The inspector general or the inspector general’s designee may, without prior notice, order a hold on the payment of a claim for reimbursement submitted by a claimant if there is reasonable cause to believe that the claim, or payment of the claim, constitutes fraud, waste, or abuse, or is otherwise inaccurate.
Terms Used In Utah Code 63A-13-205
Abuse: means :
(a)
an action or practice that:
(i)
is inconsistent with sound fiscal, business, or medical practices; and
(ii)
results, or may result, in unnecessary Medicaid related costs; or
Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
Claimant: means a person that:
(a)
provides a service; and
(b)
submits a claim for Medicaid reimbursement for the service. See Utah Code 63A-13-102
Department: means the Department of Health and Human Services created in Section 26B-1-201. See Utah Code 63A-13-102
State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
Waste: includes an activity that:
(i)
does not constitute abuse or necessarily involve a violation of law; and
(ii)
relates primarily to mismanagement, an inappropriate action, or inadequate oversight. See Utah Code 63A-13-102
(2)
The office shall, within seven days after the day on which a hold described in Subsection (1) is ordered, notify the claimant that the hold has been placed.
(3)
The inspector general or the inspector general’s designee may not maintain a hold longer than is necessary to determine whether the claim, or payment of the claim, constitutes fraud, waste, or abuse, or is otherwise inaccurate.
The inspector general may request that the attorney general’s office seek an injunction to prevent a person from disposing of an asset that is potentially subject to recovery by the state to recover funds due to a person’s fraud or abuse.
(7)
The department and the division shall fully comply with a hold ordered under this section.
Renumbered and Amended by Chapter 12, 2013 General Session
