LOUISIANA STATUTE LA RS 14.70.1 MEDICAID FRAUD

 

Louisiana Statute on Medicaid Fraud

§70.1.  Medicaid fraud

A.  The crime of Medicaid fraud is the act of any person, who, with intent to defraud the state through any medical assistance program created under the federal Social Security Act and administered by the Department of Health and Hospitals:

(1)  Presents for allowance or payment any false or fraudulent claim for furnishing services or merchandise; or

(2)  Knowingly submits false information for the purpose of obtaining greater compensation than that to which he is legally entitled for furnishing services or merchandise; or

(3)  Knowingly submits false information for the purpose of obtaining authorization for furnishing services or merchandise.

B.  Whoever commits the crime of Medicaid fraud shall be imprisoned, with or without hard labor, for not more than five years, or may be fined not more than twenty thousand dollars, or both.

Acts 1989, No. 300, §1, eff. July 1, 1989; Acts 1997, No. 1018, §1; Acts 2001, No. 403, §1, eff. June 15, 2001.

CONNECTICUT GENERAL STATUTES COVERING MEDICAID FRAUD

Connecticut does not seem to have specific  laws dedicated to Medicaid fraud.  Instead, it relies on the general laws regarding larceny and vendor fraud.

Note:  Connecticut General Statutes 53a-122 to 124 – Defines three larceny classes.

2013 Connecticut General Statutes
Title 53a – Penal Code
Chapter 952 – Penal Code: Offenses
Section 53a-290 – “Vendor fraud” defined.

 

Universal Citation: CT Gen Stat § 53a-290 (2013)

A person commits vendor fraud when, with intent to defraud and acting on such person’s own behalf or on behalf of an entity, such person provides goods or services to a beneficiary under sections 17b-22, 17b-75 to 17b-77, inclusive, 17b-79 to 17b-103, inclusive, 17b-180a, 17b-183, 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, 17b-357 to 17b-361, inclusive, 17b-600 to 17b-604, inclusive, 17b-749, 17b-807 and 17b-808 or provides services to a recipient under Title XIX of the Social Security Act, as amended, and, (1) presents for payment any false claim for goods or services performed; (2) accepts payment for goods or services performed, which exceeds either the amounts due for goods or services performed, or the amounts authorized by law for the cost of such goods or services; (3) solicits to perform services for or sell goods to any such beneficiary, knowing that such beneficiary is not in need of such goods or services; (4) sells goods to or performs services for any such beneficiary without prior authorization by the Department of Social Services, when prior authorization is required by said department for the buying of such goods or the performance of any service; or (5) accepts from any person or source other than the state an additional compensation in excess of the amount authorized by law.

See also:

Section 53a-290 – “Vendor fraud” defined.

Section 53a-291 – Vendor fraud in the first degree: Class B felony.

Section 53a-292 – Vendor fraud in the second degree: Class C felony.

Section 53a-293 – Vendor fraud in the third degree: Class D felony.

Section 53a-294 – Vendor fraud in the fourth degree: Class A misdemeanor.

Section 53a-295 – Vendor fraud in the fifth degree: Class B misdemeanor.

Section 53a-296 – Vendor fraud in the sixth degree: Class C misdemeanor.

