Definitions

  1. Law
  2. Arkansas Code
  3. Public Health and Welfare
  4. Social Services
  5. Medical Assistance
  6. Office of Medicaid Inspector General
  7. Definitions

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As used in this subchapter:

  1. (1)

    1. (A) “Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.

    2. (B) “Abuse” includes recipient practices that result in an unnecessary cost to the Medicaid program;

  2. (2)

    1. (A) “Fraud” means a purposeful deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to the person or another person.

    2. (B) “Fraud” includes any act that constitutes fraud under applicable federal or state law;

  3. (3) “Healthcare plan” means a publicly or privately funded program or organization that is formed to provide or pay for healthcare goods or services, including without limitation:

    1. (A) Health insurance plans;

    2. (B) Managed care organization plans;

    3. (C) Risk-based provider plans;

    4. (D) The Arkansas Medicaid Program;

    5. (E) The Social Security Disability Insurance program; and

    6. (F) The Medicare program;

  4. (4) “Investigation” means investigations of fraud, abuse, or illegal acts perpetrated within the medical assistance program by providers or recipients of medical assistance care, services, and supplies;

  5. (5) “Person” means an individual or entity other than a recipient of a healthcare item or service;

  6. (6) “Recovery” means any action or attempt by the Medicaid Inspector General to recoup or collect Medicaid payments already made to a provider with respect to a claim by:

    1. (A) Reducing other payments currently owed to the provider;

    2. (B) Withholding or setting off the amount against current or future payments to the provider;

    3. (C) Demanding payment back from a provider for a claim already paid; or

    4. (D) Reducing or affecting in any other manner the future claim payments to the provider; and

  7. (7) “Waste” means that taxpayers are not receiving reasonable value for money in connection with a government-funded activity due to an inappropriate act or omission involving mismanagement, inappropriate actions, and inadequate oversight by the person with control over or access to government resources.


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