Md. Code Regs. 10.09.24.14

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.09.24.14 - Fraud

A. "Medicaid fraud" means:

(1) Knowingly and willfully making or causing to be made any false statement or representation of a material fact in any application for any benefit or payment under a State plan established by Title XIX of the Social Security Act of 1939;

(2) Knowingly and willfully making or causing to be made any false statement or representation of a material fact for use in determining rights to those benefits or payments;

(3) Having knowledge of the occurrence of any event affecting:

(a) The initial or continued right to those benefits or payments, or

(b) The initial or continued right to those benefits or payments to any other individual in whose behalf an application has been made or in whose behalf benefits or payments are being received, and concealing or failing to disclose that event with an intent to secure fraudulently those benefits or payments either in a greater amount or quantity than is due or when benefits or payments are not authorized;

(4) Having made application to receive or having received any of those benefits or payments for the use and benefit of another, and knowingly and willfully converting any part of the benefit or payment to a use other than for the use and benefit of that other person;

(5) Fraudulently obtaining, attempting to obtain, or aiding another person in obtaining or attempting to obtain any drug product or any medical care, the benefit or payment of any part of which is or may be made from federal or state funds under a state Medical Assistance program, by use of:

(a) Fraud, deceit, misrepresentation, or subterfuge,

(b) Forgery or alteration of a Medical Assistance prescription, or

(c) Concealment of any material fact or by the use of false names or addresses;

(6) Possession of a blank Medical Assistance prescription, unless possession is authorized by:

(a) A contract or other power, right, or permission to manufacture, store, transport, or distribute blank prescriptions;

(b) A grant of a rendering privilege as evidenced by the issuance of a rendering number by a state Medical Assistance program by which one is authorized to prescribe pharmaceutical products for Medical Assistance recipients if the authorization:

(i) To possess a blank Medical Assistance prescription terminates 30 days after notice of suspension or termination of provider status in a state Medical Assistance program or exhaustion of final appeal rights, whichever is later, and

(ii) Does not extend to possession of blank Medical Assistance prescriptions which have been obtained from a source not authorized to distribute blank Medical Assistance prescriptions under §S(6)(a) of this regulation;

(c) Performance of one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program; or

(d) The Director, Medical Care Compliance Administration;

(7) Possession of a Medical Assistance card or Pharmacy Assistance card without the authorization of the person to whom the card is issued, unless:

(a) Possession is obtained by a provider without knowledge that the presenting party lacked authorization;

(b) Possession is pursuant to one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program; or

(c) Authorized by the Director, Medical Care Compliance Administration;

(8) Manufacture, distribution, or possession of a counterfeit Medical Assistance card, prescription blank, or Pharmacy Assistance card except when possession is obtained:

(a) By a provider without knowledge that the card or prescription blank is counterfeit; or

(b) Pursuant to one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program; and

(9) Manufacture, distribution, or possession of a provider identification plate used or capable of use to imprint Medical Assistance prescriptions unless authorized by:

(a) A contract or other power, right, or permission to manufacture, transport, distribute, handle, or possess the plates;

(b) Issuance by a state Medical Assistance program to the party in possession;

(c) Performance of one's lawful duties as a law enforcement officer or as one employed by a state Medical Assistance program; or

(d) The Director, Medical Care Compliance Administration.

B. Examples. The following are examples of circumstances that may be Medicaid fraud:

(1) Failure to report income, resources, and family composition at the time of application or reapplication;

(2) Failure to report within 10 working days any changes in income, resources, and circumstances during any period of eligibility;

(3) Lending a Medical Assistance card to another person;

(4) Using or attempting to use a Medical Assistance card with intent to secure fraudulently benefits which are not authorized.

C. LDSS Reporting. All cases of suspected Medicaid fraud that are discovered by personnel of a local department of social services shall be reported to the Division of Utilization and Eligibility Review of the Medical Care Compliance Administration on a form specified by the Division of Utilization and Eligibility Review.

D. Other Reporting. All cases of suspected Medicaid fraud that are discovered by agencies other than a local department of social services, that is, other state or federal agencies, providers, or concerned citizens, may be reported to the Division of Utilization and Eligibility Review in writing or by telephone.

E. Division of Utilization and Eligibility Review. The Division of Utilization and Eligibility Review shall review and, when appropriate, investigate all referrals when an allegation is made that a misrepresentation of a material fact has been made or is suspected to have been made.

F. Disposition of Referrals. Each referral shall be processed by the Division of Utilization and Eligibility Review for appropriate resolution which includes, but is not limited to:

(1) Referral for prosecution;

(2) Filing of charges at District Court;

(3) Recovery of incorrect benefit payments;

(4) A finding that the allegation has not been sustained;

(5) Referral to the appropriate agency; and

(6) Other administrative action.

G. Penalties. A person convicted of the crime of Medicaid fraud is subject to penalties as described in Criminal Law Article, §§ 8-510 -8-512, Annotated Code of Maryland.

Md. Code Regs. 10.09.24.14

Regulation .14 amended effective August 8, 1988 (15:16 Md. R. 1914)
.Regulations .14A amended as an emergency provision effective May 1, 1983 (10:11 Md. R. 962); adopted permanently effective September 1, 1983 (10:17 Md. R. 1521)
Regulation .14B amended as an emergency provision effective May 1, 1984 (11:10 Md. R. 858); emergency status expired August 28, 1984
Regulation .14B amended effective August 29, 1984 (11:17 Md. R. 1492)