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COMAR 10.09.24.14

1402 State of Maryland Medical Assistance Manual Revised July 2012

If the LDSS or Local Health Department LHD has granted eligibility in error and can verify the period of ineligibility, these cases are referred to the DHMH Recoveries and Financial Services Division via the completion and submission of the DHMH Form 1169. A copy of Form 1169 may be found in the Appendix of Chapter 15: Liens, Adjustments and Recoveries. 1400.1- Procedural Changes Related to Recipient Fraud and Abuse of the Medicaid Program See COMAR 10.09.24.14 and .14-1 for the definitions, policies, and procedures related to recipient fraud and abuse of the Medicaid program. There have been organizational and procedural changes since the regulations were promulgated. The Corrective Managed Care Program, described in Regulation 14-1, was discontinued when the HealthChoice managed care program was implemented in 1996. The Department of Health and Mental Hygiene, however, retains the option to re-institute the program. A HealthChoice managed care organization (MCO), in accordance with COMAR 10.09.75, has the option to implement corrective managed care for enrollees who abuse the MCO’s benefits. In July 2006, all fraud, waste, and abuse investigation was transferred to the DHMH Office of the Inspector General (OIG). The Medicaid Program Integrity (PI) Division investigates allegations of possible Medicaid recipient fraud. If suspected fraud is detected by a LDSS or LHD state member, the case must be promptly reported to the OIG/PI Division via the DHMH Form 4243. A completed DHMH Form 4243 should be sent to the following address:

Department of Health and Mental Hygiene Office of the Inspector General – Medicaid Program Integrity 201 West Preston Street Rm. 520 Baltimore, MD 21201

The DHMH Form 4243 may be obtained from the PI Division by sending a written request to the address above, by calling 1-866-770-7175, or by visiting the website at: www.DHMH.Maryland.Gov/oig/sitepages/home.aspx Click on “Report Medicaid Fraud,” then select “For agency use.” A copy of Form 4243 may also be found in the Appendix of Chapter 15: Liens, Adjustments and Recoveries. Referrals for investigation of suspected recipient fraud are also generated from providers, police departments, the Social Security Administration, and citizens. They should call or write the PI Division to provide information and request an investigation.