The Plan, The Plan: The Plan, The Plan: Creating a Fraud PlanCreating a Fraud Plan

Angela SaddlerRecipient Investigations Coordinator

Division of Medical AssistanceQuality Assurance/Program Integrity

Objective Objective

• Review federal regulations and state statutes

• Explore why a fraud plan is needed

• What criteria should be included in the plan

• Who should involved in creating the plan

Federal Regulations and State Federal Regulations and State Statutes for MedicaidStatutes for Medicaid

• 42 CFR 455.15(b) and (c)

• NCGS 108A-64, Medical Assistance Recipient Fraud

• NCGS 108A-70.28, Fraudulent Misrepresentation (used for NCHC)

• NCGS.14-100 Obtaining Property by False Pretense

Why is a Fraud Plan Needed:Why is a Fraud Plan Needed:

• Ensures that your agency is maintaining integrity within the public assistance programs it offers

• Protects the agency when there are accusations of discrimination

• Aids in the workers treating everyone in accordance with county policies

Suggested Criteria for Fraud PlanSuggested Criteria for Fraud Plan• County’s mission regarding allegations of fraud*• Statement on unusual or extenuating

circumstances• Types of errors (AE, IHE, IPV)• Timeframes for processing of referrals* • Types of investigations (front-ends vs. regular)*• Administrative Disqualification policy (applicable

to FNS and TANF only)• Court action criteria (civil and criminal)• Repayment and Collections policy

WHO SHOULD BE INVOLVED IN WHO SHOULD BE INVOLVED IN TO CREATING A FRAUD PLANTO CREATING A FRAUD PLAN

• Program Integrity staff• Director• District Attorney’s office• County Attorney/DSS Attorney• Client Advocates*• Social Services Board

QuestionsQuestions