CALIFORNIA WELFARE AND INSTITUTIONS CODE SECTION 14107 MEDICAID (MEDI-CAL) FRAUD

California Welfare and Institutions Code Section 14107

14107.  (a) Any person, including any applicant or provider as
defined in Section 14043.1, or billing agent, as defined in Section
14040.1, who engages in any of the activities identified in
subdivision (b) is punishable by imprisonment as set forth in
subdivisions (c) , (d), and (e), by a fine not exceeding three times
the amount of the fraud or improper reimbursement or value of the
scheme or artifice, or by both this fine and imprisonment.
(b) The following activities are subject to subdivision (a):
(1) A person, with intent to defraud, presents for allowance or
payment any false or fraudulent claim for furnishing services or
merchandise under this chapter or Chapter 8 (commencing with Section 14200).
(2) A person knowingly submits false information for the purpose
of obtaining greater compensation than that to which he or she is
legally entitled for furnishing services or merchandise under this
chapter or Chapter 8 (commencing with Section 14200).
(3) A person knowingly submits false information for the purpose
of obtaining authorization for furnishing services or merchandise
under this chapter or Chapter 8 (commencing with Section 14200).
(4) A person knowingly and willfully executes, or attempts to
execute, a scheme or artifice to do either of the following:
(A) Defraud the Medi-Cal program or any other health care program administered by the department or its agents or contractors.
(B) Obtain, by means of false or fraudulent pretenses,
representations, or promises, any of the money or property owned by, or under the custody or control of, the Medi-Cal program or any other health care program administered by the department or its agents or contractors, in connection with the delivery of or payment for health care benefits, services, goods, supplies, or merchandise.
(c) A violation of subdivision (a) is punishable by imprisonment
in a county jail, or in the state prison for two, three, or five
years.
(d) If the execution of a scheme or artifice to defraud as defined
in paragraph (4) of subdivision (b) is committed under circumstances
likely to cause or that do cause two or more persons great bodily
injury, as defined in Section 12022.7 of the Penal Code, or serious
bodily injury, as defined in paragraph (4) of subdivision (f) of
Section 243 of the Penal Code, a term of four years, in addition and
consecutive to the term of imprisonment imposed in subdivision (c),
shall be imposed for each person who suffers great bodily injury or
serious bodily injury.   The additional terms provided in this subdivision shall not be imposed unless the facts showing the circumstances that were likely to cause or that did cause great bodily injury or serious bodily injury to two or more persons are charged in the accusatory pleading and admitted or found to be true by the trier of fact.
(e) If the execution of a scheme or artifice to defraud, as
defined in paragraph (4) of subdivision (b) results in a death which
constitutes a second degree murder, as defined in Section 189 of the
Penal Code, the offense shall be punishable, upon conviction,
pursuant to subdivision (a) of Section 190 of the Penal Code.
(f) Any person, including an applicant or provider as defined in
Section 14043.1, or billing agent, as defined in Section 14040.1, who
has engaged in any of the activities subject to fine or imprisonment
under this section, shall be subject to the asset forfeiture
provisions for criminal profiteering.
(g) Pursuant to Section 923 of the Penal Code, the Attorney
General may convene a grand jury to investigate and indict for any of
the activities subject to fine, imprisonment, or asset forfeiture
under this section.
(h) The enforcement remedies provided under this section are not
exclusive and shall not preclude the use of any other criminal or
civil remedy. However, an act or omission punishable in different
ways by this section and other provisions of law shall not be
punished under more than one provision, but the penalty to be imposed shall be determined as set forth in Section 654 of the Penal Code.

ARIZONA STATUTE ARS 36-2918 MEDICAID FRAUD

36-2918. Prohibited acts; penalties; subpoena power

A. A person may not present or cause to be presented to this state or to a contractor:
1. A claim for a medical or other item or service that the person knows or has reason to know was not provided as claimed.
2. A claim for a medical or other item or service that the person knows or has reason to know is false or fraudulent.
3. A claim for payment that the person knows or has reason to know may not be made by the system because:
(a) The person was terminated or suspended from participation in the program on the date for which the claim is being made.
(b) The item or service claimed is substantially in excess of the needs of the individual or of a quality that fails to meet professionally recognized standards of health care.
(c) The patient was not a member on the date for which the claim is being made.
4. A claim for a physician’s service or an item or service incidental to a physician’s service, by a person who knows or has reason to know that the individual who furnished or supervised the furnishing of the service:
(a) Was not licensed as a physician.
(b) Obtained the license through a misrepresentation of material fact.
(c) Represented to the patient at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board if the individual was not certified.
5. A request for payment that the person knows or has reason to know is in violation of an agreement between the person and this state or the administration.

B. A person who violates a provision of subsection A of this section is subject, in addition to any other penalties that may be prescribed by federal or state law, to a civil penalty of not to exceed two thousand dollars for each item or service claimed and is subject to an assessment of not to exceed twice the amount claimed for each item or service.

C. The director or the director’s designee shall make the determination to assess civil penalties and is responsible for the collection of penalty and assessment amounts. The director shall adopt rules that prescribe procedures for the determination and collection of civil penalties and assessments. Civil penalties and assessments imposed under this section may be compromised by the director or the director’s designee in accordance with criteria established in rules. The director or director’s designee may make this determination in the same proceeding to exclude the person from system participation.

D. A person who is adversely affected by a determination of the director or the director’s designee under this section may appeal that decision in accordance with provider grievance provisions set forth in rule. The final decision is subject to judicial review in accordance with title 12, chapter 7, article 6.

E. Amounts recovered under this section shall be deposited in the state general fund. The amount of such penalty or assessment may be deducted from any amount then or later owing by the administration or this state to the person against whom the penalty or assessment has been imposed.

