30:4D-57 Functions, duties, powers, responsibilities of Medicaid Inspector General.

5. a. The Medicaid Inspector General shall have the following general functions, duties, powers, and responsibilities:

(1) To appoint such deputies, directors, assistants, and other officers and employees as may be needed for the office to meet its responsibilities, and to prescribe their duties and fix their compensation in accordance with State law and within the amounts appropriated therefor;

(2) To conduct and supervise all State government activities, except those of the Medicaid Fraud Control Unit in the Department of Law and Public Safety, relating to Medicaid integrity, fraud, and abuse;

(3) To call upon any department, office, division, or agency of State government to provide such information, resources, or other assistance as the Medicaid Inspector General deems necessary to discharge the duties and functions and to fulfill the responsibilities of the Medicaid Inspector General under this act. Each department, office, division, and agency of this State shall cooperate with the Medicaid Inspector General and furnish the office with the assistance necessary to accomplish the purposes of this act;

(4) To coordinate activities to prevent, detect, and investigate Medicaid fraud and abuse among the following: the Departments of Human Services, Health, Education, and Treasury; the Office of the Attorney General; and the special investigative unit maintained by each health insurer providing a Medicaid managed care plan within the State;

(5) To apply for and receive federal grants and monies with all necessary assistance as the Medicaid Inspector General shall require from the department;

(6) To enter into any applicable federal pilot programs and demonstration projects and coordinate with the department in order for the department to apply as requested by the Medicaid Inspector General, for necessary federal waivers;

(7) To recommend and implement policies relating to Medicaid integrity, fraud, and abuse, and monitor the implementation of any recommendations made by the office to other agencies or entities responsible for the administration of Medicaid;

(8) To perform any other functions that are necessary or appropriate in furtherance of the mission of the office; and

(9) To direct all public or private Medicaid service providers or recipients to cooperate with the office and provide such information or assistance as shall be reasonably required by the office.

b. As it relates to ensuring compliance with applicable Medicaid standards and requirements, identifying and reducing fraud and abuse, and improving the efficiency and effectiveness of Medicaid, the functions, duties, powers, and responsibilities of the Medicaid Inspector General shall include, but not be limited to, the following:

(1) To establish, in consultation with the department and the Attorney General, guidelines under which the withholding of payments or exclusion from Medicaid may be imposed on a provider or shall automatically be imposed on a provider;

(2) To review the utilization of Medicaid services to ensure that Medicaid funds, regardless of which agency administers the service, are appropriately spent to improve the health of Medicaid recipients;

(3) To review and audit contracts, cost reports, claims, bills, and all other expenditures of Medicaid funds to determine compliance with applicable laws, regulations, guidelines, and standards, and enhance program integrity;

(4) To consult with the department to optimize the Medicaid management information system in furtherance of the mission of the office. The department shall consult with the Medicaid Inspector General on matters that concern the operation, upgrade and implementation of the Medicaid management information system;

(5) To coordinate the implementation of information technology relating to Medicaid integrity, fraud, and abuse; and

(6) To conduct educational programs for Medicaid providers, vendors, contractors, and recipients designed to limit Medicaid fraud and abuse.

c. As it relates to investigating allegations of Medicaid fraud and abuse and enforcing applicable laws, rules, regulations, and standards, the functions, duties, powers, and responsibilities of the Medicaid Inspector General shall include, but not be limited to, the following:

(1) To conduct investigations concerning any acts of misconduct within Medicaid;

(2) To refer information and evidence to regulatory agencies and professional and occupational licensing boards;

(3) To coordinate the investigations of the office with the Attorney General, the State Inspector General, law enforcement authorities, and any prosecutor of competent jurisdiction, and endeavor to develop these investigations in a manner that expedites and facilitates criminal prosecutions and the recovery of improperly expended Medicaid funds, including:

(a) keeping detailed records for cases processed by the State Inspector General and the Attorney General and county prosecutors. The records shall include: information on the total number of cases processed and, for each case, the agency and division to which the case is referred for investigation; the date on which the case is referred; and the nature of the suspected fraud, waste, or abuse; and

(b) receiving notice from the Attorney General of each case that the Attorney General declines to prosecute or prosecutes unsuccessfully;

(4) To make information and evidence relating to suspected criminal acts which the Medicaid Inspector General may obtain in carrying out his duties available to the Medicaid Fraud Control Unit pursuant to the requirements of federal law, as well as to other law enforcement officials when appropriate, and consult with the Attorney General and county prosecutors in order to coordinate criminal investigations and prosecutions;

(5) To refer complaints alleging criminal conduct to the Attorney General or other appropriate prosecutorial authority. If the Attorney General or other appropriate prosecutorial authority decides not to investigate or prosecute the matter, the Attorney General or other appropriate prosecutorial authority shall promptly notify the Medicaid Inspector General. The Attorney General or the prosecutorial authority shall inform the Medicaid Inspector General as to whether an investigation is ongoing with regard to any matter so referred. The Medicaid Inspector General shall preserve the confidentiality of the existence of any ongoing criminal investigation.

