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The Plan, The Plan: Creating a Fraud Plan

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

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The Plan, The Plan: Creating a Fraud Plan

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

  2. 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

  3. Federal Regulations and State Statutes for Medicaid • 42 CFR 455.15(b) and (c) • NCGS 108A-64, Medical Assistance Recipient Fraud • NCGS 108A-70.28, Fraudulent Misrepresentation (used for NCHC) • NCGS.14-100 Obtaining Property by False Pretense

  4. 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

  5. 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

  6. 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

  7. Questions

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