53-6-157. Powers and duties of medicaid fraud control unit. (1) The medicaid fraud control unit shall:

Terms Used In Montana Code 53-6-157

  • Abuse: means conduct by an applicant, recipient, provider, or other person involving disregard of and an unreasonable failure to conform with the statutes, regulations, and rules governing the medical assistance program when the disregard or failure results or may result in an incorrect determination that a person is eligible for medical assistance or payment by a medicaid agency of medical assistance payments to which the provider is not entitled. See Montana Code 53-6-155
  • Applicant: means a person:

    (a)who has submitted an application for determination of medicaid eligibility to a medicaid agency on the person's own behalf or on behalf of another person; or

    (b)on whose behalf an application has been submitted. See Montana Code 53-6-155

  • Benefit: means the provision of anything of pecuniary value to or on behalf of a recipient under the medicaid program. See Montana Code 53-6-155
  • Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
  • Department: means the department of public health and human services provided for in 2-15-2201. See Montana Code 53-6-155
  • Fraud: Intentional deception resulting in injury to another.
  • Fraud: means any conduct or activity prohibited by statute, regulation, or rule involving purposeful or knowing conduct or omission to perform a duty that results in or may result in medicaid payments or benefits to which the applicant, recipient, or provider is not entitled. See Montana Code 53-6-155
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Medicaid: means the Montana medical assistance program established under Title 53, chapter 6. See Montana Code 53-6-155
  • Misappropriation of patient property: means exploitation, deliberate misplacement, or wrongful use or taking of a patient's property, whether temporary or permanent, without authorization by the patient or the patient's designated representative. See Montana Code 53-6-155
  • Patient abuse: means the willful infliction of physical or mental injury of a patient or unreasonable confinement, intimidation, or punishment that results in pain, physical or mental harm, or mental anguish of a patient. See Montana Code 53-6-155
  • Patient neglect: means a failure, through inattentiveness, carelessness, or other omission, to provide to a patient goods and services necessary to avoid physical harm, mental anguish, or mental illness when an omission is not caused by factors beyond the person's control or by good faith errors in judgment. See Montana Code 53-6-155
  • Prosecute: To charge someone with a crime. A prosecutor tries a criminal case on behalf of the government.
  • Provider: means an individual, company, partnership, corporation, institution, facility, or other entity or business association that has enrolled or applied to enroll as a provider of services or items under the medical assistance program established under this part. See Montana Code 53-6-155
  • Recipient: means a person:

    (a)who has been determined by a medicaid agency to be eligible for medicaid benefits, whether or not the person actually has received any benefits; or

    (b)who actually receives medicaid benefits, whether or not determined eligible. See Montana Code 53-6-155

  • Records: means medical, professional, business, or financial information and documents, whether in written, electronic, magnetic, microfilm, or other form:

    (i)pertaining to the provision of treatment, care, services, or items to a recipient;

    (ii)pertaining to the income and expenses of the provider; or

    (iii)otherwise relating to or pertaining to a determination of eligibility for or entitlement to payment or reimbursement under the medicaid program. See Montana Code 53-6-155

  • State: when applied to the different parts of the United States, includes the District of Columbia and the territories. See Montana Code 1-1-201

(a)investigate and prosecute under applicable criminal statutes fraud and abuse by applicants, recipients, providers, or any other persons, including but not limited to cases referred by the department;

(b)review any complaint of patient abuse, patient neglect, and misappropriation of patient property and, when appropriate, shall investigate and initiate criminal proceedings or refer the complaint to another federal, state, or local agency for action;

(c)refer to the department for collection and, when appropriate, consideration and imposition of appropriate recipient restrictions or provider sanctions cases involving recipient or provider overpayments, fraud, abuse, inappropriate use of services, or other improper activities discovered by the unit in carrying out its activities;

(d)communicate and cooperate with and, subject to applicable confidentiality laws, provide information to other federal, state, and local agencies involved in the investigation and prosecution of health care fraud, abuse, and other improper activities related to the medicaid program;

(e)transmit to other state and federal agencies, in accordance with law reports of convictions, copies of judgments and sentences imposed and other information and documents for purposes of program exclusions or other sanctions or penalties under medicaid, medicare, or other state or federal benefit or assistance programs; and

(f)recommend to state agencies appropriate or necessary adoption or revision of statutes, regulations, rules, policies, and procedures to prevent fraud, abuse, and other improper activities under the medicaid program and to aid in the investigation and prosecution of fraud, abuse, and other improper activities under the medicaid program.

(2)The medicaid fraud control unit may:

(a)initiate criminal prosecutions pursuant to subsection (1) in any court of competent jurisdiction in the state of Montana;

(b)upon written request, obtain information and records from applicants, recipients, and providers;

(c)exercise the authority granted to prosecutors with respect to criminal investigative subpoenas under Title 46, chapter 4, part 3;

(d)subject to applicable federal confidentiality laws and regulations and for purposes related to any investigation or prosecution pursuant to subsection (1), obtain from the department, local offices of public assistance, and other local, county, or state government departments or agencies records and other information, including but not limited to applicant and recipient applications, provider enrollment forms, claims and reports, individual or entity tax returns, or other information provided to or in the possession of the department of revenue or the state auditor;

(e)refer appropriate cases to other federal, state, or local agencies for investigation, prosecution, or imposition of penalties, restrictions, or sanctions;

(f)enter into agreements with the department and other federal, state, and local agencies in furtherance of the unit’s mission; and

(g)do all things necessary to comply with 42 U.S.C. § 1396a(a)(61) and 42 U.S.C. § 1396b(q) and any implementing federal regulations and policies that require the state to operate a medicaid fraud control unit.

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