Medicaid Fraud

Every now and then a statute is so specific that there's no point summarizing it. Section 35A.02 of the Texas Penal Code is extremely clear in outlining the types of acts which constitute Medicaid Fraud by any one of the parties to the transaction. A person commits the offense of Medicaid Fraud if the person:

(1) knowingly makes or causes to be made a false statement or misrepresentation of a material fact to permit a person to receive a benefit or payment under the Medicaid program that is not authorized or that is greater than the benefit or payment that is authorized;

(2) knowingly conceals or fails to disclose information that permits a person to receive a benefit or payment under the Medicaid program that is not authorized or that is greater than the benefit or payment that is authorized;

(3) knowingly applies for and receives a benefit or payment on behalf of another person under the Medicaid program and converts any part of the benefit or payment to a use other than for the benefit of the person on whose behalf it was received;

(4) knowingly makes, causes to be made, induces, or seeks to induce the making of a false statement or misrepresentation of material fact concerning:

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      (i) a hospital;

      (ii) a nursing facility or skilled nursing facility;

      (iii) a hospice;

      (iv) an intermediate care facility for the mentally retarded;

      (v) an assisted living facility; or

      (vi) a home health agency; or

  • (A) the conditions or operation of a facility in
    order that the facility may qualify for certification or
    recertification required by the Medicaid program, including
    certification or recertification as:

    (B) information required to be provided by a federal or state law, rule, regulation, or provider agreement pertaining to the Medicaid program;

(5) except as authorized under the Medicaid program, knowingly pays, charges, solicits, accepts, or receives, in addition to an amount paid under the Medicaid program, a gift, money, a donation, or other consideration as a condition to the provision of a service or product or the continued provision of a service or product if the cost of the service or product is paid for, in whole or in part, under the Medicaid program;

(6) knowingly presents or causes to be presented a claim for payment under the Medicaid program for a product provided or a service rendered by a person who:

    (A) is not licensed to provide the product or render the service, if a license is required; or

    (B) is not licensed in the manner claimed;

(7) knowingly makes a claim under the Medicaid program for:

    (A) a service or product that has not been approved or acquiesced in by a treating physician or health care practitioner;

    (B) a service or product that is substantially inadequate or inappropriate when compared to generally recognized standards within the particular discipline or within the health
    care industry; or

    (C) a product that has been adulterated, debased, mislabeled, or that is otherwise inappropriate;

(8) makes a claim under the Medicaid program and knowingly fails to indicate the type of license and the identification number of the licensed health care provider who actually provided the service;

(9) knowingly enters into an agreement, combination, or conspiracy to defraud the state by obtaining or aiding another person in obtaining an unauthorized payment or benefit from the Medicaid program or a fiscal agent;

(10) is a managed care organization that contracts with the Health and Human Services Commission or other state agency to provide or arrange to provide health care benefits or services to individuals eligible under the Medicaid program and knowingly:

    (A) fails to provide to an individual a health care benefit or service that the organization is required to provide under the contract;

    (B) fails to provide to the commission or appropriate state agency information required to be provided by law, commission or agency rule, or contractual provision; or

    (C) engages in a fraudulent activity in connection with the enrollment of an individual eligible under the Medicaid program in the organization's managed care plan or in connection with marketing the organization's services to an individual eligible under the Medicaid program;

(11) knowingly obstructs an investigation by the attorney general of an alleged unlawful act under this section or under Section 32.039, 32.0391, or 36.002, Human Resources Code; or

(12) knowingly makes, uses, or causes the making or use of a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to this state under the Medicaid program.

While there are many prosecutions for Medicare billing fraud in federal court, there is not a specific statute authorizing prosecution under Title 18. Instead, most Assistant United
States Attorneys prosecute federal Medicare fraud using the wire fraud or mail fraud statutes.

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