Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter I - Specific Policies By Service › Sec2 144-101-I-1 - GENERAL ADMINISTRATIVE POLICIES AND PROCEDURES › Subsection 144-101-I-1.22 - FRAUD/ABUSE BY A PROVIDER, INDIVIDUAL OR ENTITY, AND SUSPENSION OF PAYMENTS

Current through 2024-29, July 17, 2024
1.22-1
Fraud
A. Fraud includes intentional deception or
					 misrepresentation, oral or written, which an individual knows to be false, or
					 does not believe to be true, made with knowledge that deception or
					 misrepresentation could result in some unauthorized benefits. The requisite
					 intent is present if the misrepresentation was made knowingly or with a
					 reckless disregard for the truth.
B. Examples of conduct that could constitute
					 fraud include, but are not limited to, the following:
1. Billings for services, supplies, or
					 equipment that were not rendered to, or used for, MaineCare members;
2. Billings for supplies or equipment that
					 are clearly unsuitable for the member's needs or are so lacking in quality or
					 sufficiency for the purpose as to be virtually worthless;
3. Flagrant and persistent over utilization
					 of medical or paramedical services with little or no regard for results, the
					 member's ailments, condition, medical needs, or the provider's
					 orders;
4. Claiming of costs for
					 non-covered or non-chargeable services, supplies or equipment disguised as
					 covered items;
5. Misuse of the
					 "rounding rule," Section 1.03-8(J), in billing for services;
6. Material misrepresentations of dates and
					 descriptions of services rendered, or of the identity of the member or the
					 individual who rendered the services;
7. Duplicate billing which appears to be
					 deliberate. This includes, but is not limited to: billing MaineCare twice for
					 the same service or billing both MaineCare, a third party insurer, and/or the
					 member, family, or representative for the same services, billing for the same
					 service under different codes or different policies, billing separately for a
					 service that is included in a per diem or other bundled rate, or billing for
					 the same service under different provider numbers;
8. Arrangements by providers with employees,
					 independent contractors, suppliers, and others that appear to be designed
					 primarily to overcharge MaineCare with various devices (commissions, fee
					 splitting) used to siphon off or conceal profits;
9. Charging to MaineCare, by subterfuge,
					 costs not incurred or which were attributable to non-program activities, other
					 enterprises, or personal expenses of principals;
10. Deliberately providing, or receiving
					 medical services on the MaineCare account of another individual;
11. Deliberately billing members rather than
					 MaineCare for covered services;
12.
					 Concealing business activities that would prevent compliance with the
					 provisions of the Provider Agreement;
13. Falsifying provider records in order to
					 meet or continue to meet the conditions of participation; and
14. Soliciting, offering, or receiving a
					 kickback, bribe, or rebate.