False claims for medical benefits prohibited.

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  • (1) A person may not make or present or cause to be made or presented to an employee or officer of the state a claim for a medical benefit:
    • (a) which is wholly or partially false, fictitious, or fraudulent;
    • (b) for services which were not rendered or for items or materials which were not delivered;
    • (c) which misrepresents the type, quality, or quantity of items or services rendered;
    • (d) representing charges at a higher rate than those charged by the provider to the general public;
    • (e) for items or services which the person or the provider knew were not medically necessary in accordance with professionally recognized standards;
    • (f) which has previously been paid;
    • (g) for services also covered by one or more private sources when the person or provider knew of the private sources without disclosing those sources on the claim; or
    • (h) where a provider:
      • (i) unbundles a product, procedure, or group of procedures usually and customarily provided or performed as a single billable product or procedure into artificial components or separate procedures; and
      • (ii) bills for each component of the product, procedure, or group of procedures:
        • (A) as if they had been provided or performed independently and at separate times; and
        • (B) the aggregate billing for the components exceeds the amount otherwise billable for the usual and customary single product or procedure.
  • (2) In addition to the prohibitions in Subsection (1), a person may not:
    • (a) fail to credit the state for payments received from other sources;
    • (b) recover or attempt to recover payment in violation of the provider agreement from:
      • (i) a recipient under a medical benefit program; or
      • (ii) the recipient's family;
    • (c) falsify or alter with intent to deceive, any report or document required by state or federal law, rule, or Medicaid provider agreement;
    • (d) retain any unauthorized payment as a result of acts described by this section; or
    • (e) aid or abet the commission of any act prohibited by this section.




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