Opinion ID: 777287
Heading Depth: 3
Heading Rank: 2

Heading: Payment and verification of provider claims

Text: 20 Under the Medicaid Act, [t]he state plan is required to establish ... a scheme for reimbursing health care providers for the medical services provided to needy individuals. Wilder, 496 U.S. at 502, 110 S.Ct. 2510. Various statutory provisions and regulations require the States to verify the legitimacy of payment claims. See, e.g., 42 U.S.C. § 1396a(a)(42) (explaining that a state plan must provide that the records of any entity participating in the plan and providing services reimbursable on a cost-related basis will be audited as ... necessary to insure that proper payments are made under the plan); 42 C.F.R. § 447.202 (The Medicaid agency must assure appropriate audit of records if payment is based on costs of services or on a fee plus costs of materials.). 21 A provider may face various consequences for submitting an improper claim. A state's Medicaid agency can withhold payments to providers upon receipt of reliable evidence that a provider has engaged in fraud or willful misrepresentation. 42 C.F.R. § 455.23(a). Overpayments can be recovered through administrative proceedings. See e.g., Cal. Code Regs. tit. 22, § 51047. Providers can be decertified and barred from participation in the Medicaid program. 42 U.S.C. § 1320a-7b(a)(1) & (6). Medicaid fraud also may result in criminal prosecution. 42 U.S.C. § 1320a-7b(a) (setting forth criminal penalties for false statements or representations in provider claims for payments); 18 U.S.C. § 1347 (specifying criminal penalties for scheme to defraud health care benefit program); see also United States v. Woodley, 9 F.3d 774, 778 (9th Cir.1993) (upholding mail fraud conviction against Medicare provider).