§ 1007.1 - Definitions.

§ 1007.1 Definitions.

As used in this part, unless otherwise indicated by the context:

Data mining is defined as

Abuse of patients or residents means any act that constitutes abuse of a patient or resident of a health care facility or board and care facility under applicable State law. Such conduct may include the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or financial harm, pain, or mental anguish.

Board and care facility means a residential setting that receives payment (regardless of whether such payment is made under Title XIX of the Social Security Act) from or on behalf of two or more unrelated adults who reside in such facility, and for whom one or both of the following is provided:

(1) Nursing care services provided by, or under the supervision of, a registered nurse, licensed practical nurse, or licensed nursing assistant.

(2) A substantial amount of personal care services that assist residents with the activities of daily living, including personal hygiene, dressing, bathing, eating, toileting, ambulation, transfer, positioning, self-medication, body care, travel to medical services, essential shopping, meal preparation, laundry, and housework.

Data mining means the practice of electronically sorting Medicaid or other relevant data, including, but not limited to, the use of statistical models and intelligent technologies, to uncover patterns and relationships within that data to identify aberrant utilization, billing, or other practices that are potentially fraudulent.

Employ or employee, as the context requires, means full-time duty intended to last at least a year. It includes an arrangement whereby an individual is on full-time detail or assignment to the unit

Director means a professional employee of the Unit who supervises all Unit employees, either directly or through other Unit managers.

Exclusive effort means that a Unit's professional employees, except as otherwise permitted in § 1007.13, dedicate their efforts “exclusively” to the functions and responsibilities of a Unit as described in this part. Exclusive effort requires that duty with the Unit be intended to last for at least one

(1) year and includes an arrangement in which an employee is on detail or assignment from another government agency, but only if the detail or

assignment

arrangement is intended to last for

a period of

at least one (1) year

and involves supervision by the unit. Provider means an individual or entity that furnishes

.

Fraud means any act that constitutes criminal or civil fraud under applicable State law. Such conduct may include deception, concealment of material fact, or misrepresentation made intentionally, in deliberate ignorance of the truth, or in reckless disregard of the truth.

Full-time employee means an employee of the Unit who has full-time status as defined by the State.

Health care facility means a provider that receives payments under Medicaid and furnishes food, shelter, and some treatment or services to four or more persons unrelated to the proprietor in an inpatient setting.

Misappropriation of patient or resident funds means the wrongful taking or use, as defined under applicable State law, of funds or property of a patient or resident of a health care facility or board and care facility.

Neglect of patients or residents means any act that constitutes neglect of a patient or resident of a health care facility or board and care facility under applicable State law. Such conduct may include the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Part-time employee means an employee of the Unit who has part-time status as defined by the State.

Professional employee means an investigator, attorney, or auditor.

Program abuse means provider practices that do not meet the definition of civil or criminal fraud under applicable State law, but nonetheless are inconsistent with sound fiscal, business, or medical practices.

Provider means:

(1) An individual or entity that furnishes or arranges for the furnishing of items or services for which payment is claimed under Medicaid, including an individual or entity in a managed care network;

(2) An individual or entity that is required to enroll in a State Medicaid program, such as an ordering, prescribing, or referring physician; or

(3) Any individual or entity that may operate as a health care provider under applicable State law.

Unit means the State Medicaid fraud control unit.

[57 FR 3355, Jan. 29, 1992, as amended at 78 FR 29061, May 17, 2013]

Fraud Control Unit.