2023 Tennessee Code › Title 71 - WELFARE (§§ 71-1-101 — 71-7-103) › Chapter 5 - PROGRAMS AND SERVICES FOR POOR PERSONS (§§ 71-5-NEW — 71-5-2604) › Part 26 - PREVENTION OF FRAUD AND ABUSE IN TENNCARE (§§ 71-5-2601 — 71-5-2604) › Section 71-5-2601 - Offenses - Penalties - Remedies - Limitations

(a)
(1)
(A)
A person, including an enrollee, recipient, or applicant, commits an offense who knowingly obtains, or attempts to obtain, or aids or abets any person to obtain, by means of a willfully false statement, representation, or impersonation, or by concealment of any material fact, or by any other fraudulent means, or in any manner not authorized by any rule, regulation, or statute governing TennCare:
(i)
Medical assistance benefits or any assistance provided pursuant to any rule, regulation, procedure, or statute governing TennCare to which such person is not entitled, or of a greater value than that to which such person is authorized;
(ii)
Benefits by knowingly making a willfully false statement, or concealing a material fact relating to personal or household income, thereby resulting in the assessment of a lower monthly premium than the person would be required to pay if not for the false statement or concealment of a material fact; or
(iii)
Controlled substance benefits by knowingly, willfully and with the intent to deceive, failing to disclose to a physician, nurse practitioner, ancillary staff, or other health care provider from whom the person obtains a controlled substance, or a prescription for a controlled substance, that the person has received either the same controlled substance or a prescription for the same controlled substance, or a controlled substance of similar therapeutic use or a prescription for a controlled substance of similar therapeutic use, from another practitioner within the previous thirty (30) days and the person used TennCare to obtain the benefits.
(B)
An offense under subdivision (a)(1)(A) is a Class D felony. In addition to restitution, a person who pleads guilty or nolo contendere or is found guilty of violating this section shall be fined:
(i)
Two hundred fifty dollars ($250) for the first offense;
(ii)
Five hundred dollars ($500) for the second offense; and
(iii)
One thousand dollars ($1,000) for a third or subsequent offense.
(C)
The fines authorized under subdivision (a)(1)(B) shall be collected by the county court clerk with five percent (5%) of the fine going to the clerk of the court and the remaining ninety-five percent (95%) of the fine transmitted to the state treasurer on a monthly basis for deposit in the general fund.
(2)
(A)
A person, firm, corporation, partnership or any other entity, including a vendor, other than an enrollee, recipient, or applicant, commits an offense who knowingly obtains, or attempts to obtain, or aids or abets any person or entity to obtain, by means of a willfully false statement, report, representation, claim or impersonation, or by concealment of any material fact, or by any other fraudulent means, including knowingly presenting or causing to be presented to TennCare or any of its contractors, subcontractors or vendors a false or fraudulent claim for payment or approval, or in any manner not authorized by any rule, regulation, procedure, or statute governing TennCare, medical assistance payments provided pursuant to any rule, regulation, procedure, or statute governing TennCare to which the person or entity is not entitled, or of a greater value than that to which the person or entity is authorized. For purposes of this subsection (a), "attempts to obtain" includes making or presenting to any person a claim for any payment under any rule, regulation, procedure, or statute governing TennCare, knowing the claim to be false, fictitious or fraudulent.
(B)
An offense under subdivision (a)(2)(A) is a Class D felony unless the value of the property or services obtained meets the threshold set for a Class B or Class C offense under §
39-14-105
, in which case the appropriate higher class shall apply. In addition to any other penalty, a sentence that includes a fine, when imposed upon an entity or upon a person for actions benefiting an entity, shall include the corporation fine specified in §
40-35-111
.
