C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 433—STATE FISCAL ADMINISTRATION › Subpart F—Refunding of Federal Share of Medicaid Overpayments to Providers

42 C.F.R. § 433.304

Definitions

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As used in this subpart—

Discovery (or discovered) means identification by any State Medicaid agency official or other State official, the Federal Government, or the provider of an overpayment, and the communication of that overpayment finding or the initiation of a formal recoupment action without notice as described in § 433.316.

Final written notice means that written communication, immediately preceding the first level of formal administrative or judicial proceedings, from a Medicaid agency official or other State official that notifies the provider of the State's overpayment determination and allows the provider to contest that determination, or that notifies the State Medicaid agency of the filing of a civil or criminal action.

Fraud (in accordance with § 455.2) means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

Overpayment means the amount paid by a Medicaid agency to a provider which is in excess of the amount that is allowable for services furnished under section 1902 of the Act and which is required to be refunded under section 1903 of the Act.

Provider (in accordance with § 400.203) means any individual or entity furnishing Medicaid services under a provider agreement with the Medicaid agency.

Recoupment means any formal action by the State or its fiscal agent to initiate recovery of an overpayment without advance official notice by reducing future payments to a provider.

Third party (in accordance with § 433.136) means an individual, entity, or program that is or may be liable to pay for all or part of the expenditures for medical assistance furnished under a State plan.

[54 FR 5460, Feb. 3, 1989; 54 FR 8435, Feb. 28, 1989, as amended at 77 FR 31511, May 29, 2012]
Notes of Decisions
Cited in 10 cases, 2006–2016 · leading case: West Virginia Department of Health & Human Resources v. Sebelius
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West Virginia Department of Health & Human Resources v. Sebelius (2011) ca4 · cites it 6× “” 42 C.F.R. § 433.304 ; see also 42 U.S.C. § 1396b(d)(3)(A) (explaining “overpayment” as “[t]he pro rata share to which the United States is equitably entitled, as determined by the • Secretary, of the net amount recovered during any quarter by the State or any political…”
Goldstar Medical Services, Inc. v. Department of Social Services (2008) conn “See 42 C.F.R. § 433.304 (stating that, in accordance with 42 C.”
LifeCare Medical Transports, Inc. v. Virginia Department of Medical Assistance Services (2014) vactapp · cites it 2× “1:1 (“shall collect by any means available ... any amount owed ... because of overpayment .”
West Virginia Department of Health & Human Resources v. Sebelius (2016) wvsd · cites it 3× “42 C.F.R. § 433.304 .- Because these types of overpay-ments are based on expenditures that are not allowable under the statute in the first place, CMS is entitled to recoup the share of federal' money expended in an unauthorized way.”
Hidden Heights Assisted Living, Inc. v. State, Department of Health & Social Services, Division of Health Care Services (2009) alaska “See 42 C.FR. § 433.304 (defining overpayment).”
In re Maxi Drug, Inc. (2006) nh “§ 1396b allow for “recoupment,” defined as “any formal action by the State or its fiscal agent to initiate recovery of an overpayment without advance official notice by reducing future payments to a provider,” 42 C.F.R. § 433.304 (2005), and, following 42 U.”
Georgia Department of Community Health v. United States Department of Health and Human Services (2015) dcd “” 42 C.F.R. § 433.304 . Stated differently, an overpayment is a payment by a state to a medical provider that is impermissible and therefore not eligible for FFP under the state’s Medicaid plan.”
West Virginia Department of Health and Human Resources v. Sebelius (2010) wvsd · cites it 4× “” 42 C.F.R. § 433.304 . B. Facts 1. West Virginia’s Settlement with Dey On October 11, 2001, West Virginia’s Attorney General filed a lawsuit against Dey, LP and other pharmaceutical manufacturers on behalf of West Virginia’s Department of Health and Human Resources…”
in Re Patti J. Wagner, as Guardian of Jenny Wagner, an Incapacitated Adult (2015) texapp “Refund to the Department any "ove1payment" (as defined in 42 CFR §433.304 ) to the Program Provider.”
Virginia ex rel. Hunter Labs LLC v. Quest Diagnostics Inc. (2015) vaed “2011) (citing 42 C.F.R. § 433.304 ); see also 42 U.S.C.”
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