(1) A person commits medicaid fraud and waste when that person knowingly and willfully:
With intent to defraud, makes a claim, or causes a claim to be made, knowing theclaim contains material information that is false, in whole or in part, by commission or omission;
With intent to defraud, makes a statement or representation, or causes a statement orrepresentation to be made, for use in obtaining or seeking to obtain authorization to provide a good or a service, knowing the statement or representation contains material information that is false, in whole or in part, by commission or omission;
With intent to defraud, makes a statement or representation, or causes a statement orrepresentation to be made, for use by another in obtaining a good or a service under the medicaid program, knowing the statement or representation contains material information that is false, in whole or in part, by commission or omission;
With intent to defraud, makes a statement or representation, or causes a statement orrepresentation to be made, for use in qualifying as a provider of a good or service under the medicaid program, knowing the statement or representation contains material information that is false, in whole or in part, by commission or omission;
With intent to defraud, signs or submits, or causes to be signed or submitted, a statement described in section 24-31-807 with the knowledge that the application, report, claim, or invoice for services provided under contract contains material information that is false, in whole or in part, by commission or omission;
Except as authorized by law, and without consent of the beneficiary, charges anybeneficiary money or other consideration in addition to or in excess of rates of remuneration established under the medicaid program for the services provided to the beneficiary;
Having submitted a claim for or received payment for a good or a service under themedicaid program:
With the intent to prevent their disclosure and review by representatives of the stateor their designees, alters, falsifies, or conceals any records that are necessary to fully disclose the nature of all goods or services for which the claim was submitted, or for which reimbursement was received; destroys or removes such records; or fails to maintain such records as required by law or the rules of the department of health care policy and financing for a period of at least six years following the date on which payment was received; or
Alters, falsifies, or conceals any records that are necessary to disclose fully all income and expenditures upon which rates of reimbursements were based, or destroys or removes such records with the intent to prevent their review by representatives of the state or their designees;
Makes or causes to be made a statement or representation for use in qualifying as aprovider of a good or service under the medicaid program stating that he or she is in compliance with all provisions of section 25.5-4-416, knowing that the statement or representation contains material information that is false, in whole or in part, through commission or omission; or
Except as authorized by law, and without consent of the beneficiary, recovers or attempts to recover payment from a beneficiary under the medicaid program or from the beneficiary's family or fails to credit the state for payments received from other sources.
Absent knowing or willful conduct, a provider is not liable for medicaid fraud andwaste committed by a third party. A provider does not knowingly and willfully violate a requirement, standard, or directive contained in written materials issued by the department of health care policy and financing that was not promulgated in accordance with the "State Administrative Procedure Act", article 4 of title 24, unless the provider has actual knowledge of such requirement, standard, or directive at the time of the violation.
Medicaid fraud in violation of subsections (1)(a) to (1)(c) or (1)(f) of this section is:
A class 1 petty offense where the aggregate amount of payments illegally claimed orreceived is less than fifty dollars;
A class 3 misdemeanor where the aggregate amount of payments illegally claimed orreceived is fifty dollars or more but less than three hundred dollars;
A class 2 misdemeanor where the aggregate amount of payments illegally claimed orreceived is three hundred dollars or more but less than seven hundred fifty dollars;
A class 1 misdemeanor where the aggregate amount of payments illegally claimed orreceived is seven hundred fifty dollars or more but less than two thousand dollars;
A class 6 felony where the aggregate amount of payments illegally claimed or received is two thousand dollars or more but less than five thousand dollars;
A class 5 felony where the aggregate amount of payments illegally claimed or received is five thousand dollars or more but less than twenty thousand dollars;
A class 4 felony where the aggregate amount of payments illegally claimed or received is twenty thousand dollars or more but less than one hundred thousand dollars;
A class 3 felony where the aggregate amount of payments illegally claimed or received is one hundred thousand dollars or more but less than one million dollars; and
A class 2 felony where the aggregate amount of payments illegally claimed or received is one million dollars or more.
Medicaid fraud as a violation of subsection (1)(d), (1)(e), (1)(g), (1)(h), or (1)(i) ofthis section is a class 5 felony and shall be punished as provided in section 18-1.3-401.
A person may not be convicted of medicaid fraud and waste in addition to theft orforgery with respect to the same transaction.
Source: L. 2018: Entire part added, (HB 18-1211), ch. 159, p. 1116, § 2, effective January 1, 2019.