F. If a civil penalty or assessment imposed pursuant to subsection C of this section is not paid, this state or the administration shall file an action to collect the civil penalty or assessment in the superior court in Maricopa county. Matters that were raised or could have been raised in a hearing before the director or in an appeal pursuant to title 12, chapter 7, article 6 may not be raised as a defense to the civil action. An action brought pursuant to this subsection shall be initiated within six years after the date the claim was presented, except that the time to file a collection action is tolled either:
1. After any administrative action arising out of or referencing the wrongful acts is commenced and until the action’s final resolution, including any legal challenges to the action.
2. While the state and the administration did not know, and with the exercise of reasonable diligence, should not have known, that a claim was false, fraudulent or not provided as claimed.

G. Pursuant to an investigation of prohibited acts or fraud and abuse involving the system, the director, and any person designated by the director in writing, may examine any person under oath and issue a subpoena to any person to compel the attendance of a witness. The administration by subpoena may compel the production of any record in any form necessary to support an investigation or an audit. The administration shall serve the subpoenas in the same manner as subpoenas in a civil action. If the subpoenaed person does not appear or does not produce the record, the director or the director’s designee by affidavit may apply to the superior court in the county in which the controversy occurred and the court in that county shall proceed as though the failure to comply with the subpoena had occurred in an action in the court in that county.

ALASKA STATUTE SECTION 47.05.210 MEDICAID ASSISTANCE FRAUD (MEDICARE FRAUD)

Alaska Stat. § 47.05.210. : Alaska Statutes – Section 47.05.210.: Medical assistance fraud.

(a) A person commits the crime of medical assistance fraud if the person (1) knowingly submits or authorizes the submission of a claim to a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, services, or benefit; (2) knowingly prepares or assists another person to prepare a claim for submission to a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, services, or benefit; (3) except as otherwise authorized under the medical assistance program, confers, offers to confer, solicits, agrees to accept, or accepts property, services, or a benefit (A) to refer a medical assistance recipient to a health care provider; or (B) for providing health care to a medical assistance recipient if the property, services, or benefit is in addition to payment by a medical assistance agency; (4) does not produce medical assistance records to a person authorized to request the records; (5) knowingly makes a false entry in or falsely alters a medical assistance record; (6) knowingly destroys, mutilates, suppresses, conceals, removes, or otherwise impairs the verity, legibility, or availability of a medical assistance record knowing that the person lacks the authority to do so; or (7) violates a provision of AS 47.07 or AS 47.08 or a regulation adopted under AS 47.07 or AS 47.08.

(b) Medical assistance fraud under (a)(1), (2), or (3) of this section is
(1) a class B felony if the portion of the claim or claims submitted in violation of (a)(1) or (2) of this section, or the value of the property, services, or benefit that is in violation of (a)(3) of this section, is $25,000 or more; (2) a class C felony if the portion of the claim or claims submitted in violation of (a)(1) or (2) of this section, or the value of the property, services, or benefit that is in violation of (a)(3) of this section, is $500 or more but less than $25,000; (3) a class A misdemeanor if the portion of the claim or claims submitted in violation of (a)(1) or (2) of this section, or the value of the property, services, or benefit that is in violation of (a)(3) of this section, is less than $500.

(c) Medical assistance fraud under (a)(4), (5), or (6) of this section is a class A misdemeanor.

(d) Medical assistance fraud under (a)(7) of this section is a class B misdemeanor.

ALABAMA CODE SECTION 22-1-11 MEDICAID FRAUD

ALA CODE § 22-1-11

MAKING FALSE STATEMENT OR REPRESENTATION OF MATERIAL FACT IN CLAIM OR APPLICATION FOR PAYMENTS ON MEDICAL BENEFITS FROM MEDICAID AGENCY GENERALLY; KICKBACKS, BRIBES, ETC.; EXCEPTIONS; MULTIPLE OFFENSES

(a) Any person who, with intent to defraud or deceive, makes, or causes to be made or assists in the preparation of any false statement, representation, or omission of a material fact in any claim or application for any payment, regardless of amount, from the Medicaid Agency, knowing the same to be false; or with intent to defraud or deceive, makes, or causes to be made, or assists in the preparation of any false statement, representation, or omission of a material fact in any claim or application for medical benefits from the Medicaid Agency, knowing the same to be false; shall be guilty of a felony and upon conviction thereof shall be fined not more than ten thousand dollars ($10,000) or imprisoned for not less than one nor more than five years, or both. The offense set out herein shall not be complete until the claim or application is received by the Medicaid Agency or the contractor with the Medicaid Agency or its successor.

(b) Any person who solicits or receives any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind:

(1) In return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part by the Medicaid Agency or its agents, or

(2) In return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part by the Medicaid Agency, or its agents shall be guilty of a felony and upon conviction thereof, shall be fined not more than ten thousand dollars ($10,000) or imprisoned for not less than one nor more than five years, or both.

