C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 455—PROGRAM INTEGRITY: MEDICAID › Subpart A—Medicaid Agency Fraud Detection and Investigation Program

42 C.F.R. § 455.15

Full investigation

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If the findings of a preliminary investigation give the agency reason to believe that an incident of fraud or abuse has occurred in the Medicaid program, the agency must take the following action, as appropriate:

(a) If a provider is suspected of fraud or abuse, the agency must—

(1) In States with a State Medicaid fraud control unit certified under subpart C of part 1002 of this title, refer the case to the unit under the terms of its agreement with the unit entered into under § 1002.309 of this title; or

(2) In States with no certified Medicaid fraud control unit, or in cases where no referral to the State Medicaid fraud control unit is required under paragraph (a)(1) of this section, conduct a full investigation or refer the case to the appropriate law enforcement agency.

(b) If there is reason to believe that a beneficiary has defrauded the Medicaid program, the agency must refer the case to an appropriate law enforcement agency.

(c) If there is reason to believe that a beneficiary has abused the Medicaid program, the agency must conduct a full investigation of the abuse.

[48 FR 3756, Jan. 27, 1983, as amended at 51 FR 34788, Sept. 30, 1986]
Notes of Decisions
Cited in 2 cases (1 in the last 5 years), 2019–2023 · leading case: State v. Chalice Renee Zeitner
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State v. Chalice Renee Zeitner (2019) ariz “14 , and must refer suspected provider or beneficiary fraud to the state's fraud control unit or "appropriate law enforcement agency," respectively, 42 C.F.R. § 455.15 . A state's fraud control unit must have "[a]ccess to .”
Mark J. Den Hartog v. Iowa Department of Human Services (2023) iowactapp “42 C.F.R. § 455.15 (2015). That investigation “must continue” until any number of conclusions are reached, those conclusions include a resolution between the department and provider wherein the department terminates the provider’s participation in Medicaid or seeks recovery of…”
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