Sec. 412. Requirements for operation of State health care fraud and abuse control units
536 words·~2 min read·
/bill/113/hr/1200/ih/section-412·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
In order to meet the requirement of section 404(b)(1)(K), each State health security program shall establish and maintain a health care fraud and abuse control unit (in this section referred to as a fraud unit ) that meets requirements of this section and other requirements of the Board. Such a unit may be a State medicaid fraud control unit (described in section 1903(q) of the Social Security Act ). The fraud unit shall— be a single identifiable entity of the State government; be separate and distinct from the State agency with principal responsibility for the administration of the State health security program; and meet one of the following requirements:
It shall be a unit of the office of the State Attorney General or of another department of State government which possesses statewide authority to prosecute individuals for criminal violations. If it is in a State the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the Board, that— assure its referral of suspected criminal violations relating to the State health insurance plan to the appropriate authority or authorities in the States for prosecution; and assure its assistance of, and coordination with, such authority or authorities in such prosecutions.
It shall have a formal working relationship with the office of the State Attorney General and have formal procedures (including procedures for its referral of suspected criminal violations to such office) which are approved by the Board and which provide effective coordination of activities between the fraud unit and such office with respect to the detection, investigation, and prosecution of suspected criminal violations relating to the State health insurance plan. The fraud unit shall— have the function of conducting a statewide program for the investigation and prosecution of violations of all applicable State laws regarding any and all aspects of fraud in connection with any aspect of the provision of health care services and activities of providers of such services under the State health security program; have procedures for reviewing complaints of the abuse and neglect of patients of providers and facilities that receive payments under the State health security program, and, where appropriate, for acting upon such complaints under the criminal laws of the State or for referring them to other State agencies for action; and provide for the collection, or referral for collection to a single State agency, of overpayments that are made under the State health security program to providers and that are discovered by the fraud unit in carrying out its activities.
The fraud unit shall— employ such auditors, attorneys, investigators, and other necessary personnel; be organized in such a manner; and provide sufficient resources (as specified by the Board), as is necessary to promote the effective and efficient conduct of the unit’s activities. The fraud unit shall have cooperative agreements (as specified by the Board) with— similar fraud units in other States; the Inspector General; and the Attorney General of the United States. The fraud unit shall submit to the Inspector General an application and annual reports containing such information as the Inspector General determines to be necessary to determine whether the unit meets the previous requirements of this section.