N.J. Admin. Code § 10:49-13.4
Current through Register Vol. 56, No. 19, October 7, 2024
Section 10:49-13.4 - Rewards for information relating to fraud and abuse(a) The Division of Medical Assistance and Health Services may pay a monetary reward for information that leads to the recovery of at least $ 100.00 from individuals or entities that have engaged in health care-related fraud or abuse including ineligible receipt of benefits involving the programs administered by DMAHS (including, but not limited to, the New Jersey Medicaid and NJ FamilyCare programs), the Pharmaceutical Assistance to the Aged and Disabled (PAAD) program administered by Department of Health and Senior Services, and/or the Work First New Jersey General Assistance (GA) program administered by the Division of Family Development. The determination of whether an individual or entity meets the criteria for an award, and the amount of the award, is at the discretion of DMAHS. DMAHS shall pay a reward only if a reward is not otherwise provided for by law. When DMAHS applies the criteria specified in (b), (c) and (e) below to determine the eligibility and the amount of the reward, DMAHS shall notify the beneficiary of the reward as specified in (d) below.(b) The following pertain to information eligible for reward.1. In order for an individual or entity to be eligible to receive a reward, the information supplied shall relate to the activities of a specific individual or entity, and shall specify the time period of the alleged activities.2. DMAHS shall not give a reward for information relating to an individual or entity that, at the time the information is provided, is already the subject of a review or investigation by DMAHS or its contractors; the New Jersey Department of Human Services (DHS); the New Jersey Department of Health and Senior Services; the New Jersey Department of Law and Public Safety; the Health Care Financing Administration and the Office of the Inspector General of the U.S. Department of Health and Human Services or their contractors; the U.S. Department of Justice; the Federal Bureau of Investigation; or any other Federal, State, county or municipal law enforcement agency.(c) Any individual or entity (other than one excluded under (c)1 below) is eligible to receive a reward under this section if the information is submitted in the manner set forth in (f) below. 1. The following are excluded from eligibility to receive a reward:i. An individual who was or is an immediate family member of an officer or employee of any of the agencies or entities listed in (b)2 above at the time he or she came into possession of, or divulged, information leading to a recovery shall not be eligible to receive a reward under this section;ii. Any other Federal, State, county or municipal employee, contractor or grantee shall not be eligible for a reward under this section if the information submitted came to their knowledge in the course of their official duties;iii. An individual or entity that illegally obtained the information submitted shall be excluded from receiving a reward under this section; andiv. An individual or entity that participated in the sanctionable offense with respect to which payment would be made shall be excluded from receiving a reward under this section.(d) After all funds have been recovered and DMAHS has determined a participant eligible to receive a reward under the provisions of this section, it shall notify the informant of his or her eligibility, by mail, at the most recent address supplied by the individual or entity. It is the individual's or entity's responsibility to ensure that the reward program has been notified of any change in their address or other relevant information (for example, change of name, phone number). 1. If the individual or entity has relocated to an unknown address, the individual or entity or their legal representative may claim the reward by contacting DMAHS within one year from the date on which DMAHS first attempted to notify the individual or entity about a reward. DMAHS does not consider the individual or entity or their legal representative eligible for a reward more than one year after the date on which it first attempted to give notice. DMAHS does not pay interest on rewards that are not immediately claimed.2. If an individual has become incapacitated or has died, an executor, administrator, or other legal representative may claim the reward on behalf of the individual or the individual's estate. The claimant shall submit certified copies of the letters testamentary, letters of administration, or other similar evidence to show his or her authority to claim the reward. The claim shall be filed within one year from the date, on which DMAHS first gave or attempted to give notice of the reward.(e) The following pertain to the amount and payment of a reward: 1. In determining whether it shall pay a reward and, if so, the amount of the reward, DMAHS shall take into account all relevant factors, including the significance of the information furnished in relation to the ultimate resolution of the case and the recovery.2. The amount of the reward represents what DMAHS considers to be adequate compensation in the particular case, not to exceed 10 percent of the overpayments recovered in the case, or $ 1,000, whichever is less.3. If more than one individual or entity is eligible to receive a reward in a particular case, DMAHS shall allocate the total reward amount (not to exceed 10 percent of the overpayments recovered in that case, or $ 1,000, whichever is less) among the participants.4. DMAHS bases rewards only on recovered overpayments, not on amounts collected as interest, penalties and/or fines, and not on estimates of cost savings or cost avoidance.5. DMAHS shall make payments as promptly as the circumstances of the case permit, but not until it has collected all overpayments, interest, penalties and fines.6. No Division employee may make any offer or promise or otherwise bind DMAHS or DHS with respect to the payment or any reward under this subsection or the amount of the reward.(f) An individual or entity may submit information on persons or entities engaging in, or that have engaged in, health care-related fraud and/or abuse against the programs listed in (a) above to Bureau of Program Integrity, Division of Medical Assistance and Health Services, PO Box 712, Trenton, NJ 08625-0712, or by calling the DMAHS Fraud and Abuse Hotline at 1-888-9 FRAUD-5 (1-888-937-2835). 1. A participant interested in receiving a reward shall provide his or her name, address, telephone number, and any other requested identifying information so that he or she may be contacted, if necessary, for additional information and, when applicable, for the payment of a reward upon resolution of the case.(g) DMAHS shall not reveal a participant's identity to any person, except as required by law.(h) If, after a reward is accepted, DMAHS finds that the awardee was ineligible to receive the reward, neither DMAHS nor DHS shall be liable for the reward, and the awardee shall refund all monies received.(i) Receipt of a reward under this section by any applicant for, or beneficiary of, benefits under any program administered in whole or in part by the Division of Medical Assistance and Health Services, including, but not limited to, Medically Needy (N.J.A.C. 10:70), Medicaid Only (N.J.A.C. 10:71), New Jersey Care ... Special Medicaid Programs (N.J.A.C. 10:72), NJ FamilyCare (N.J.A.C. 10:78) and NJ KidCare (N.J.A.C. 10:79), Pharmaceutical Assistance to the Aged and Disabled, Work First New Jersey/General Assistance or AFDC-Related Medicaid shall not affect that individual's eligibility or continued eligibility for those benefits.N.J. Admin. Code § 10:49-13.4
New Rule, R.2000 d.288, effective 7/17/2000.
See: 31 New Jersey Register 2673(b), 32 New Jersey Register 2613(a).
Amended by R.2002 d.124, effective 4/15/2002.
See: 33 New Jersey Register 4188(a), 34 New Jersey Register 1546(a).
Rewrote (i).
Amended by R.2003 d.82, effective 2/18/2003.
See: 34 New Jersey Register 2650(a), 35 New Jersey Register 1118(a).