Current through Register Vol. 54, No. 44, November 2, 2024
(a)General. The restitution regulations contained in §§ 255.81-255.84 (relating to MA restitution provisions for the medically needy), will apply to medically needy and categorically needy persons who meet the requirements of MA. The regulations will apply to overpayments resulting from error of client or provider, fraudulent or nonfraudulent.(b)Client error and fraud. Overpayments caused by client action or failure to act may include, but will not be limited to, the following: (1) Withholding of information at time of application which would make the applicant ineligible for Medical Assistance.(2) Failure to report changes which would affect eligibility for Medical Assistance.(3) Use of medical identification card after notice of ineligibility or after expiration date.(4) Securing forged prescriptions for drugs.(5) "Shopping." Getting the same prescription from different doctors.(6) Allowing other persons to use the identification card.(c)Provider error and fraud. Overpayments caused by provider action or failure to act may include, but will not be limited to, the following:(1) Billing for services which were not rendered to or used for the patient.(2) Billing for services, medicine, and the like which are clearly unsuitable for the needs of the patient or so lacking in quality or sufficiency as to be virtually worthless.(3) Billing for noncovered or nonchargeable services or supplies disguised as covered items.(4) Flagrant and persistent overutilization of services with little or no regard for results, no regard for the ailments of the patient or no regard for the orders of the physician.(5) Overcharging or underfilling of prescriptions.(6) Inattention to eligibility dates on the identification card.(7) Failure to assure the correct identity of the patient.(d)Computation and collection of claim. The Bureau of Medical Assistance will be responsible for computing claims and collecting overpayments caused by provider error and fraud. In other cases the claim settlement area office will be responsible for computing the amount of the overpayment and for taking the action necessary to effect repayment.The provisions of this §255.81 adopted August 4, 1977, effective 8/5/1977, 7 Pa.B. 2180. This section cited in 55 Pa. Code § 255.71 (relating to policy); and 55 Pa. Code § 255.82 (relating to definitions).