Medicaid Inspector General — Duties

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

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The Medicaid Inspector General shall, in consultation with the Secretary of the Department of Inspector General:

  1. (1) Hire deputies, directors, assistants, and other officers and employees needed for the performance of his or her duties and prescribe the duties of deputies, directors, assistants, and other officers and fix the compensation of deputies, directors, assistants, and other officers within the amounts appropriated;

  2. (2)

    1. (A) Conduct and supervise activities to prevent, detect, and investigate medical assistance program fraud and abuse.

    2. (B)

      1. (i) The Office of Medicaid Inspector General shall review provider records only for the three (3) years before an investigation begins.

      2. (ii) However, if a credible allegation of fraud has been made or if the Office of Medicaid Inspector General has reason to believe that fraud has occurred, the Office of Medicaid Inspector General may review provider records for the five (5) years before the investigation began;

  3. (3) Work in a coordinated and cooperative manner with:

    1. (A) Federal, state, and local law enforcement agencies;

    2. (B) The Medicaid Fraud Control Unit of the Office of the Attorney General;

    3. (C) United States Attorneys;

    4. (D) The United States Department of Health and Human Services' Office of Inspector General;

    5. (E) The Federal Bureau of Investigation;

    6. (F) The United States Drug Enforcement Administration;

    7. (G) Prosecuting attorneys;

    8. (H) The Centers for Medicare & Medicaid Services; and

    9. (I) An investigative unit maintained by a health insurer;

  4. (4) Solicit, receive, and investigate complaints related to fraud and abuse within the medical assistance program;

  5. (5)

    1. (A) Inform the Governor, the secretary, the Attorney General, the President Pro Tempore of the Senate, and the Speaker of the House of Representatives regarding efforts to prevent, detect, investigate, and prosecute fraud and abuse within the medical assistance program.

    2. (B) All cases in which fraud is determined to have occurred shall be referred to the appropriate law enforcement agency for prosecution;

  6. (6)

    1. (A) Pursue civil and administrative enforcement actions against an individual or entity that engages in fraud, abuse, or illegal or improper acts within the medical assistance program, including without limitation:

      1. (i) Referral of information and evidence to regulatory agencies and licensure boards;

      2. (ii) Withholding payment of medical assistance funds in accordance with state laws and rules and federal laws and regulations;

      3. (iii) Imposition of administrative sanctions and penalties in accordance with state laws and rules and federal laws and regulations;

      4. (iv) Exclusion of providers, vendors, and contractors from participation in the medical assistance program;

      5. (v) Initiating and maintaining actions for civil recovery and, where authorized by law, seizure of property or other assets connected with improper payments;

      6. (vi) Entering into civil settlements; and

      7. (vii) Recovery of improperly expended medical assistance program funds from those who engage in fraud or abuse or illegal or improper acts perpetrated within the medical assistance program.

    2. (B) In investigating civil and administrative enforcement actions under subdivision (a)(6)(A) of this section, the Medicaid Inspector General shall consider the quality and availability of medical care and services and the best interest of both the medical assistance program and recipients;

  7. (7) Make available to appropriate law enforcement officials information and evidence relating to suspected criminal acts that have been obtained in the course of the Medicaid Inspector General's duties;

  8. (8)

    1. (A) Refer suspected fraud or criminal activity to the Medicaid Fraud Control Unit.

    2. (B) After a referral and with ten (10) days' written notice to the Medicaid Fraud Control Unit, the Medicaid Inspector General may provide relevant information about suspected fraud or criminal activity to another federal or state law enforcement agency that the Medicaid Inspector General deems appropriate under the circumstances;

  9. (9) Subpoena and enforce the attendance of witnesses, administer oaths or affirmations, examine witnesses under oath, and take testimony in connection with an investigation or audit under this subchapter and under rules governing these investigations;

  10. (10) Require and compel the production of books, papers, records, and documents as he or she deems relevant or material to an investigation, examination, or review undertaken under this section;

  11. (11)

    1. (A) Examine and copy or remove documents or records related to the medical assistance program or necessary for the Medicaid Inspector General to perform his or her duties if the documents are prepared, maintained, or held by or available to a state agency or local governmental entity the patients or clients of which are served by the medical assistance program, or the entity is otherwise responsible for the control of fraud and abuse within the medical assistance program.

    2. (B) A document or record examined and copied or removed by the Medicaid Inspector General under subdivision (11)(A) of this section is confidential.

    3. (C) The removal of a record under subdivision (11)(A) of this section is limited to circumstances in which a copy of the record is insufficient for an appropriate legal or investigative purpose.

    4. (D) For a removal under subdivision (11)(A) of this section, the Medicaid Inspector General shall copy the record and ensure the expedited return of the original, or of a copy if the original is required for an appropriate legal or investigative purpose, so that the information is expedited and the original or copy is readily accessible for the care and treatment needs of the patient;

  12. (12)

    1. (A) Recommend and implement policies relating to the prevention and detection of fraud and abuse.

    2. (B) The Medicaid Inspector General shall obtain the consent of the Attorney General before the implementation of a policy under subdivision (12)(A) of this section that may affect the operations of the office of the Attorney General;

  13. (13)

    1. (A) Monitor the implementation of a recommendation made by the Office of Medicaid Inspector General to an agency or other entity with responsibility for administration of the medical assistance program and produce a report detailing the results of its monitoring activity as necessary.

