(1)An overpayment is any payment made by the Department or case management entity to an independent provider that is more than the independent provider is permitted to receive under DHS rules. An independent provider may only receive payment for a number of hours that are actually provided and do not exceed the amount stated in a Service Agreement.
(2)Overpayments are categorized as follows:
(a)ADMINISTRATIVE ERROR. The case management entity failed to authorize, compute, or process the correct amount of service hours or wage rate.
(b)INDEPENDENT PROVIDER ERROR. The Department overpays the independent provider due to a misunderstanding or unintentional error.
(c)FRAUD. “Fraud” means taking actions that may result in the independent provider receiving a benefit in excess of the correct amount whether by intentional deception, misrepresentation, or failure to account for payments or money received. “Fraud” also means spending payments or money the independent provider was not entitled to and any act that constitutes fraud under applicable federal or state law (including 42 CFR 455.2). The Department of Justice, Medicaid Fraud Unit determines when a Medicaid fraud allegation is pursued for prosecution.
(3)The Department may recover an overpayment established by a judgment in a state or federal court, by the Department or another administrative agency in a contested case proceeding, or by a signed document in which the person acknowledges the overpayment and waives the right to a contested case hearing.
(4)Overpayments for personal support workers are recovered as follows:
(a)Overpayments are collected prior to garnishments, such as child support, Internal Revenue Service back taxes, or educational loans.
(b)Overpayments due to administrative error or personal support worker error are recouped at no more than five percent of the total for the hours paid until repaid in full.
(c)When a fraud overpayment has occurred, the Department shall determine the manner and the amount to be recovered.
(d)When a provider is no longer employed as a personal support worker, any remaining overpayment is deducted from the final check to the provider. The provider is responsible for repaying the amount in full when the final check is insufficient to cover the remaining overpayment.
(5)Overpayments for independent providers who are not personal support workers are recovered as described in OAR chapter 407, division 120.
Rule 411-375-0045 — Overpayments,