Policy/Memo 53

Number: Policy Memo 53
Date Issued: March 21, 1991
Policy File Ref: A410

ISSUE:

Resolution of cases of fraud and benefit abuse.

Background:

This Policy Memo addresses the Division's response to cases where there is evidence of fraud and abuse by plan providers. (In Policy Memo #15 a procedure was established to inform management of suspected cases of fraud and abuse by enrollees. These procedures remain in effect.)

Policy:

When documented evidence reveals provider fraud and/or benefit abuse, the Contract Management Unit will instruct the appropriate carrier to use their resources to recoup plan payments to the extent possible. The providers (including pharmacies) will be reported to appropriate regulatory agencies by the Division Director when:

(1) An audit or other investigation discloses substantial evidence of fraud. Fraud is defined as the obtaining of something of value unlawfully through willful misrepresentation;
(2) Evidence discloses that the health or well-being of an Empire Plan enrollee could be adversely affected; or,
(3) The suspect practices involve controlled substances.

Appropriate regulatory agencies may include but are not limited to:

(1) Attorney General's Office;
(2) Office of Professional Discipline;
(3) Board of Regents; and,
(4) Medicaid and Medicare Fraud Units.

Appropriate Division staff will work with the regulatory agencies, upon request, to further any investigation such agency deems appropriate.