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. § 455.16

Resolution of full investigation

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A full investigation must continue until—

(a) Appropriate legal action is initiated;

(b) The case is closed or dropped because of insufficient evidence to support the allegations of fraud or abuse; or

(c) The matter is resolved between the agency and the provider or beneficiary. This resolution may include but is not limited to—

(1) Sending a warning letter to the provider or beneficiary, giving notice that continuation of the activity in question will result in further action;

(2) Suspending or terminating the provider from participation in the Medicaid program;

(3) Seeking recovery of payments made to the provider; or

(4) Imposing other sanctions provided under the State plan.

[43 FR 45262, Sept. 29, 1978, as amended at 48 FR 3756, Jan. 27, 1983]
Notes of Decisions
Cited in 2 cases (1 in the last 5 years), 2004–2023 · leading case: Westmed Rehab, Inc. v. Dep't of Soc. Servs., 2004 SD 104 (S.D. 2004).
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Westmed Rehab, Inc. v. Dep't of Soc. Servs., 2004 SD 104 (S.D. 2004). · cites it 2× “42 C.F.R. § 455.16 . DSS overstates its case.”
Carr v. Becerra (D. Conn. 2023). “A beneficiary is not validly enrolled if (1) the determination of eligibility was incorrect at the time it was made due to agency error or (2) eligibility was erroneously granted due to beneficiary fraud for which the beneficiary has been convicted or beneficiary abuse as…”
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