False statement to receive health care payment prohibited--kickback,bribe, purpose, prohibited, exceptions--abuseprohibited--penalty--prosecution, procedure--Medicaid fraudreimbursement fund created--restitution--civilpenalty--notification to disciplinary agencies--civil actionauthorized.
191.905. 1. No health care provider shall knowingly make or cause tobe made a false statement or false representation of a material fact inorder to receive a health care payment, including but not limited to:
(1) Knowingly presenting to a health care payer a claim for a healthcare payment that falsely represents that the health care for which thehealth care payment is claimed was medically necessary, if in fact it wasnot;
(2) Knowingly concealing the occurrence of any event affecting aninitial or continued right under a medical assistance program to have ahealth care payment made by a health care payer for providing health care;
(3) Knowingly concealing or failing to disclose any information withthe intent to obtain a health care payment to which the health careprovider or any other health care provider is not entitled, or to obtain ahealth care payment in an amount greater than that which the health careprovider or any other health care provider is entitled;
(4) Knowingly presenting a claim to a health care payer that falselyindicates that any particular health care was provided to a person orpersons, if in fact health care of lesser value than that described in theclaim was provided.
2. No person shall knowingly solicit or receive any remuneration,including any kickback, bribe, or rebate, directly or indirectly, overtlyor covertly, in cash or in kind in return for:
(1) Referring another person to a health care provider for thefurnishing or arranging for the furnishing of any health care; or
(2) Purchasing, leasing, ordering or arranging for or recommendingpurchasing, leasing or ordering any health care.
3. No person shall knowingly offer or pay any remuneration, includingany kickback, bribe, or rebate, directly or indirectly, overtly orcovertly, in cash or in kind, to any person to induce such person to referanother person to a health care provider for the furnishing or arrangingfor the furnishing of any health care.
4. Subsections 2 and 3 of this section shall not apply to a discountor other reduction in price obtained by a health care provider if thereduction in price is properly disclosed and appropriately reflected in theclaim made by the health care provider to the health care payer, or anyamount paid by an employer to an employee for employment in the provisionof health care.
5. Exceptions to the provisions of subsections 2 and 3 of thissubsection shall be provided for as authorized in 42 U.S.C. Section1320a-7b(3)(E), as may be from time to time amended, and regulationspromulgated pursuant thereto.
6. No person shall knowingly abuse a person receiving health care.
7. A person who violates subsections 1 to 3 of this section is guiltyof a class C felony upon his or her first conviction, and shall be guiltyof a class B felony upon his or her second and subsequent convictions. Anyperson who has been convicted of such violations shall be referred to theOffice of Inspector General within the United States Department of Healthand Human Services. The person so referred shall be subject to thepenalties provided for under 42 U.S.C. Chapter 7, Subchapter XI, Section1320a-7. A prior conviction shall be pleaded and proven as provided bysection 558.021, RSMo. A person who violates subsection 6 of this sectionshall be guilty of a class C felony, unless the act involves no physical,sexual or emotional harm or injury and the value of the property involvedis less than five hundred dollars, in which event a violation of subsection6 of this section is a class A misdemeanor.
8. Any natural person who willfully prevents, obstructs, misleads,delays, or attempts to prevent, obstruct, mislead, or delay thecommunication of information or records relating to a violation of sections191.900 to 191.910 is guilty of a class D felony.
9. Each separate false statement or false representation of amaterial fact proscribed by subsection 1 of this section or act proscribedby subsection 2 or 3 of this section shall constitute a separate offenseand a separate violation of this section, whether or not made at the sameor different times, as part of the same or separate episodes, as part ofthe same scheme or course of conduct, or as part of the same claim.
10. In a prosecution pursuant to subsection 1 of this section,circumstantial evidence may be presented to demonstrate that a falsestatement or claim was knowingly made. Such evidence of knowledge mayinclude but shall not be limited to the following:
(1) A claim for a health care payment submitted with the health careprovider's actual, facsimile, stamped, typewritten or similar signature onthe claim for health care payment;
(2) A claim for a health care payment submitted by means of computerbilling tapes or other electronic means;
(3) A course of conduct involving other false claims submitted tothis or any other health care payer.