(3)
(A)
A person, firm, corporation, partnership or any other entity commits an offense when providing a willfully false statement regarding another's medical condition or eligibility for insurance, to aid or abet another in obtaining or attempting to obtain medical assistance payments, medical assistance benefits or any assistance provided under any rule, regulation, procedure, or statute governing TennCare to which the person is not entitled or to a greater value than that to which such person is authorized. For purposes of this subsection (a), "attempting to obtain" includes making or presenting to any person a claim for any payment under any rule, regulation, procedure, or statute governing TennCare, knowing such claim to be false, fictitious or fraudulent.
(B)
An offense under subdivision (a)(3)(A) is a Class D felony unless the value of the property or services obtained meets the threshold set for a Class B or Class C offense under §
39-14-105
, in which case the appropriate higher class shall apply. In addition to any other penalty, a sentence that includes a fine, when imposed upon an entity or upon a person for actions benefiting an entity, shall include the corporation fine specified in §
40-35-111
.
(4)
Any person, firm, corporation, partnership or other entity is guilty of a Class D felony that, in connection with the investigation of a violation of offenses set forth in this section, knowingly and willfully:
(A)
Falsifies, conceals or omits by any trick, scheme, artifice, or device a material fact;
(B)
Makes any materially false, fictitious or fraudulent statement or representation; or
(C)
Makes or uses any materially false writing or document.
(5)
(A)
A person commits an offense who knowingly sells, delivers, or aids and abets any person in the sale or delivery of a drug and used TennCare to obtain the drug.
(B)
As used in this subdivision (a)(5), "drug", "deliver" and "delivery" shall have the same meaning as set forth in §
39-17-402
.
(C)
This subdivision (a)(5) shall not apply to any duly licensed physician, nurse practitioner, pharmacist, or other provider authorized to issue or dispense a prescription acting in good faith in the course of that person's profession.
(D)
An offense under this subdivision (a)(5) is a Class D felony.
(b)
In addition to any other penalties provided for any person, firm, corporation, partnership or other entity under subsection (a), the court shall also:
(1)
(A)
Order restitution to TennCare in the greater of the total amount of all medical assistance payments made to all providers, or the total amount of all payments to a managed care entity, related to the services underlying the offense; and
(B)
Report the person or entity to the appropriate professional licensure board or the department of commerce and insurance for disciplinary action.
(2)
In addition to any other penalties provided under this section, the court may also, to the full extent permitted by federal law and the TennCare waiver as interpreted by the CMS, order any such person or entity disqualified from participation in the medical assistance program; such disqualification may also apply to any person who is convicted of a criminal offense involving the selling of prescription drugs obtained through the TennCare program. Any person or entity disqualified from participation in the medical assistance program shall make restitution in the total amount of the medical assistance or underpayment which forms the basis for the conviction before such person or entity can reenroll in the TennCare program.
(3)
A subsequent denial of eligibility or denial of a claim for payment does not, of itself, establish proof of falsity of a statement, representation, report or claim for payment under subsection (a).
(c)
Nothing in this section shall be construed as prohibiting a person or entity violating this section from being prosecuted for theft of property or services under title 39, chapter 14.
(d)
In addition to any other remedy available, including those provided in this section, the state may recover from any person or such person's estate, or from a firm, corporation, partnership or other entity, including a vendor, the amount of medical assistance benefits or payments improperly paid as a result of fraudulent means or actions not authorized by any rule, regulation, procedure, or statute governing TennCare.
(e)
Notwithstanding any other law to the contrary, prosecutions for violations of this section shall be commenced within four (4) years after the commission of the offense.
Amended by 2016 Tenn. Acts, ch. 744,s 2, eff. 7/1/2016.
Amended by 2016 Tenn. Acts, ch. 744,s 1, eff. 7/1/2016.
Amended by 2013 Tenn. Acts, ch. 159,Secs.s1, s2 eff. 4/16/2013.
Acts 2004, ch. 784, § 1; 2007, ch. 103, § 1; 2007, ch. 458, §§ 1, 2; 2008, ch. 1139, § 1.