If you read the United States Code of Federal Regulations, you realize there are crazy rules that are designed to attempt to limit the ability of auditors to help the taxpayers.
The State Medicaid Fraud Control Units are designed to try and stop the billions of dollars in fraud that occurs each year in the Medicaid program. These units should be funded properly and staffed with competent employees aggressively seeking to stop the ripoff of taxpayer funds.
Under the Title 42 of the Public Health Code 1007.19 (e) (2) , the Federal government does not want to participate in paying for costs associated with efforts to identify situations in which a question of fraud may exist, including
- the screening of claims,
- analysis of patterns of practice,
- or routine verification with recipients of whether services billed by providers were actually received
What a silly rule!
42 C.F.R. § 1007.19 Federal financial participation (FFP).
Title 42 - Public Health
§ 1007.19 Federal financial participation (FFP).
(a) Rate of FFP. Subject to the limitation of this section, the Secretary will reimburse each State by an amount equal to 90 percent of the costs incurred by a certified unit which are attributable to carrying out its functions and responsibilities under this part.
(b) Retroactive certification. The Secretary may grant certification retroactive to the date on which the unit first met all the requirements of the statute and of this part. For any quarter with respect to which the unit is certified, the Secretary will provide reimbursement for the entire quarter.
(c) Amount of FFP. FFP for any quarter will not exceed the higher of $125,000 or one-quarter of 1 percent of the sums expended by the Federal, State, and local governments during the previous quarter in carrying out the State Medicaid program.
(d) Costs subject to FFP. (1) FFP is available under this part for the expenditures attributable to the establishment and operation of the unit, including the cost of training personnel employed by the unit. Reimbursement will be limited to costs attributable to the specific responsibilities and functions set forth in this part in connection with the investigation and prosecution of suspected fraudulent activities and the review of complaints of alleged abuse or neglect of patients in health care facilities.
(2) (i) Establishment costs are limited to clearly identifiable costs of personnel that—
(A) Devote full time to the establishment of the unit which does achieve certification; and
(B) Continue as full-time employees after the unit is certified.
(ii) All establishment costs will be deemed made in the first quarter of certification.
(e) Costs not subject to FFP. FFP is not available under this part for expenditures attributable to—
(1) The investigation of cases involving program abuse or other failures to comply with applicable laws and regulations, if these cases do not involve substantial allegations or other indications of fraud;
(2) Efforts to identify situations in which a question of fraud may exist, including the screening of claims, analysis of patterns of practice, or routine verification with recipients of whether services billed by providers were actually received;
(3) The routine notification of providers that fraudulent claims may be punished under Federal or State law;
(4) The performance by a person other than a full-time employee of the unit of any management function for the unit, any audit or investigation, any professional legal function, or any criminal, civil or administrative prosecution of suspected providers;
(5) The investigation or prosecution of cases of suspected recipient fraud not involving suspected conspiracy with a provider; or
(6) Any payment, direct or indirect, from the unit to the Medicaid agency, other than payments for the salaries of employees on detail to the unit.
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