36-2957

36-2957. Prohibited acts; penalties

A. No person may present or cause to be presented to the administration or to a
program contractor:

1. A claim for an item or service that the person knows or has reason to know was
not provided as claimed.

2. A claim for an item or service that the person knows or has reason to know is
false or fraudulent.

3. A claim for payment which the person knows or has reason to know may not be made
by the system because:

(a) The person was not a member on the date for which the claim is being made.

(b) The item or service claimed is substantially in excess of the needs of the
individual or of a quality that fails to meet professionally recognized standards of
care.

4. A claim for a physician's service, or an item or service incidental to a
physician's service, by a person who knows or has reason to know that the individual who
furnished or supervised the furnishing of the service:

(a) Was not licensed as a physician.

(b) Obtained a license through a misrepresentation of material fact.

(c) Represented to the patient at the time the service was furnished that the
physician was certified in a medical specialty by a medical specialty board if the person
was not certified.

5. A request for payment which the person knows or has reason to know is in
violation of an agreement between the person and the administration or the program
contractor.

B. A person who violates a provision of subsection A is subject, in addition to any
other penalties that may be prescribed by law, to a civil penalty of not to exceed two
thousand dollars for each item or service claimed and is subject to an assessment of not
to exceed twice the amount claimed for each item or service.

C. The director or his designee shall make the determination to assess civil
penalties and is responsible for the collection of penalty and assessment amounts. The
director shall adopt rules that prescribe procedures for the determination and collection
of civil penalties and assessments. Civil penalties and assessments imposed under this
section may be compromised by the director or his designee in accordance with criteria
established in rules. The director or his designee may make a determination in the same
proceeding to exclude the person from system participation.

D. A person adversely affected by a determination of the director or his designee
under this section may appeal that decision in accordance with grievance provisions set
forth in rule. The final decision is subject to judicial review in accordance with title
12, chapter 7, article 6.

E. Amounts recovered under this section shall be deposited in the Arizona long-term
care system fund. The amount of such penalty or assessment may be deducted from any
amount then or later owing by the administration to the person against whom the penalty
or assessment has been imposed.

F. If a civil penalty or assessment imposed pursuant to subsection C is not paid,
this state or the administration shall file an action to collect the civil penalty or
assessment in the superior court in Maricopa county. Matters that were raised or could
have been raised in a hearing before the director or in an appeal pursuant to title 12,
chapter 7, article 6 may not be raised as a defense to the civil action. An action
brought pursuant to this subsection shall be initiated within six years after the date
the claim was presented.