    2. (B) The report shall be submitted to the:

      1. (i) Secretary;

      2. (ii) President Pro Tempore of the Senate;

      3. (iii) Speaker of the House of Representatives;

      4. (iv) Legislative Council;

      5. (v) Arkansas Legislative Audit; and

      6. (vi) Attorney General;

  14. (14) Prepare cases, provide testimony, and support administrative hearings and other legal proceedings;

  15. (15) Review and audit contracts, cost reports, claims, bills, and other expenditures of medical assistance program funds to determine compliance with applicable state laws and rules and federal laws and regulations and take actions authorized by state laws and rules and federal laws and regulations;

  16. (16)

    1. (A) Work with the fiscal agent employed to operate the Medicaid Management Information System of the Department of Human Services to optimize the system, including without limitation the ability to add edits and audits in consultation with the Department of Human Services.

    2. (B) The Medicaid Inspector General shall be consulted before an edit or audit is added or discontinued by the Department of Human Services;

  17. (17) Work in a coordinated and cooperative manner with relevant agencies in the implementation of information technology relating to the prevention and identification of fraud and abuse in the medical assistance program;

  18. (18)

    1. (A) Conduct educational programs for medical assistance program providers, vendors, contractors, and recipients designed to limit fraud and abuse within the medical assistance program.

    2. (B) The Office of Medicaid Inspector General shall regularly communicate with and educate providers about the Office of Medicaid Inspector General's fraud and abuse prevention program and its audit policies and procedures.

    3. (C) The Office of Medicaid Inspector General shall educate providers annually concerning its areas of focus within the medical assistance program, appropriate billing and documentation, and methods for improving compliance with program rules, policies, and procedures;

  19. (19)

    1. (A) Develop protocols to facilitate the efficient self-disclosure consistent with the Patient Protection and Affordable Care Act, Pub. L. No. 111-148, and the collection of overpayments and monitor collections, including those that are self-disclosed by providers.

    2. (B) A provider's good faith self-disclosure of overpayments may be considered as a mitigating factor in the determination of an administrative enforcement action;

  20. (20) Receive and investigate complaints of alleged failures of state and local officials to prevent, detect, and prosecute fraud and abuse in the medical assistance program;

  21. (21) Implement rules relating to the prevention, detection, investigation, and referral of fraud and abuse within the medical assistance program and to the recovery of improperly expended medical assistance program funds;

  22. (22) Conduct, in the context of the investigation of fraud and abuse, on-site inspections of a facility or an office;

  23. (23)

    1. (A) Take appropriate authorized actions to ensure that the medical assistance program is the payor of last resort; and

    2. (B) Recommend to the Department of Human Services that it take appropriate actions authorized under the jurisdiction of the Department of Human Services to ensure that the medical assistance program is the payor of last resort;

  24. (24) Annually submit a budget request for the next state fiscal year to the Governor;

  25. (25) Identify and order the return of underpayments to providers;

  26. (26) Maintain the confidentiality of all information and documents that are deemed confidential by law;

  27. (27) Implement, facilitate, and maintain federally required directives and contracts required for Medicaid integrity programs;

  28. (28) Implement and maintain a hotline for reporting complaints regarding fraud, waste, and abuse by providers;

  29. (29) Audit, investigate, and access Medicaid encounter data, premium data, or other information from an entity contracted with for the purpose of serving Medicaid programs;

  30. (30)

    1. (A) Promulgate administrative rules to establish policies and procedures for audits and investigations that are consistent with the duties of the Office of Medicaid Inspector General under this chapter.

    2. (B) The rules shall be posted on the Office of Medicaid Inspector General's website;

  31. (31) Identify conflicts between the Medicaid state plan, Department of Human Services rules, Medicaid provider manuals, Medicaid notices, or other guidance and recommend that the Department of Human Services reconcile inconsistencies;

  32. (32) When conducting an audit, investigation, or review under this subchapter, classify violations as either:

    1. (A) Errors that do not rise to the level of fraud or abuse; or

    2. (B) Fraud or abuse;

  33. (33)

    1. (A) If a credible allegation of fraud has been made, review provider records that have been the subject of a previous audit or review for the purpose of fraud investigation and referral.

    2. (B) However, the Medicaid Inspector General shall not duplicate an audit of a contract, cost report, claim, bill, or expenditure of a medical assistance program fund that has been the subject of a previous audit or review by or on behalf of the Office of Medicaid Inspector General, the Medicaid Fraud Control Unit, or other federal agency with authority over the medical assistance program if the audit or review was performed in accordance with the Government Auditing Standards;

  34. (34)

    1. (A) Utilize a quality improvement organization as part of the assessment of quality of services.

    2. (B) The quality improvement organization shall refer all identified improper payments due to technical deficiencies, abuse, waste, or fraud to the Medicaid Inspector General for further investigation and appropriate action, including without limitation recovery; and

  35. (35) Perform other functions necessary or appropriate to fulfill the duties and responsibilities of the Office of Medicaid Inspector General.


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