11. Any person convicted of a violation of this section, in additionto any fines, penalties or sentences imposed by law, shall be required tomake restitution to the federal and state governments, in an amount atleast equal to that unlawfully paid to or by the person, and shall berequired to reimburse the reasonable costs attributable to theinvestigation and prosecution pursuant to sections 191.900 to 191.910. Allof such restitution shall be paid and deposited to the credit of the "MOHealthNet Fraud Reimbursement Fund", which is hereby established in thestate treasury. Moneys in the MO HealthNet fraud reimbursement fund shallbe divided and appropriated to the federal government and affected stateagencies in order to refund moneys falsely obtained from the federal andstate governments. All of such cost reimbursements attributable to theinvestigation and prosecution shall be paid and deposited to the credit ofthe "MO HealthNet Fraud Prosecution Revolving Fund", which is herebyestablished in the state treasury. Moneys in the MO HealthNet fraudprosecution revolving fund may be appropriated to the attorney general, orto any prosecuting or circuit attorney who has successfully prosecuted anaction for a violation of sections 191.900 to 191.910 and been awarded suchcosts of prosecution, in order to defray the costs of the attorney generaland any such prosecuting or circuit attorney in connection with theirduties provided by sections 191.900 to 191.910. No moneys shall be paidinto the MO HealthNet fraud protection revolving fund pursuant to thissubsection unless the attorney general or appropriate prosecuting orcircuit attorney shall have commenced a prosecution pursuant to thissection, and the court finds in its discretion that payment of attorneys'fees and investigative costs is appropriate under all the circumstances,and the attorney general and prosecuting or circuit attorney shall prove tothe court those expenses which were reasonable and necessary to theinvestigation and prosecution of such case, and the court approves suchexpenses as being reasonable and necessary. Any moneys remaining in the MOHealthNet fraud reimbursement fund after division and appropriation to thefederal government and affected state agencies shall be used to increase MOHealthNet provider reimbursement until it is at least one hundred percentof the Medicare provider reimbursement rate for comparable services. Theprovisions of section 33.080, RSMo, notwithstanding, moneys in the MOHealthNet fraud prosecution revolving fund shall not lapse at the end ofthe biennium.
12. A person who violates subsections 1 to 3 of this section shall beliable for a civil penalty of not less than five thousand dollars and notmore than ten thousand dollars for each separate act in violation of suchsubsections, plus three times the amount of damages which the state andfederal government sustained because of the act of that person, except thatthe court may assess not more than two times the amount of damages whichthe state and federal government sustained because of the act of theperson, if the court finds:
(1) The person committing the violation of this section furnishedpersonnel employed by the attorney general and responsible forinvestigating violations of sections 191.900 to 191.910 with allinformation known to such person about the violation within thirty daysafter the date on which the defendant first obtained the information;
(2) Such person fully cooperated with any government investigation ofsuch violation; and
(3) At the time such person furnished the personnel of the attorneygeneral with the information about the violation, no criminal prosecution,civil action, or administrative action had commenced with respect to suchviolation, and the person did not have actual knowledge of the existence ofan investigation into such violation.
13. Upon conviction pursuant to this section, the prosecutionauthority shall provide written notification of the conviction to allregulatory or disciplinary agencies with authority over the conduct of thedefendant health care provider.
14. The attorney general may bring a civil action against any personwho shall receive a health care payment as a result of a false statement orfalse representation of a material fact made or caused to be made by thatperson. The person shall be liable for up to double the amount of allpayments received by that person based upon the false statement or falserepresentation of a material fact, and the reasonable costs attributable tothe prosecution of the civil action. All such restitution shall be paidand deposited to the credit of the MO HealthNet fraud reimbursement fund,and all such cost reimbursements shall be paid and deposited to the creditof the MO HealthNet fraud prosecution revolving fund. No reimbursement ofsuch costs attributable to the prosecution of the civil action shall bemade or allowed except with the approval of the court having jurisdictionof the civil action. No civil action provided by this subsection shall bebrought if restitution and civil penalties provided by subsections 11 and12 of this section have been previously ordered against the person for thesame cause of action.
15. Any person who discovers a violation by himself or herself orsuch person's organization and who reports such information voluntarilybefore such information is public or known to the attorney general shallnot be prosecuted for a criminal violation.
