Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 465 - INTRODUCTION TO THE PROGRAM MANUAL › Chapter 2 - PROGRAM UNIVERSALS › Section 465-2-007 - Fraud and Abuse and Intentional Program Violations

Current through June 17, 2024
This section establishes policy and procedure for reporting
				  suspected fraud and abuse cases and intentional program violations to the
				  Special Investigation Unit for follow-up which includes investigation and
				  possible prosecution.
Fraud is defined by Section
				  68-1017,
Reissue Revised Statutes of Nebraska, 1943
. Federal
				  regulations regarding fraud and abuse are
				  45 CFR
				  235.110 and 42 CFR Part 455. Intentional
				  program violations are addressed in
				  7 CFR
				  273.16.
007.01
Definitions:
The following definitions apply to fraud and abuse and
				  intentional program violations:
Abuse (Medicaid)
: Provider
				  practices that are inconsistent with sound fiscal, business, or medical
				  practices and result in an unnecessary cost to the Nebraska Medical Assistance
				  Program (NMAP) or in reimbursement for services that are not medically
				  necessary or that fail to meet professionally recognized standards for health
				  care. Abuse also includes recipient practices that result in unnecessary cost
				  to NMAP.
Complainant
: Any individual,
				  including a Department employee, who initiates a referral for investigation of
				  a suspected fraud case using Form ASD-63, "Referral for Investigation," or any
				  other method.
Fraud
: As defined by state law,
				  fraud includes, but is not limited to, the willful false statement or
				  representation, or impersonation or other device, made by a recipient or
				  applicant, provider, Departmental employee, or any other person, for the
				  purpose of obtaining or attempting to obtain, or aiding or abetting any person
				  to obtain -
1. Any commodity, food
				stuff, food coupons, or payment to which the individual is not
				entitled;
2. A larger amount of
				payment than that to which the individual is entitled;
3. Any other benefit administered by the
				Nebraska Department of Social Services to which the individual is not entitled;
				or
4. Assistance in violation of
				any statutory provision relating to programs administered by the Nebraska
				Department of Social Services.
As defined by federal Medicaid regulation, fraud is an
				  intentional deception or misrepresentation made by a person with the knowledge
				  that the deception could result in some unauthorized benefit to himself/herself
				  or some other person. It includes any act that constitutes fraud under
				  applicable federal or state law.
Intentional Program Violation (Food Stamp
				  Program)
: Intentional program violation consists of any action by
				  an individual to purposely:
1. Make a
				false statement, either verbally or in writing, or conceal information to
				obtain benefits to which the household is not entitled;
2. Use or receive food stamp benefits in a
				transaction involving the sale of a controlled substance;
3. Use or receive food stamp benefits in a
				transaction involving the sale of firearms, ammunition, or
				explosives;
4. Traffic food stamp
				benefits for an aggregate amount of $500 or more;
5. Commit and be convicted of a drug-related
				felony with the following exceptions:
a.
				Remain eligible after first conviction when participating in or have completed
				a national-licensed or state-approved substance abuse treatment
				program;
b. Remain eligible after
				second conviction when participating in or have completed a national-licensed
				or state-approved substance abuse treatment program after the
				conviction;
6. Fleeing to
				avoid prosecution or custody for a crime or an attempt to commit a crime that
				would be classified as a felony or violating a condition of probation or
				parole; or
7. Make a fraudulent
				statement or representation with respect to his/her identity or place of
				residence to receive multiple food stamp benefits simultaneously.
Special Investigation Unit (SIU)
: A
				  unit within the Division of Enforcement Services whose purpose is to
				  investigate and prepare for prosecution all cases of fraud, except Medicaid
				  provider fraud.
Surveillance and Utilization Review Unit
				  (SURS)
: A unit within the Medicaid Division of Health and Human
				  Services, Finance and Support, responsible for investigation and appropriate
				  disposition of all cases of Medicaid provider fraud and program
				  abuse.