Iowa Administrative Code › Agency 481 - Inspections and Appeals Department › Inspections Division › Chapter 73 - Medicaid Fraud Control Unit › Rule 481-73.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Abuse "
or
"neglect"
means
				  any act that constitutes abuse or neglect of a patient or resident under
				  applicable state law and includes, but is not limited to, incidents involving
				  physical harm inflicted as a result of an intentional act or negligence,
				  consensual or nonconsensual sexual contact, misappropriation of money or
				  property, theft of medications, or degradation of personal dignity. The victim
				  is a patient or resident receiving health care services in a health care
				  facility that receives Medicaid funds or in a board and care facility at the
				  time of the abuse or neglect.
"Board and care facility "
means a
				  residential setting where two or more unrelated adults reside and receive one
				  or both of the following:
1. Nursing
				care services provided by, or under the supervision of, a registered nurse,
				licensed practical nurse, or licensed nursing assistant.
2. A substantial amount of personal care
				services that assist residents with activities of daily living, including
				personal hygiene, dressing, bathing, eating, personal sanitation, ambulation,
				transfer, positioning, self-medication, body care, travel to medical services,
				essential shopping, meal preparation, laundry, and housework.
"Department"
means the department of
				  inspections and appeals.
"Director"
means the director of the
				  department of inspections and appeals.
"Fraud"
means an intentional deception or
				  misrepresentation made by an individual or entity with the knowledge that the
				  deception or misrepresentation could result in an unauthorized benefit to the
				  individual or entity, or another individual or entity, and includes any act
				  that constitutes fraud under applicable federal or state law, including but not
				  limited to Iowa Code chapters 249A and 685.
"Medicaid provider"
means:
1. Any individual, agency, institution, or
				organization enrolled with the department of human services, Iowa Medicaid
				enterprise, or contracted managed care organizations (MCOs), and approved to
				provide goods or services to Iowa Medicaid beneficiaries and be paid by Iowa
				Medicaid enterprise, or contracted MCOs, for the provided goods or services;
				or
2. Any third party acting on
				behalf of or under the authority or direction of a Medicaid provider as defined
				in "1" to prepare or submit necessary documentation to Iowa Medicaid
				enterprise, or contracted MCOs, in order for the Medicaid provider to receive
				payment for goods or services.
"MFCU director "
means the director of the
				  Iowa MFCU.
"Overpayment"
means any payment greater than
				  that to which a Medicaid provider is entitled.
"Prosecutorial agency"
includes, but is not
				  limited to, county attorney offices, United States Attorney offices or the Iowa
				  attorney general's office.
"Referral"
means any information submitted
				  to the Iowa Medicaid fraud control unit in written or verbal form indicating
				  potential criminal or fraudulent activity which the Iowa MFCU maintains
				  jurisdiction to investigate.
"Regulatory agency "
includes, but is not
				  limited to, state licensing boards, other divisions or bureaus of the
				  department of inspections and appeals, or other divisions or bureaus of the
				  U.S. Department of Health and Human Services.
"Respondent"
means the recipient of a
				  subpoena and may be an individual or an organization.
"State medical assistance program "
or
"Medicaid"
means medical assistance programs per the Code of
				  Federal Regulations, Title 42, Chapter IV, Subchapter C, Parts 430 through 489.
				  Iowa Code chapter 249A authorizes Iowa's participation in the program. The
				  policies specific to the Medicaid program are in 441-Chapters 73 to 88.
"Unit"
or
"Iowa MFCU"
or
"MFCU"
means the Iowa Medicaid fraud control unit.
"Unit personnel"
includes investigators,
				  auditors, and attorneys assigned to the Iowa Medicaid fraud control unit, along
				  with the MFCU director.