False statement to receive health care payment prohibited--kickback,bribe, purpose, prohibited, exceptions--abuseprohibited--penalty--prosecution, procedure--Medicaid fraudreimbursement fund created--restitution--civilpenalty--notification to disciplinary agencies--civil actionauthorized.
191.905. 1. No health care provider shall knowingly make or cause tobe made a false statement or false representation of a material fact inorder to receive a health care payment, including but not limited to:
(1) Knowingly presenting to a health care payer a claim for a healthcare payment that falsely represents that the health care for which thehealth care payment is claimed was medically necessary, if in fact it wasnot;
(2) Knowingly concealing the occurrence of any event affecting aninitial or continued right under a medical assistance program to have ahealth care payment made by a health care payer for providing health care;
(3) Knowingly concealing or failing to disclose any information withthe intent to obtain a health care payment to which the health careprovider or any other health care provider is not entitled, or to obtain ahealth care payment in an amount greater than that which the health careprovider or any other health care provider is entitled;
(4) Knowingly presenting a claim to a health care payer that falselyindicates that any particular health care was provided to a person orpersons, if in fact health care of lesser value than that described in theclaim was provided.
2. No person shall knowingly solicit or receive any remuneration,including any kickback, bribe, or rebate, directly or indirectly, overtlyor covertly, in cash or in kind in return for:
(1) Referring another person to a health care provider for thefurnishing or arranging for the furnishing of any health care; or
(2) Purchasing, leasing, ordering or arranging for or recommendingpurchasing, leasing or ordering any health care.
3. No person shall knowingly offer or pay any remuneration, includingany kickback, bribe, or rebate, directly or indirectly, overtly orcovertly, in cash or in kind, to any person to induce such person to referanother person to a health care provider for the furnishing or arrangingfor the furnishing of any health care.
4. Subsections 2 and 3 of this section shall not apply to a discountor other reduction in price obtained by a health care provider if thereduction in price is properly disclosed and appropriately reflected in theclaim made by the health care provider to the health care payer, or anyamount paid by an employer to an employee for employment in the provisionof health care.
5. Exceptions to the provisions of subsections 2 and 3 of thissubsection shall be provided for as authorized in 42 U.S.C. Section1320a-7b(3)(E), as may be from time to time amended, and regulationspromulgated pursuant thereto.
6. No person shall knowingly abuse a person receiving health care.
7. A person who violates subsections 1 to 3 of this section is guiltyof a class C felony upon his or her first conviction, and shall be guiltyof a class B felony upon his or her second and subsequent convictions. Anyperson who has been convicted of such violations shall be referred to theOffice of Inspector General within the United States Department of Healthand Human Services. The person so referred shall be subject to thepenalties provided for under 42 U.S.C. Chapter 7, Subchapter XI, Section1320a-7. A prior conviction shall be pleaded and proven as provided bysection 558.021, RSMo. A person who violates subsection 6 of this sectionshall be guilty of a class C felony, unless the act involves no physical,sexual or emotional harm or injury and the value of the property involvedis less than five hundred dollars, in which event a violation of subsection6 of this section is a class A misdemeanor.
8. Any natural person who willfully prevents, obstructs, misleads,delays, or attempts to prevent, obstruct, mislead, or delay thecommunication of information or records relating to a violation of sections191.900 to 191.910 is guilty of a class D felony.
9. Each separate false statement or false representation of amaterial fact proscribed by subsection 1 of this section or act proscribedby subsection 2 or 3 of this section shall constitute a separate offenseand a separate violation of this section, whether or not made at the sameor different times, as part of the same or separate episodes, as part ofthe same scheme or course of conduct, or as part of the same claim.
10. In a prosecution pursuant to subsection 1 of this section,circumstantial evidence may be presented to demonstrate that a falsestatement or claim was knowingly made. Such evidence of knowledge mayinclude but shall not be limited to the following:
(1) A claim for a health care payment submitted with the health careprovider's actual, facsimile, stamped, typewritten or similar signature onthe claim for health care payment;
(2) A claim for a health care payment submitted by means of computerbilling tapes or other electronic means;
(3) A course of conduct involving other false claims submitted tothis or any other health care payer.
