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COMAR 10.09.24.14

1401 State of Maryland Medical Assistance Manual Revised July 2012

1400.1 Introduction-Fraud and Abuse Medicaid fraud is defined as:

Knowingly and willfully making or causing to be made any false statement or false representation of a material fact (whether or not the individual is found eligible): o In an application for a Medicaid benefit or payment; o For use in determining rights to a Medicaid benefit or payment.

Having knowledge of the occurrence of any event affecting the initial or continued right to Medicaid benefits or payments for the individual who filed the application or on whose behalf the application was filed, and concealing or failing to disclose that event with an intent to secure fraudulently those benefits or payments either in a greater amount or quantity than is due or when benefits or payments are not authorized; Applying to receive or receiving Medicaid benefits or payments for use and benefit of someone else, and knowingly and willfully converting any part of the Medicaid benefit or payment to a use other than the benefit of the enrolled Medicaid recipient; Fraudulently obtaining, attempting to obtain, or aiding another person in obtaining or attempting to obtain a Medicaid covered service by the use of:

o Fraud, deceit, misrepresentation, or subterfuge; o Forgery or alteration of a Medicaid prescription; o Concealment of a material fact; or o Use of false names or addresses.

Unauthorized possession of a blank provider prescription form; Possession of a Medical Care Program recipient identification card without authorization from the individual to whom the card was issued; or Manufacture, distribution, or possession of a counterfeit Medical Care Program recipient identification card or a provider prescription form.

Following are examples of the most frequent types of recipient fraud:

Intentionally under-reporting or not reporting income and resources; Falsely reporting household composition, such as omitting wage earners from the Medicaid application. Failing to report changes in income, resources, or other circumstances within 10 days as required – e.g., moving out of state, receipt of cash lump sums; Failing to report third party insurance coverage; Lending a Medical Care Program recipient identification card to another person; and Forging or altering prescriptions.