(c) Any person who offers or pays any remuneration including any kickback, bribe, or rebate directly or indirectly, overtly or covertly, in cash or in kind to any person to induce a person to refer an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part by the Medicaid Agency or its agents, or to purchase, lease, order, or arrange for or recommend purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part by the Medicaid Agency, or its agents, shall be guilty of a felony and upon conviction thereof shall be fined not more than ten thousand dollars ($10,000) or imprisoned for not less than one nor more than five years, or both.

(d) Subsections (b) and (c) of this section shall not apply to a discount or other reduction in price obtained by a provider of services or other entity under Medicaid if the reduction in price is properly disclosed and appropriately reflected in costs claimed or charges made by the provider or entity to the Medicaid Agency or its agents, or any amount paid by an employer to an employee who has a bona fide employment relationship with employer for employment in the provision of covered items or services.

(e) Any two or more offenses in violation of this section may be charged in the same indictment in separate counts for each offense and the offense shall be tried together, with separate sentences being imposed for each offense for which the defendant is found guilty.

MEDICAID AUDITING COSTS PER CAPITA

Most states spend around $1 dollar per capita for Medicaid Fraud Control Units.   If we compare the data on Medicaid Fraud Unit cost from the  National Association of Medicaid Fraud Control Units (NAMFCU), and then compare to population, we can see that there is a giant range.

Medicaid_Audits_UNIT_COSTS_PER_CAPITASource: Barraclough analysis using census data and data from National Association of Medicaid Fraud Control Units (NAMFCU).

Most states spend around $1 per capita on combating fraud in Medicaid.  There are exceptions:  The District of Columbia towers above all states with an expenditure of $5 per capita, followed by 3 for New York, and $2 dollars per capia for Delaware and Alaska.

DOCTORS PER MEDICAID AUDITOR UNEVEN FROM STATE TO STATE

How many doctors are there per Medicaid auditor in a state?  Perhaps the higher the number of doctors per auditor, then the less of a chance of getting audited?

If we compare data on the number of doctors for each state, and then compare it to data from the  National Association of Medicaid Fraud Control Units (NAMFCU), we can see that there is a giant range.

Medicaid_Audits_MDperAuditorSOURCE: Barraclough Analysis with data from Kaiser and National Association of Medicaid Fraud Control.

Massachusetts, Nevada, and Minnesota have more than twice the national average.   Idaho, Maine and Mississippi have the least doctors per auditor, so perhaps there is a higher chance of getting audited.

What is remarkable is the extreme differences in auditing capabilities between different states.

2013 CMS RAC REPORT SHOWS DOCTORS IN SOME STATES PAY 18 TIMES MORE RECOVERY FEES

The Centers for Medicare & Medicaid Services (CMS) recently released its annual report to Congress:   Recovery Auditing in Medicare for Fiscal Year 2013: FY 2013 Report to Congress as Required by Section 1893(h) of the Social Security Act.

The report is full of statistics on the Medicare auditing program.  It presents a picture of “profit”, that is, less money is spent by the government on running the auditing program than is recovered.  It is “cost effective” to use government parlance.   (This calculation does not account for the costs born by the health care providers.)

One would think that from state to state, the amount recovered “clawed back” by the Recovery Audit Contractors (RACs) would be about the same, but it is not.   See the Figure below.

2013_RAC_DATA_Analysis_doctorsBy taking the amount recovered in a state and dividing it by the number of doctors in the same state, we can see that in Mississippi the recovery per doctor was around $18,000 dollars.   But in Maryland, it was around $1,000 dollars – an eighteen times difference! 

It would be interesting to learn more about why this occurs.

 

2013 CMS REPORT ON RACS SHOWS MASSIVE DIFFERENCES IN RECOVERY PER CAPITA

The Centers for Medicare & Medicaid Services (CMS) recently released its annual report to Congress:   Recovery Auditing in Medicare for Fiscal Year 2013: FY 2013 Report to Congress as Required by Section 1893(h) of the Social Security Act.

The report is full of statistics on the Medicare auditing program.  It presents a picture of “profit”, that is, less money is spent by the government on running the auditing program than is recovered.

The report, however, does not address the discrepancies between states for recovery “claw back” of Medicare claims.   The calculation is shown in the figure below.

2013_RAC_DATA_AnalysisWhen we chart the amount recovered and compare it to the number of persons living in the state, the difference is vast.   In Maine, for example, there was $2 per state resident recovered.   However, in North Dakota, there was $36 dollars recovered for each resident.

Does this mean that the health care providers in some states are being more strictly audited than in others?   The CMS report does not give any clue to the answer.