C.F.R. » Title 42 » CHAPTER V—OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—OIG AUTHORITIES › PART 1007—STATE MEDICAID FRAUD CONTROL UNITS › Subpart B—Requirements for Certification

42 C.F.R. § 1007.11

Duties and responsibilities of Unit

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(a) The Unit will conduct a statewide program for investigating and prosecuting (or referring for prosecution) violations of all applicable State laws, including criminal statutes as well as civil false claims statutes or other civil authorities, pertaining to the following:

(1) Fraud in the administration of the Medicaid program, the provision of medical assistance, or the activities of providers.

(2) Fraud in any aspect of the provision of health care services and activities of providers of such services under any Federal health care program (as defined in section 1128B(f)(1)of the Act), if the Unit obtains the written approval of the Inspector General of the relevant agency and the suspected fraud or violation of law in such case or investigation is primarily related to the State Medicaid program.

(b)(1) The Unit will also review complaints alleging abuse or neglect of patients or residents in health care facilities receiving payments under Medicaid and may review complaints of the misappropriation of funds or property of patients or residents of such facilities.

(2) At the option of the Unit, it may review complaints of abuse or neglect, including misappropriation of funds or property, of patients or residents of board and care facilities, regardless of whether payment to such facilities is made under Medicaid.

(3) If the initial review of the complaint indicates substantial potential for criminal prosecution, the Unit will investigate the complaint or refer it to an appropriate criminal investigative or prosecutorial authority.

(4) If the initial review does not indicate a substantial potential for criminal prosecution, the Unit will, if appropriate, refer the complaint to the proper Federal, State, or local agency.

(c) If the Unit, in carrying out its duties and responsibilities under paragraphs (a) and (b) of this section, discovers that overpayments have been made to a health care facility or other provider, the Unit will either recover such overpayment as part of its resolution of a fraud case or refer the matter to the appropriate State agency for collection.

(d) Where a prosecuting authority other than the Unit is to assume responsibility for the prosecution of a case investigated by the Unit, the Unit will ensure that those responsible for the prosecutorial decision and the preparation of the case for trial have the fullest possible opportunity to participate in the investigation from its inception and will provide all necessary assistance to the prosecuting authority throughout all resulting prosecutions.

(e)(1) The Unit, if requested, will make available to OIG investigators and attorneys, or to other Federal investigators and prosecutors, all information in the Unit's possession concerning investigations or prosecutions conducted by the Unit.

(2) The Unit will coordinate with OIG investigators and attorneys, or with other Federal investigators and prosecutors, on any Unit cases involving the same suspects or allegations that are also under investigation or prosecution by OIG or other Federal investigators or prosecutors.

(3) The Unit will establish a practice of regular Unit meetings or communication with OIG investigators and Federal prosecutors.

(4) When the Unit lacks the authority or resources to pursue a case, including for allegations of Medicare fraud and for civil false claims actions in a State without a civil false claims act or other State authority, the Unit will make appropriate referrals to OIG investigators and attorneys or other Federal investigators or prosecutors.

(5) The Unit will establish written policy consistent with paragraphs (e)(1) through (4) of this section.

(f) The Unit will guard the privacy rights of all beneficiaries and other individuals whose data is under the Unit's control and will provide adequate safeguards to protect sensitive information and data under the Unit's control.

(g)(1) The Unit will transmit to OIG pertinent information on all convictions, including charging documents, plea agreements, and sentencing orders, for purposes of program exclusion under section 1128 of the Act.

(2) Convictions include those obtained either by Unit prosecutors or non-Unit prosecutors in any case investigated by the Unit.

(3) Such information will be transmitted to OIG within 30 days of sentencing, or as soon as practicable if the Unit encounters delays in receiving the necessary information from the court.

Notes of Decisions
Cited in 7 cases (1 in the last 5 years), 1998–2025 · leading case: Planned Parenthood of Indiana v. Carter
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Planned Parenthood of Indiana v. Carter (2006) indctapp · cites it 10× “§ 1396b(q)(4)(A)G), 42 C.F.R. § 1007.11 (b)(2). We must now determine the proper constitutional scope of IMFCU's investigative authority in this case.”
People v. Kanaan (2008) michctapp “” 8 We also note 42 CFR 1007.11(a), which provides that “[t]he unit will conduct a Statewide program for investigating and prosecuting (or referring for prosecution) violations of all applicable State laws pertaining to fraud in the administration of the Medicaid program, the…”
Dr. Behzad Nazari, D.D.S. v. State (2018) tex “§ 1396a(a)(42)(B)(ii)(IV)(cc), which investigates program violations and can refer matters for criminal prosecution or "to an appropriate State agency" for other action, 42 C.F.R. § 1007.11 (b)(3) (2018). In Texas, such enforcement actions can take the form of criminal, 20…”
State v. Chalice Renee Zeitner (2019) ariz “" 42 C.F.R. § 1007.11 (e). ¶12 As evinced by these federal laws, the disclosure of patient information relevant to a law enforcement investigation and prosecution of fraud against a state's Medicaid agency is closely tied to the administration of a state's plan.”
Danahy v. Buscaglia (1998) ca2 “42 C.F.R. § 1007.11 (1996) which describes the duties and responsibilities of the unit states in part: (a) the unit will conduct a Statewide program for investigating and prosecuting (or referring for prosecution) violations of all applicable State laws pertaining to fraud in…”
Massachusetts v. Mylan Laboratories, Inc. (2007) mad “§§ 1396a and 1396b; 42 C.F.R. § 1007.11 (e) (2006)), obligates the Commonwealth in some fashion to share discovery information.”
The State of Texas v. Nonparty Patient No. 1, Nonparty Patient No. 2, Nonparty Patient No. 3, Nonparty Patient No. 4, No (2025) texapp “§ 1396a(a)(42)(B)(ii)(IV)(cc), which Defensive Nature of Counterclaims investigates program violations and can refer matters for criminal prosecution or “to an appropriate State agency” for other action, 42 C.F.R. § 1007.11 (b)(3) (2018). In Texas, Finally, the Court concludes…”
— 42 C.F.R. § 1007.11(a) — 1 case
People v. Kanaan (2008) michctapp “” 8 We also note 42 CFR 1007.11(a), which provides that “[t]he unit will conduct a Statewide program for investigating and prosecuting (or referring for prosecution) violations of all applicable State laws pertaining to fraud in the administration of the Medicaid program, the…”
— 42 C.F.R. § 1007.11(b) — 1 case
Planned Parenthood of Indiana v. Carter (2006) indctapp “§ 1396b(q)(4)(A)G), 42 C.F.R. § 1007.11 (b)(2). We must now determine the proper constitutional scope of IMFCU's investigative authority in this case.”
— 42 C.F.R. § 1007.11(b)(2) — 1 case
Planned Parenthood of Indiana v. Carter (2006) indctapp “§ 1396b(q)(4)(A)G), 42 C.F.R. § 1007.11 (b)(2). We must now determine the proper constitutional scope of IMFCU's investigative authority in this case.”
— 42 C.F.R. § 1007.11(f) — 1 case
Planned Parenthood of Indiana v. Carter (2006) indctapp “§ 1396b(q)(4)(A)G), 42 C.F.R. § 1007.11 (b)(2). We must now determine the proper constitutional scope of IMFCU's investigative authority in this case.”
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