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Federal and State Program Integrity in Connecticut

Federal and State Program Integrity

Connecticut safeguards the integrity of federal and state programs by:

  • Imposing liability on individuals that submit false claims for payment from the medical assistance program or otherwise attempt to defraud the program.1
  • Imposing liability on individuals that make false statements on documents that licensed health care institutions must furnish to the Department of Public Health or maintain on file.2
  • Prohibiting Medicare and Medicaid vendors from participating in the programs if they have been convicted of a Medicare or Medicaid fraud3 and terminating vendor participation if they “willfully refuse” to refund an individual that pays for covered services before their eligibility was determined.4
  • Suspending payments to hospitals that submit false cost data and imposing liability on individuals that “knowingly” submit false data. 5
  • Imposing liability on health care providers that fail to comply with claims and record requirements while participating in certain federal demonstration projects.6
  • Fining health care providers that overcharge for Medicare covered services or equipment.7
  • Investigating pharmacies that submit a high number of improper payment claims8 or improperly bill brand name drugs. 9
  • Establishing “a state-wide fraud early detection system” that can identify fraudulent applications for state programs, including Medicaid, before granting assistance.10

 

Footnotes

  • 1. C.G.S.A. § 17b-301b.
  • 2. C.G.S.A. § 19a-500.
  • 3. C.G.S.A. § 17b-99.
  • 4. C.G.S.A. § 17b-103.
  • 5. C.G.S.A. § 17b-238.
  • 6. C.G.S.A. § 17b-343a.
  • 7. C.G.S.A. § 17b-552.
  • 8. C.G.S.A. § 17b-265f.
  • 9. C.G.S.A. § 17b-274.
  • 10. C.G.S.A. § 17b-7a.

 

Federal and State Program Integrity in Connecticut

Subtopic Statute/Regulation Description
Federal and State Program Integrity Billing for clinical laboratory services. Cost of diagnostic tests. Financial disclosures to patients. Billing practices re anatomic pathology services - Conn. Gen. Stat. § 20-7a Any provider who agrees to make payments to clinical laboratories for individual patient tests must disclose this fact on patient bills or bills to...
Limitation of charges. Civil penalty. Regulations - Conn. Gen. Stat. § 17b-552 Health care providers may not charge Medicare beneficiaries for Medicare covered services or equipment in excess of the amount determined by the...
Payment by the department for pharmacy claims. Limitations. Investigation of pharmacy - Conn. Gen. Stat. § 17b-265f Pharmacies may only claim payment for prescriptions dispensed to individuals that have prescription insurance if the prescription coverage is...
Payment of claims for home health services provided under Medicare and Medicaid. Liability. Sanctions - Conn. Gen. Stat. § 17b-343a Home health service providers participating in a 42 U.S.C. § 1395b-1 demonstration project that fail to file claims or medical records in...
Penalty for material false statement - Conn. Gen. Stat. § 19a-500 Connecticut imposes liability on persons that make material false statements in documents that licensed health care institutions must furnish to the...
Periodic investigations of pharmacies by Division of Criminal Justice. Brand medically necessary. Procedure for prior approval to dispense brand name drug. Disclosure - Conn. Gen. Stat. § 17b-274 The Division of Criminal Justice must conduct periodic pharmacy investigations to assess whether pharmacies are improperly billing Connecticut’...
Prohibited acts re medical assistance. Penalties - Conn. Gen. Stat. § 17b-301b Connecticut prohibits persons from (1) knowingly making a false or fraudulent claim for medical assistance program payment or approval; (2) knowingly...
Refunds by vendors to persons eligible for medical assistance. Penalty - Conn. Gen. Stat. § 17b-103 Vendors must refund an individual for Medicaid covered services if the individual pays for the service before their eligibility for Medicaid is...
State payments to hospitals - Conn. Gen. Stat. § 17b-238 Hospitals that receive state assistance must submit annual cost data to the Commissioner of Social Services. The Commissioner may suspend payments to...
State-wide fraud early detection system. Regulations. Quarterly reports - Conn. Gen. Stat. § 17b-7a The Commissioner of Social Services must establish “a state-wide fraud early detection system” that can identify fraudulent applications...
Vendor fraud penalties. Distribution of medical assistance program rules. Regulations. Audits of service providers. Appeal - Conn. Gen. Stat. § 17b-99 Vendors that are guilty of “vendor fraud” pursuant to Connecticut’s Criminal Code face suspension or revocation of their license or...