11. Any person convicted of a violation of this section, in additionto any fines, penalties or sentences imposed by law, shall be required tomake restitution to the federal and state governments, in an amount atleast equal to that unlawfully paid to or by the person, and shall berequired to reimburse the reasonable costs attributable to theinvestigation and prosecution pursuant to sections 191.900 to 191.910. Allof such restitution shall be paid and deposited to the credit of the "MOHealthNet Fraud Reimbursement Fund", which is hereby established in thestate treasury. Moneys in the MO HealthNet fraud reimbursement fund shallbe divided and appropriated to the federal government and affected stateagencies in order to refund moneys falsely obtained from the federal andstate governments. All of such cost reimbursements attributable to theinvestigation and prosecution shall be paid and deposited to the credit ofthe "MO HealthNet Fraud Prosecution Revolving Fund", which is herebyestablished in the state treasury. Moneys in the MO HealthNet fraudprosecution revolving fund may be appropriated to the attorney general, orto any prosecuting or circuit attorney who has successfully prosecuted anaction for a violation of sections 191.900 to 191.910 and been awarded suchcosts of prosecution, in order to defray the costs of the attorney generaland any such prosecuting or circuit attorney in connection with theirduties provided by sections 191.900 to 191.910. No moneys shall be paidinto the MO HealthNet fraud protection revolving fund pursuant to thissubsection unless the attorney general or appropriate prosecuting orcircuit attorney shall have commenced a prosecution pursuant to thissection, and the court finds in its discretion that payment of attorneys'fees and investigative costs is appropriate under all the circumstances,and the attorney general and prosecuting or circuit attorney shall prove tothe court those expenses which were reasonable and necessary to theinvestigation and prosecution of such case, and the court approves suchexpenses as being reasonable and necessary. Any moneys remaining in the MOHealthNet fraud reimbursement fund after division and appropriation to thefederal government and affected state agencies shall be used to increase MOHealthNet provider reimbursement until it is at least one hundred percentof the Medicare provider reimbursement rate for comparable services. Theprovisions of section 33.080, RSMo, notwithstanding, moneys in the MOHealthNet fraud prosecution revolving fund shall not lapse at the end ofthe biennium.
12. A person who violates subsections 1 to 3 of this section shall beliable for a civil penalty of not less than five thousand dollars and notmore than ten thousand dollars for each separate act in violation of suchsubsections, plus three times the amount of damages which the state andfederal government sustained because of the act of that person, except thatthe court may assess not more than two times the amount of damages whichthe state and federal government sustained because of the act of theperson, if the court finds:
(1) The person committing the violation of this section furnishedpersonnel employed by the attorney general and responsible forinvestigating violations of sections 191.900 to 191.910 with allinformation known to such person about the violation within thirty daysafter the date on which the defendant first obtained the information;
(2) Such person fully cooperated with any government investigation ofsuch violation; and
(3) At the time such person furnished the personnel of the attorneygeneral with the information about the violation, no criminal prosecution,civil action, or administrative action had commenced with respect to suchviolation, and the person did not have actual knowledge of the existence ofan investigation into such violation.
13. Upon conviction pursuant to this section, the prosecutionauthority shall provide written notification of the conviction to allregulatory or disciplinary agencies with authority over the conduct of thedefendant health care provider.
14. The attorney general may bring a civil action against any personwho shall receive a health care payment as a result of a false statement orfalse representation of a material fact made or caused to be made by thatperson. The person shall be liable for up to double the amount of allpayments received by that person based upon the false statement or falserepresentation of a material fact, and the reasonable costs attributable tothe prosecution of the civil action. All such restitution shall be paidand deposited to the credit of the MO HealthNet fraud reimbursement fund,and all such cost reimbursements shall be paid and deposited to the creditof the MO HealthNet fraud prosecution revolving fund. No reimbursement ofsuch costs attributable to the prosecution of the civil action shall bemade or allowed except with the approval of the court having jurisdictionof the civil action. No civil action provided by this subsection shall bebrought if restitution and civil penalties provided by subsections 11 and12 of this section have been previously ordered against the person for thesame cause of action.
15. Any person who discovers a violation by himself or herself orsuch person's organization and who reports such information voluntarilybefore such information is public or known to the attorney general shallnot be prosecuted for a criminal violation.
