|
Utah False Claims Act
(Title
26. Utah Health Code )
Short
title.
This
chapter shall be known and may be cited as the
"False Claims Act."
1981
Definitions.
As
used in this chapter:
(1)
"Benefit" means the receipt of money,
goods, or any other thing of pecuniary value.
(2) "False
statement" or "false
representation" means a statement or
representation which is knowingly and willfully
made if the person making the statement or
representation has knowledge of the falsity
thereof.
(3)
"Knowing" and "knowingly"
mean that a person is aware of the nature of his
conduct and that his conduct is substantially
certain to cause the intended result.
(4)
"Medical benefit" means a benefit paid
or payable to a recipient or a provider under a
program administered by the state under Titles V
and XIX of the federal Social Security Act, Title
X of the federal Public Health Services Act, the
federal Child Nutrition Act of 1966 as amended by
P.L. 94-105 and any programs for medical
assistance of the state.
(5)
"Person" means an individual,
corporation, unincorporated association,
professional corporation, partnership, or other
form of business association.
1986
False
statement or representation relating to medical
benefits.
(1) A person
shall not make or cause to be made a false
statement or false representation of a material
fact in an application for medical benefits.
(2) A person
shall not make or cause to be made a false
statement or false representation of a material
fact for use in determining rights to a medical
benefit.
(3) A person,
who having knowledge of the occurrence of an
event affecting his initial or continued right to
receive a medical benefit or the initial or
continued right of any other person on whose
behalf he has applied for or is receiving a
medical benefit, shall not conceal or fail to
disclose that event with intent to obtain a
medical benefit to which the person or any other
person is not entitled or in an amount greater
than that to which the person or any other person
is entitled.
1986
Kickbacks or
bribes prohibited.
A person may not
solicit, offer, pay, or receive a kickback or
bribe in connection with the furnishing of goods
or services for which payment is or may be made
in whole or in part pursuant to a medical benefit
program, or pay or receive a rebate of a fee or
charge for referring an individual to another
person for the furnishing of goods or services.
1986
False
statements or false representations relating to
qualification of health institution or facility
prohibited - Felony.
(1) A person
shall not knowingly and willfully make, or induce
or seek to induce the making of a false statement
or false representation of a material fact with
respect to the conditions or operation of an
institution or facility in order that the
institution or facility may qualify, upon initial
certification or upon recertification, as a
hospital, skilled nursing facility, intermediate
care facility, or home health agency.
(2) A person who
violates this section is guilty of a second
degree felony.
1981
Conspiracy to
defraud prohibited.
A person shall
not enter into an agreement, combination, or
conspiracy to defraud the state by obtaining or
aiding another to obtain the payment or allowance
of a false, fictitious, or fraudulent claim for a
medical benefit.
1986
False claims
for medical benefits prohibited.
(1) No person
may make or present or cause to be made or
presented to an employee or officer of the state
a claim for a medical benefit, knowing the claim
to be false, fictitious, or fraudulent.
(2) In addition,
no person shall knowingly:
(a) file a claim
for a medical benefit for services which were not
rendered or for items or materials which were not
delivered;
(b) file a claim
for a medical benefit which misrepresents the
type, quality, or quantity of items or services
rendered;
(c) file a claim
for a medical benefit representing charges at a
higher rate than those charged by the provider to
the general public;
(d) file a claim
for a medical benefit for items or services which
the person or the provider knew were not
medically necessary in accordance with
professionally recognized standards;
(e) file a claim
for a medical benefit which has previously been
paid;
(f) fail to
credit the state for payments received from other
sources;
(g) file a claim
for a medical benefit 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;
(h) recover or
attempt to recover payment from a recipient under
a medical benefit program, or the recipient's
family in violation of the provider agreement;
(i) file a claim
for a medical benefit where a provider divides an
accepted multiple medical procedure into
artificial components or single procedures
requesting full medical benefits for performing
those component procedures as if they had each
been performed independently and at separate
times;
(j) falsify or
alter with intent to deceive, any report or
document required by state or federal law, rule,
or Medicaid provider agreement;
(k) retain any
unauthorized payment as a result of acts
described by this section; or
(l) aid or abet
the commission of any act prohibited by this
section.
1987
Knowledge of
past acts not necessary to establish fact that
false statement or representation knowingly made.
