The Plan, The Plan: Creating a Fraud Plan Angela Saddler Recipient Investigations Coordinator Division of Medical Assistance Quality Assurance/Program.

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Presentation transcript:

The Plan, The Plan: Creating a Fraud Plan Angela Saddler Recipient Investigations Coordinator Division of Medical Assistance Quality Assurance/Program Integrity

Objective Review federal regulations and state statutes Explore why a fraud plan is needed What criteria should be included in the plan Who should involved in creating the plan

Federal Regulations and State Statutes for Medicaid Federal Regulations and State Statutes for Medicaid 42 CFR (b) and (c) NCGS 108A-64, Medical Assistance Recipient Fraud NCGS 108A-70.28, Fraudulent Misrepresentation (used for NCHC) NCGS Obtaining Property by False Pretense

Why is a Fraud Plan Needed: Ensures that your agency is maintaining integrity within the public assistance programs it offers Protects the agency when there are accusations of discrimination Aids in the workers treating everyone in accordance with county policies

Suggested Criteria for Fraud Plan County’s mission regarding allegations of fraud* Statement on unusual or extenuating circumstances Types of errors (AE, IHE, IPV) Timeframes for processing of referrals* Types of investigations (front-ends vs. regular)* Administrative Disqualification policy (applicable to FNS and TANF only) Court action criteria (civil and criminal) Repayment and Collections policy

WHO SHOULD BE INVOLVED IN TO CREATING A FRAUD PLAN Program Integrity staff Director District Attorney’s office County Attorney/DSS Attorney Client Advocates* Social Services Board

Questions