MN ADC 9505.2200

Identifying Fraud, Theft, Abuse, or Error

The Department of Human Services must investigate vendors of medical services or beneficiaries of medical assistance to monitor compliance and to identify allegations of fraud, theft, abuse or error.  The Department may contact any person, agency or organization in its investigation, including governmental agencies, third party payors, recipients, vendors of medical care, professional organizations, and members of the public.  The responsibility to investigate also gives the Department the power to examine health and financial records, prescriptions, verification of a professional’s credentials, and consultation with peer review mechanisms.  Once the investigation is completed, the Department must determine whether:

1. The vendor is in compliance with the program and payments have been properly made;
2. Insufficient evidence exists as to whether theft, fraud, abuse or error occurred;

The evidence of theft, fraud or abuse supports civil or criminal action.