In prosecution
under this chapter, it shall not be necessary to
show that the person had knowledge of similar
acts having been performed in the past on the
part of persons acting on his behalf nor to show
that the person had actual notice that the acts
by the persons acting on his behalf occurred to
establish the fact that a false statement or
representation was knowingly made.
1981
Criminal
penalties.
(1) The
punishment for violation of any provision of this
chapter, except as provided under Section
26-20-5, is determined by the cumulative value of
the funds or other benefits received or claimed
in the commission of all violations of a similar
nature, and not by each separate violation.
(2) Punishment
for violation of this chapter, except as provided
under Section 26-20-5 , is as follows:
(a) as a felony
of the second degree if the cumulative value of
the funds or other benefits received or claimed
in violation of this chapter exceeds $1,000;
(b) as a felony
of the third degree if the cumulative value of
the funds or other benefits received or claimed
in violation of this chapter exceeds $250 but
does not exceed $1,000;
(c) as a class A
misdemeanor if the cumulative value of the funds
or other benefits received or claimed in
violation of this chapter exceeds $100 but does
not exceed $250; or
(d) as a class B
misdemeanor if the cumulative value of the funds
or other benefits received or claimed in
violation of this chapter does not exceed $100.
1986
Civil
penalties.
(1) Any person
who violates this chapter shall, in addition to
other penalties provided by law, be subject to
the following civil penalties:
(a) in all
cases, shall be required to make full and
complete restitution to the state of all medical
benefits improperly obtained;
(b) in all
cases, shall be required to pay the state its
costs of enforcement of this chapter in that
case, including but not limited to the cost of
investigators, attorneys, and other public
employees, as determined by the Bureau of
Medicaid Fraud;
(c) may be
required, in the discretion of the court, to pay
to the state a civil penalty not to exceed three
times the amount of value improperly claimed or
received as a medical benefit; or
(d) may be
required, in the discretion of the court, to pay
to the state a civil penalty of up to $2,000 for
each claim filed or act done in violation of this
chapter.
(2) Any civil
penalties assessed under Subsection (1) shall be
awarded by the court as part of its judgment in
both criminal and civil actions.
(3) A criminal
action need not be brought against a person in
order for that person to be civilly liable under
this section.
1987
Revocation of
license of assisted living facility - Appointment
of receiver.
(1) If the
license of an assisted living facility is revoked
for violation of this chapter, the county
attorney may file a petition with the district
court for the county in which the facility is
located for the appointment of a receiver.
(2) The district
court shall issue an order to show cause why a
receiver should not be appointed returnable
within five days after the filing of the
petition.
(3) If the court
finds that the facts warrant the granting of the
petition, the court shall appoint a receiver to
take charge of the facility. The court may
determine fair compensation for the receiver.
(4) A receiver
appointed pursuant to this section shall have the
powers and duties prescribed by the court.
1998
Presumption
based on paid state warrant - Value of medical
benefits - Repayment of benefits.
(1) In any civil
or criminal action brought under this chapter, a
paid state warrant, made payable to the order of
a party, creates a presumption that the party
received funds from the state.
(2) In any civil
or criminal action brought under this chapter,
the value of the benefits received shall be the
ordinary or usual charge for similar benefits in
the private sector.
(3) In any
criminal action under this chapter, the repayment
of funds or other benefits obtained in violation
of the provisions of this chapter does not
constitute a defense to, or grounds for dismissal
of that action.
1986
Violation of
other laws.
This chapter
shall not be construed to prohibit or limit an
action against a person for violation of any
other law.
1986
Medicaid
fraud enforcement.
(1) This chapter
shall be enforced in accordance with this
section.
(2) The
department shall be responsible for:
(a)
investigating and prosecuting all civil
violations of this chapter; and
(b) promptly
referring suspected criminal violations of this
chapter to the attorney general for criminal
investigation and prosecution.
(3) The attorney
general shall be responsible for:
(a)
investigating criminal violations of this chapter
that are reported to the attorney general by the
department or others;
(b) promptly
referring probable civil violations of this
chapter that are not related to a criminal
investigation or prosecution to the department
for civil investigation and prosecution; and
(c) prosecuting
criminal violations of this chapter.
(4) The
department and the attorney general may enter
into an interagency agreement regarding the
investigation and prosecution of violations of
this chapter in accordance with this section, the
requirements of Title XIX of the federal Social
Security Act, and applicable federal regulations.
2000
|
