[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR1007.11]



[Page 1208]

 

                         TITLE 42--PUBLIC HEALTH

 

      GENERAL--HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

PART 1007_STATE MEDICAID FRAUD CONTROL UNITS--Table of Contents

 

Sec.  1007.11  Duties and responsibilities of the unit.



    (a) The unit will conduct a Statewide program for investigating and 

prosecuting (or referring for prosecution) violations of all applicable 

State laws pertaining to fraud in the administration of the Medicaid 

program, the provision of medical assistance, or the activities of 

providers of medical assistance under the State Medicaid plan.

    (b) (1) The unit will also review complaints alleging abuse or 

neglect of patients in health care facilities receiving payments under 

the State Medicaid plan and may review complaints of the 

misappropriation of patient's private funds in such facilities.

    (2) If the initial review indicates substantial potential for 

criminal prosecution, the unit will investigate the complaint or refer 

it to an appropriate criminal investigative or prosecutive authority.

    (3) If the initial review does not indicate a substantial potential 

for criminal prosecution, the unit will refer the complaint to an 

appropriate State agency.

    (c) If the unit, in carrying out its duties and responsibilities 

under paragraphs (a) and (b) of this section, discovers that 

overpayments have been made to a health care facility or other provider 

of medical assistance under the State Medicaid plan, the unit will 

either attempt to collect such overpayment or refer the matter to an 

appropriate State agency for collection.

    (d) Where a prosecuting authority other than the unit is to assume 

responsibility for the prosecution of a case investigated by the unit, 

the unit will insure that those responsible for the prosecutive decision 

and the preparation of the case for trial have the fullest possible 

opportunity to participate in the investigation from its inception and 

will provide all necessary assistance to the prosecuting authority 

throughout all resulting prosecutions.

    (e) The unit will make available to Federal investigators or 

prosecutors all information in its possession concerning fraud in the 

provision or administration of medical assistance under the State plan 

and will cooperate with such officials in coordinating any Federal and 

State investigations or prosecutions involving the same suspects or 

allegations.

    (f) The unit will safeguard the privacy rights of all individuals 

and will provide safeguards to prevent the misuse of information under 

the unit's control.