[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: 42CFR1007.19]



[Page 1210]

 

                         TITLE 42--PUBLIC HEALTH

 

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

 

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

 

Sec.  1007.19  Federal financial participation (FFP).



    (a) Rate of FFP. Subject to the limitation of this section, the 

Secretary will reimburse each State by an amount equal to 90 percent of 

the costs incurred by a certified unit which are attributable to 

carrying out its functions and responsibilities under this part.

    (b) Retroactive certification. The Secretary may grant certification 

retroactive to the date on which the unit first met all the requirements 

of the statute and of this part. For any quarter with respect to which 

the unit is certified, the Secretary will provide reimbursement for the 

entire quarter.

    (c) Amount of FFP. FFP for any quarter will not exceed the higher of 

$125,000 or one-quarter of 1 percent of the sums expended by the 

Federal, State, and local governments during the previous quarter in 

carrying out the State Medicaid program.

    (d) Costs subject to FFP. (1) FFP is available under this part for 

the expenditures attributable to the establishment and operation of the 

unit, including the cost of training personnel employed by the unit. 

Reimbursement will be limited to costs attributable to the specific 

responsibilities and functions set forth in this part in connection with 

the investigation and prosecution of suspected fraudulent activities and 

the review of complaints of alleged abuse or neglect of patients in 

health care facilities.

    (2) (i) Establishment costs are limited to clearly identifiable 

costs of personnel that--

    (A) Devote full time to the establishment of the unit which does 

achieve certification; and

    (B) Continue as full-time employees after the unit is certified.

    (ii) All establishment costs will be deemed made in the first 

quarter of certification.

    (e) Costs not subject to FFP. FFP is not available under this part 

for expenditures attributable to--

    (1) The investigation of cases involving program abuse or other 

failures to comply with applicable laws and regulations, if these cases 

do not involve substantial allegations or other indications of fraud;

    (2) Efforts to identify situations in which a question of fraud may 

exist, including the screening of claims, analysis of patterns of 

practice, or routine verification with recipients of whether services 

billed by providers were actually received;

    (3) The routine notification of providers that fraudulent claims may 

be punished under Federal or State law;

    (4) The performance by a person other than a full-time employee of 

the unit of any management function for the unit, any audit or 

investigation, any professional legal function, or any criminal, civil 

or administrative prosecution of suspected providers;

    (5) The investigation or prosecution of cases of suspected recipient 

fraud not involving suspected conspiracy with a provider; or

    (6) Any payment, direct or indirect, from the unit to the Medicaid 

agency, other than payments for the salaries of employees on detail to 

the unit.



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