, in order for the Medicaid provider to receive payment for goods or services.

"MFCU director " means the director of the Iowa MFCU.

"Overpayment" means any payment greater than that to which a Medicaid provider is entitled.

"Prosecutorial agency" includes, but is not limited to, county attorney offices, United States Attorney offices or the Iowa attorney general's office.

"Referral" means any information submitted to the Iowa Medicaid fraud control unit in written or verbal form indicating potential criminal or fraudulent activity which the Iowa MFCU maintains jurisdiction to investigate.

"Regulatory agency " includes, but is not limited to, state licensing boards, other divisions or bureaus of the department of inspections and appeals, or other divisions or bureaus of the U.S. Department of Health and Human Services.

"Respondent" means the recipient of a subpoena and may be an individual or an organization.

"State medical assistance program " or"Medicaid" means medical assistance programs per the Code of Federal Regulations, Title 42, Chapter IV, Subchapter C, Parts 430 through 489. Iowa Code chapter 249A authorizes Iowa's participation in the program. The policies specific to the Medicaid program are in 441-Chapters 73 to 88.

"Unit" or"Iowa MFCU" or"MFCU" means the Iowa Medicaid fraud control unit.

"Unit personnel" includes investigators, auditors, and attorneys assigned to the Iowa Medicaid fraud control unit, along with the MFCU director.

Iowa Admin. Code r. 481-73.1

Amended by IAB May 9, 2018/Volume XL, Number 23, effective 6/13/2018