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Code of Federal Regulations Title 42. Public Health § 42.455.15 Full investigation

Current as of October 02, 2022 | Updated by FindLaw Staff

If the findings of a preliminary investigation give the agency reason to believe that an incident of fraud or abuse has occurred in the Medicaid program, the agency must take the following action, as appropriate:

(a) If a provider is suspected of fraud or abuse, the agency must—

(1) In States with a State Medicaid fraud control unit certified under subpart C of part 1002 of this title, refer the case to the unit under the terms of its agreement with the unit entered into under § 1002.309 of this title;  or

(2) In States with no certified Medicaid fraud control unit, or in cases where no referral to the State Medicaid fraud control unit is required under paragraph (a)(1) of this section, conduct a full investigation or refer the case to the appropriate law enforcement agency.

(b) If there is reason to believe that a beneficiary has defrauded the Medicaid program, the agency must refer the case to an appropriate law enforcement agency.

(c) If there is reason to believe that a beneficiary has abused the Medicaid program, the agency must conduct a full investigation of the abuse.

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Cite this article: FindLaw.com - Code of Federal Regulations Title 42. Public Health § 42.455.15 Full investigation - last updated October 02, 2022 | https://codes.findlaw.com/cfr/title-42-public-health/cfr-sect-42-455-15/

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