South carolina department of health and human services medicaid policy and procedures manual

101.15.02 Beneficiary Lock-In Program Procedures (Eff. 11/01/08)

The Department of Recipient Utilization will develop beneficiaries’ profiles and review monthly for patterns of inappropriate, excessive, or duplicative use of pharmacy services. Initial criteria for Lock-In will include beneficiaries who:

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  Use 4 or more pharmacies in a six month period, and
  
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  Use 5 or more prescribers in a six month period, and
  
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  Have a prescription for Schedule II drugs, with a quantity of more than 900.
  

Program Integrity can revise these criteria as needed. Lock-In candidates will also be considered from complaints received on the Fraud Hotline and from referrals.

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  Send via Certified Mail the initial letter informing the beneficiary that they will be placed in the Medicaid Lock-In Program, and giving them the opportunity to choose a pharmacy from which they will receive all their Medicaid prescriptions.
  
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  The letter will include a mail-in form and addressed envelope the beneficiary can use to inform SCDHHS of the pharmacy selected.
  
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  SCDHHS will review the beneficiary’s choice of a pharmacy and once this is approved, will inform the beneficiary by a second Certified mail letter that they are now locked-in to the pharmacy they have selected, and that they must go to that pharmacy to receive all pharmacy services.
  
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  SCDHHS will concurrently send a letter to the pharmacy selected to inform them of the beneficiary lock-in.
  
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  If the beneficiary does not select a pharmacy within 14 days of the date of the letter, SCDHHS will select a pharmacy from the list of pharmacies previously used by the beneficiary. Both the pharmacy selected and the beneficiary will be informed of the choice.
  
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  Division of Hearings and Appeals will be contacted before the beneficiary is locked in to insure he/she has not filed an appeal.
  
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  SCDHHS will concurrently inform First Health of the beneficiaries locked-in and the selected pharmacies.
  

101.16 Fraud (Eff. 10/01/05)

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/her or some other person. It includes any act that constitutes fraud under applicable federal or state law.

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  A person to knowingly and willfully make, or cause to be made, a false statement or representation of material fact on an application for assistance, goods or services under the state's Medicaid program when the false statement or representation is made for the purpose of determining the person's eligibility for Medicaid.
  
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  Any applicant, beneficiary or other person acting on his behalf to knowingly and willfully conceal or fail to disclose any material fact affecting the initial or continued eligibility of the applicant/beneficiary for Medicaid.
  
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  A person eligible to receive benefits, services or goods under the state's Medicaid program to sell, lease, lend or otherwise exchange rights, privileges or benefits to another person.
  

101.16.01 Fraud Penalties (Rev. 11/01/08)

A person who violates the provisions of Section 43-7-70 of the S.C. Code of Laws is guilty of medical assistance fraud which is a Class A misdemeanor. Upon conviction, the person must be imprisoned not more than three (3) years or fined not more than $1,000 or both. Section 43-7-70 does not prohibit the prosecution of a person for conduct that constitutes a crime under another statute or at common law.

101.16.02 Referral of Suspected Fraud Cases (Rev. 10/01/10)

Cases of suspected fraud will be investigated by DHHS in coordination with the Attorney General's Office. A Medicaid eligibility worker who suspects that fraud has been committed must discuss the case with his/her supervisor and refer the case for investigation by forwarding a fraud summary to:

Division of Program Integrity

Post Office Box 8206

1801 Main Street

Columbia, South Carolina 29202-8206

Table of Contents

101.16.03 Fraud Summary (Rev. 10/01/10)

The fraud summary must include the following information:

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  Identifying Information
  

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  Name and address of beneficiary;
  
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  Type of benefits received or requested;
  
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  County, case number and Medicaid number; and
  
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  Name of worker making the report.
  

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  Summary of the Situation
  

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  Date of certification;
  
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  Date of review prior to date that alleged fraud was discovered;
  
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  A brief statement concerning the beneficiary's circumstances as reported at the last review;
  
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  The date alleged fraud was discovered and a statement of the facts supporting the fraud allegation; and
  
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  The period of ineligibility.
  

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  Verification
  

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  Names and location of records used;
  
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  Names and addresses of persons providing information;
  
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  Names of other sources used to substantiate the information; and
  
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  A copy of the application form and last review form, when applicable.
  

The fraud summary must be signed by the Medicaid eligibility worker’s supervisor, indicating that the supervisor has reviewed the case record and fraud summary and have determined that, to the best of his/her knowledge, it contains all of the relevant information. DHHS Division of Program Integrity will contact the Medicaid eligibility worker should additional information about the facts of the case be required.