36-2993. Prohibited acts; penalties
A. A person shall not present or cause to be presented to this state or to a
contractor:
1. A claim for a medical service or any other item that the person knows or has
reason to know was not provided as claimed.
2. A claim for a medical service or any other item that the person knows or has
reason to know is false or fraudulent.
3. A claim for payment that the person knows or has reason to know may not be made
by the administration because:
(a) The person was terminated or suspended from participation in the program 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
health care.
(c) The person was not a member on the date for which the claim is being made.
4. A claim for a service or an item 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 or another health care professional requiring
state licensure.
(b) Obtained the individual's license through a misrepresentation of material fact.
(c) Represented to the member at the time the service was furnished that the
physician was certified in a medical specialty by a medical specialty board if the
individual was not certified.
5. A request for payment that the person knows or has reason to know is in
violation of an agreement between the person and this state or the administration.
B. A person who violates this section is subject, in addition to any other
penalties that may be prescribed by law, to a civil penalty of not more than two thousand
dollars for each item or service claimed and is subject to an assessment of not more than
twice the amount claimed for each item or service.
C. The director or the director's 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 the designee in
accordance with criteria established in rules. The director or the director's designee
may make this determination in the same proceeding to exclude the person from
participation in the program.
D. A person adversely affected by a determination of the director or the director's
designee under this section may appeal that decision in accordance with provider
grievance provisions prescribed by rule. The final decision is subject to judicial
review pursuant to title 12, chapter 7, article 6.
E. The administration shall deposit, pursuant to sections 35-146 and 35-147, monies
collected pursuant to this section in the state general fund. The amount of the penalty
or assessment may be deducted from any amount then or later owing by the administration
or this state to the person against whom the penalty or assessment has been imposed.
F. If a civil penalty or assessment imposed pursuant to this section 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.
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