False statement to receive health care payment prohibited--kickback,bribe, purpose, prohibited, exceptions--abuseprohibited--penalty--prosecution, procedure--Medicaid fraudreimbursement fund created--restitution--civilpenalty--notification to disciplinary agencies--civil actionauthorized.
191.905. 1. No health care provider shall knowingly make or cause tobe made a false statement or false representation of a material fact inorder to receive a health care payment, including but not limited to:
(1) Knowingly presenting to a health care payer a claim for a healthcare payment that falsely represents that the health care for which thehealth care payment is claimed was medically necessary, if in fact it wasnot;
(2) Knowingly concealing the occurrence of any event affecting aninitial or continued right under a medical assistance program to have ahealth care payment made by a health care payer for providing health care;
(3) Knowingly concealing or failing to disclose any information withthe intent to obtain a health care payment to which the health careprovider or any other health care provider is not entitled, or to obtain ahealth care payment in an amount greater than that which the health careprovider or any other health care provider is entitled;
(4) Knowingly presenting a claim to a health care payer that falselyindicates that any particular health care was provided to a person orpersons, if in fact health care of lesser value than that described in theclaim was provided.
2. No person shall knowingly solicit or receive any remuneration,including any kickback, bribe, or rebate, directly or indirectly, overtlyor covertly, in cash or in kind in return for:
(1) Referring another person to a health care provider for thefurnishing or arranging for the furnishing of any health care; or
(2) Purchasing, leasing, ordering or arranging for or recommendingpurchasing, leasing or ordering any health care.
3. No person shall knowingly offer or pay any remuneration, includingany kickback, bribe, or rebate, directly or indirectly, overtly orcovertly, in cash or in kind, to any person to induce such person to referanother person to a health care provider for the furnishing or arrangingfor the furnishing of any health care.
4. Subsections 2 and 3 of this section shall not apply to a discountor other reduction in price obtained by a health care provider if thereduction in price is properly disclosed and appropriately reflected in theclaim made by the health care provider to the health care payer, or anyamount paid by an employer to an employee for employment in the provisionof health care.
5. Exceptions to the provisions of subsections 2 and 3 of thissubsection shall be provided for as authorized in 42 U.S.C. Section1320a-7b(3)(E), as may be from time to time amended, and regulationspromulgated pursuant thereto.
6. No person shall knowingly abuse a person receiving health care.
7. A person who violates subsections 1 to 3 of this section is guiltyof a class C felony upon his or her first conviction, and shall be guiltyof a class B felony upon his or her second and subsequent convictions. Anyperson who has been convicted of such violations shall be referred to theOffice of Inspector General within the United States Department of Healthand Human Services. The person so referred shall be subject to thepenalties provided for under 42 U.S.C. Chapter 7, Subchapter XI, Section1320a-7. A prior conviction shall be pleaded and proven as provided bysection 558.021, RSMo. A person who violates subsection 6 of this sectionshall be guilty of a class C felony, unless the act involves no physical,sexual or emotional harm or injury and the value of the property involvedis less than five hundred dollars, in which event a violation of subsection6 of this section is a class A misdemeanor.
8. Any natural person who willfully prevents, obstructs, misleads,delays, or attempts to prevent, obstruct, mislead, or delay thecommunication of information or records relating to a violation of sections191.900 to 191.910 is guilty of a class D felony.
9. Each separate false statement or false representation of amaterial fact proscribed by subsection 1 of this section or act proscribedby subsection 2 or 3 of this section shall constitute a separate offenseand a separate violation of this section, whether or not made at the sameor different times, as part of the same or separate episodes, as part ofthe same scheme or course of conduct, or as part of the same claim.
10. In a prosecution pursuant to subsection 1 of this section,circumstantial evidence may be presented to demonstrate that a falsestatement or claim was knowingly made. Such evidence of knowledge mayinclude but shall not be limited to the following:
(1) A claim for a health care payment submitted with the health careprovider's actual, facsimile, stamped, typewritten or similar signature onthe claim for health care payment;
(2) A claim for a health care payment submitted by means of computerbilling tapes or other electronic means;
(3) A course of conduct involving other false claims submitted tothis or any other health care payer.
