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Policy/Memo 15r3

Number: Policy Memo 15r3
Date Issued: December 14, 1988
Date Revised: June 28, 2004
Policy File Ref: A410
Subject: Internal Policies, Procedures

ISSUE:

Determine the proper procedure when instances of enrollee health benefit fraud or abuse are suspected.

Background:

Internal control mandates require that the Division ensure that there is a standard procedure for its employees to follow in reporting suspected enrollee fraud or abuse.

Policy:

Health benefits fraud will not be condoned or ignored. When an EBD employee learns of an instance of possible fraud or abuse, the employee will complete and submit an Identification of Suspected Benefit Fraud or Abuse form (PS-1600) to the Audit Unit immediately. The Audit Unit will investigate and gather any additional information. If the Audit Unit determines that it appears fraud has occurred, they will report their findings to the Division Director and the vendor, carrier or HMO involved. After Senior Staff review, the Division Director will direct cases requiring further action to Counsel's office. The Audit Unit will act as liaison between the Division and Counsel and will also coordinate with the carriers concerning all recovery matters.