(a) If the Attorney General or the prosecutorial authority decides not to investigate or act upon the matter referred, the Inspector General is authorized to continue an investigation after the receipt of such a notice.

(b) Upon the completion of an investigation or, in a case in which the investigation leads to prosecution, upon completion of the prosecution, the Attorney General or the prosecutorial authority shall report promptly the findings and results to the Medicaid Inspector General. In the course of informing the Medicaid Inspector General, the Attorney General or prosecutorial authority shall give full consideration to the authority, duties, functions, and responsibilities of the Medicaid Inspector General, the public interest in disclosure, and the need for protecting the confidentiality of complainants and informants.

(c) The Medicaid Inspector General shall maintain a record of all matters referred and the responses received and shall be authorized to disclose information received as appropriate and as may be necessary to resolve the matter referred, to the extent consistent with the public interest in disclosure and the need for protecting the confidentiality of complainants and informants and preserving the confidentiality of ongoing criminal investigations.

(d) Notwithstanding any referral made pursuant to this subsection, the Medicaid Inspector General may pursue any administrative or civil remedy under the law;

(6) In furtherance of an investigation, to compel at a specific time and place, by subpoena, the appearance and sworn testimony of any person whom the Medicaid Inspector General reasonably believes may be able to give information relating to a matter under investigation;

(a) For this purpose, the Medicaid Inspector General is empowered to administer oaths and examine witnesses under oath, and compel any person to produce at a specific time and place, by subpoena, any documents, books, records, papers, objects, or other evidence that the Medicaid Inspector General reasonably believes may relate to a matter under investigation.

(b) If any person to whom a subpoena is issued fails to appear or, having appeared, refuses to give testimony, or fails to produce the books, papers, or other documents required, the Medicaid Inspector General may apply to the Superior Court and the court may order the person to appear and give testimony or produce the books, papers, or other documents, as applicable. Any person failing to obey that order may be punished by the court as for contempt;

(7) Subject to applicable State and federal law, to have full and unrestricted access to all records, reports, audits, reviews, documents, papers, data, recommendations, or other material available to State and local departments of health and human services, other State and local government agencies, and Medicaid service providers relating to programs and operations with respect to which the office has responsibilities under this act;

(8) To solicit, receive, and investigate complaints related to Medicaid integrity, fraud, and abuse;

(9) To prepare cases, provide expert testimony, and support administrative hearings and other legal proceedings; and

(10) Upon reasonable belief of the commission of a fraudulent or abusive act, to conduct on-site facility inspections.

d. As it relates to recovering improperly expended Medicaid funds, imposing administrative sanctions, damages or penalties, negotiating settlements, and developing an effective third-party liability program to assure that all private or other governmental medical resources have been exhausted before a claim is paid by Medicaid or that reimbursement is sought when there is discovered a liable third party after payment of a claim, the functions, duties, powers, and responsibilities of the Medicaid Inspector General shall include, but not be limited to, the following:

(1) On behalf of the department, to collect all overpayments for reimbursable services that are self-disclosed by providers pursuant to current law;

(2) To pursue civil and administrative enforcement actions against those who engage in fraud, abuse, or illegal acts perpetrated within Medicaid, including providers, contractors, agents, recipients, individuals, or other entities involved directly or indirectly with the provision of Medicaid care, services, and supplies. These civil and administrative enforcement actions shall include the imposition of administrative sanctions, penalties, suspension of fraudulent, abusive, or illegal payments, and actions for civil recovery and seizure of property or other assets connected with such payments;

(3) To initiate civil suits consistent with the provisions of this act, maintain actions for civil recovery on behalf of the State, and enter into civil settlements;

(4) To withhold payments to any provider for Medicaid services if the provider unreasonably fails to produce complete and accurate records related to an investigation that is initiated by the office with reasonable cause;

(5) To ensure that Medicaid is the payor of last resort, and to provide for the coordination of benefits with each health insurer operating in the State and the recoupment of any duplicate reimbursement paid by the State. Every such health insurer shall be required to provide such information and reports as may be deemed necessary by the Medicaid Inspector General for the coordination of benefits and shall maintain files in a manner and format approved by the department; and

(6) To monitor and pursue the recoupment of Medicaid overpayments, damages, penalties, and sanctions.

L.2007, c.58, s.5; amended 2012, c.17, s.393.