11. Any person convicted of a violation of this section, in additionto any fines, penalties or sentences imposed by law, shall be required tomake restitution to the federal and state governments, in an amount atleast equal to that unlawfully paid to or by the person, and shall berequired to reimburse the reasonable costs attributable to theinvestigation and prosecution pursuant to sections 191.900 to 191.910. Allof such restitution shall be paid and deposited to the credit of the "MOHealthNet Fraud Reimbursement Fund", which is hereby established in thestate treasury. Moneys in the MO HealthNet fraud reimbursement fund shallbe divided and appropriated to the federal government and affected stateagencies in order to refund moneys falsely obtained from the federal andstate governments. All of such cost reimbursements attributable to theinvestigation and prosecution shall be paid and deposited to the credit ofthe "MO HealthNet Fraud Prosecution Revolving Fund", which is herebyestablished in the state treasury. Moneys in the MO HealthNet fraudprosecution revolving fund may be appropriated to the attorney general, orto any prosecuting or circuit attorney who has successfully prosecuted anaction for a violation of sections 191.900 to 191.910 and been awarded suchcosts of prosecution, in order to defray the costs of the attorney generaland any such prosecuting or circuit attorney in connection with theirduties provided by sections 191.900 to 191.910. No moneys shall be paidinto the MO HealthNet fraud protection revolving fund pursuant to thissubsection unless the attorney general or appropriate prosecuting orcircuit attorney shall have commenced a prosecution pursuant to thissection, and the court finds in its discretion that payment of attorneys'fees and investigative costs is appropriate under all the circumstances,and the attorney general and prosecuting or circuit attorney shall prove tothe court those expenses which were reasonable and necessary to theinvestigation and prosecution of such case, and the court approves suchexpenses as being reasonable and necessary. Any moneys remaining in the MOHealthNet fraud reimbursement fund after division and appropriation to thefederal government and affected state agencies shall be used to increase MOHealthNet provider reimbursement until it is at least one hundred percentof the Medicare provider reimbursement rate for comparable services. Theprovisions of section 33.080, RSMo, notwithstanding, moneys in the MOHealthNet fraud prosecution revolving fund shall not lapse at the end ofthe biennium.
12. A person who violates subsections 1 to 3 of this section shall beliable for a civil penalty of not less than five thousand dollars and notmore than ten thousand dollars for each separate act in violation of suchsubsections, plus three times the amount of damages which the state andfederal government sustained because of the act of that person, except thatthe court may assess not more than two times the amount of damages whichthe state and federal government sustained because of the act of theperson, if the court finds:
(1) The person committing the violation of this section furnishedpersonnel employed by the attorney general and responsible forinvestigating violations of sections 191.900 to 191.910 with allinformation known to such person about the violation within thirty daysafter the date on which the defendant first obtained the information;
(2) Such person fully cooperated with any government investigation ofsuch violation; and
(3) At the time such person furnished the personnel of the attorneygeneral with the information about the violation, no criminal prosecution,civil action, or administrative action had commenced with respect to suchviolation, and the person did not have actual knowledge of the existence ofan investigation into such violation.
13. Upon conviction pursuant to this section, the prosecutionauthority shall provide written notification of the conviction to allregulatory or disciplinary agencies with authority over the conduct of thedefendant health care provider.
14. The attorney general may bring a civil action against any personwho shall receive a health care payment as a result of a false statement orfalse representation of a material fact made or caused to be made by thatperson. The person shall be liable for up to double the amount of allpayments received by that person based upon the false statement or falserepresentation of a material fact, and the reasonable costs attributable tothe prosecution of the civil action. All such restitution shall be paidand deposited to the credit of the MO HealthNet fraud reimbursement fund,and all such cost reimbursements shall be paid and deposited to the creditof the MO HealthNet fraud prosecution revolving fund. No reimbursement ofsuch costs attributable to the prosecution of the civil action shall bemade or allowed except with the approval of the court having jurisdictionof the civil action. No civil action provided by this subsection shall bebrought if restitution and civil penalties provided by subsections 11 and12 of this section have been previously ordered against the person for thesame cause of action.
15. Any person who discovers a violation by himself or herself orsuch person's organization and who reports such information voluntarilybefore such information is public or known to the attorney general shallnot be prosecuted for a criminal violation.
