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New Mexico
Medicaid Fraud Control Unit of New Mexico
Description
The New Mexico Medicaid Fraud Control Unit is administratively housed in the Office of the Attorney General. The entire Unit is centrally located in Albuquerque, and serves the entire State of New Mexico. This Unit is required pursuant to Federal regulations and organized to accomplish its mission to investigate and prosecute Medicaid provider fraud and the abuse, neglect, and exploitation of Medicaid recipients or persons in long-term care Medicaid funded facilities. The Unit now has expanded jurisdiction to investigate fraud and abuse in board and care facilities as well as Medicare fraud when it is committed in conjunction with Medicaid fraud. The Unit primarily investigates criminal allegations, but also examines cases of civil fraud allegations.
From July 1, 2004 through June 30, 2005, the MFCU averaged 21 staff members: 4 lawyers, 3 auditors, 12 investigators (including 2 commissioned peace officers and 2 medical care investigators), and 2 administrative assistant.
Contact Information
Medicaid Fraud Control Unit of New Mexico
Office of the Attorney General
111 Lomas Blvd. N.W.
Suite 300
Albuquerque, NM 87102
| Phone: | (505) 222-9080 |
| Fax: | (505) 222-9008 |
Statutes
| TOPIC | OFFICIAL STATUTORY CITATION |
|---|---|
(1) PROVIDER ISSUES |
|
(a) Enrollment Procedures |
§ 30-44-4 NMSA (1978) § 30-44-7A (4)(G) NMSA (1978) |
(b) Criminal History Checks |
§ 29-17- 1 et seq. NMSA 1978) |
(c) Survey Bond Requirements |
None |
(d) Program Exclusions Sanctions |
None |
(e) Licensing Actions |
None |
(f) Contracts/Agreements |
None |
(g) Ownership Disclosure |
None |
(h) Managed Care Provider |
|
(1) Duty to refer fraud or abuse |
None |
(2) Requirement of in-house fraud investigative unit |
None |
(3) Anti-trust issues |
None |
(i) Suspension of Non-providers |
None |
(j) Transfer of Business Liability |
None |
(k) Bankruptcy |
None |
(2) REPORTING MEDICAID FRAUD |
|
(a) Incentive Awards for Providing Information Concerning Medicaid Fraud |
None |
(b) Whistle blower Protection |
None |
(c) Qui Tam Suits |
None |
(d) State Attorney General as Relator in Federal Suit |
None |
(e) Private party as Relator in State Qui-Tam Suit |
None |
(f) Hotline |
1-800-525-6519 |
(3) FRAUD ISSUES |
|
(a) Criminal Medicaid Fraud Statutes |
§ 30-44-1 et seq. NMSA (1978) |
(b) Criminal Medicaid Fraud Penalties |
§ 30-44-7 NMSA (1978) |
(1) Felonies |
§ 31-19-1 NMSA (1978) |
(2) Misdemeanors |
§ 31-19-1 NMSA (1978) |
(c) Civil Monetary Penalties |
§ 30-44-8A(2) and (3) NMSA (1978) |
(d) Civil False Claims |
§ 30-44-8 NMSA (1978) |
(e) Civil Remedies |
§ 30-44-8 NMSA (1978) |
(f) Interest to Identified Recoveries |
§ 30-44-8(A)(1) NMSA (1978) |
(g) Anti-kickback Bribery |
§ 30-44-7(A)(1) NMSA (1978) |
(h) Safe Harbors |
None |
(i) Self Referrals |
None |
(j) Managed Care Fraud |
§ 30-44-7A(2)(3) and (4) NMSA (1978) |
(k) Restitution |
§ 31-17-1 NMSA (1978) |
(l) Recovering Costs of Investigation |
§ 30-44-8C NMSA (1978) |
(m) Revolving Fund to Fund Investigation Efforts |
None |
(n) Compliance Programs |
None |
(o) Pre-payment Review Procedures |
None |
(p) Withholding Procedures |
None |
(q) Detection Systems |
None |
(r) Use of Private Collection Agencies |
None |
(s) Patient Abuse |
§ 30-47-1 et seq. NMSA (1978) |
(t) Venue |
§ 38-3-1 NMSA (1978) Civil § 30-1-14 NMSA (1978) Criminal |
(4) DOCUMENTATION & RECORD RETENTION |
|
(a) Precluding Provider from Claiming Any Privilege Held by Patient as a Basis for Refusing to Produce Records |
None |
(b) Criminalizes Failure to Maintain Patient Records |
§ 30-44-5 NMSA (1978) |
(c) Confidentiality of Records |
None |
(d) Administrative Subpoena Power |
None |
(5) REFERRALS FROM STATE AGENCY |
|
(a) Memorandum of Understanding Between State Agency & MFCU |
§ 30-44-7H NMSA (1978) |
(b) Referrals of other Agencies |
N/A |
(c) Procedures for Referring Cases to Local Prosecuting Authorities |
N/A |
(6) CONTRACTS WITH FISCAL AGENT TO ADMINISTER PROGRAM AND PROCESS CLAIMS |
None |
(7) LIENS ON STATE INCOME TAX REFUNDS TO PROVIDERS |
None |
(8) SPECIFIC STATUTE MAKING IT A CRIME TO USE A COMPUTER TO COMMIT A CRIME, I.E., ELECTRONIC CLAIMS SUBMISSION |
§ 30-45-1 et seq. NMSA (1978) |
(9) USE OF STATISTIC SAMPLING OR EXTRAPOLATION EVIDENCE TO PROVE AMOUNT OF FRAUD. REBUTTABLE PRESUMPTION THAT SAMPLING IS CORRECT AMOUNT OF EXCESS PAYMENTS |
None |
(10) INCREASED FINES FOR CORPORATE DEFENDANT |
§ 30-44-7G NMSA (1978) |
(11) PRESCRIPTION BLANK LEGISLATION |
N/A |
(12) REINSTATEMENT OF PROVIDER UNTIL ALL MONIES OWED TO MEDICAID & HAVE BEEN REPAID, OR OTHER CONDITIONS MET |
None |
(13) RECIPIENT ISSUES |
|
(a) Fraud |
§ 30-40-1 et seq. NMSA (1978) |
(b) Lock-in |
None |
(c) Termination of Benefits |
None |
(d) Restitution |
§ 31-17-1 NMSA (1978) |
(14) ELIGIBILITY COMPARISON WITH PRIVATE INSURERS |
None |
(15) ESTATE RECOVERY |
§ 27-2A-1 et seq. NMSA (1978) |
(16) DIVESTMENT |
N/A |
(17) SUSPENSION OF DRIVER’S LICENSE (OR OTHER LICENSES) FOR FAILURE TO RE-PAY OVERPAYMENTS |
N/A |
(18) ATTORNEY FEE LIMITATIONS/PROHIBITIONS |
None |
(19) CONFIDENTIALITY OF INVESTIGATIONS |
None |
(20) THIRD PARTY LIABILITY |
§ 27-2-23 NMSA (1978) |
(21) THIRD PARTY FORFEITURE |
N/A |
(22) SERVICE RELATED ISSUES |
|
(a) Over utilization |
§ 30-44-1 et seq. NMSA (1978) |
(b) Sub-Standard Quality |
§ 30-44-1 et seq. NMSA (1978) |
(c) Unnecessary Services |
§ 30-44-1 et seq. NMSA (1978) |
(d) Diversion of Prescription Medications |
§ 30-44-1 et seq. NMSA (1978) |