Source: http://www.barracloughllc.com/dir/2014/10/
Timestamp: 2018-03-23 13:09:44
Document Index: 738115499

Matched Legal Cases: ['§70', '§1', '§1', '§1', '§ 53', '§ 53', '§ 47', '§ 22']

October 2014 - Reverse Medicare and Medicaid Audits
LOUISIANA STATUTE LA RS 14.70.1 MEDICAID FRAUD
Louisiana Statute on Medicaid Fraud
§70.1. Medicaid fraud
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.
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.
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.
2013 Connecticut General Statutes Title 53aConnecticut Medicaid FraudCT Gen Stat § 53a-290 (2013)CT Gen Stat Section 53a-290MEDICAID FRAUD
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.
(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:
(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
(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
(h) The enforcement remedies provided under this section are not
exclusive and shall not preclude the use of any other criminal or
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.
California Welfare and Institutions Code Section 14107MEDI-CALMEDI-CAL FRAUDMEDICAID FRAUD
ARIZONA STATUTE ARS 36-2918 MEDICAID FRAUD
36-2918. Prohibited acts; penalties; subpoena power
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:
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.
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.
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.
ARIZONA STATUTE 36-2918MEDICAID FRAUD
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.
ALASKA CODE SECTION 47.05.210AS 47.05.201MEDICAID FRAUDMEDICAL ASSISTANCE FRAUD
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.
Alabama Code Section 22-1-11MEDICAID FRAUD
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.
Source: 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.
Medicaid Audit CostsMedicaid Fraud UnitMEDICAID FRAUD UNIT COSTS PER CAPITANAMFCUNational Association of Medicaid Fraud Control Units
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.
SOURCE: 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.
MedicaidMedicaid AuditsNational Association of Medicaid Fraud Control Units