26-20-7 - False claims for medical benefits prohibited. - Utah Statutes

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Statutes > Utah > Title-26 > Chapter-20 > 26-20-7

26-20-7. False claims for medical benefits prohibited.
(1) A person may not make or present or cause to be made or presented to an employeeor 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 notdelivered;
(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 generalpublic;
(e) for items or services which the person or the provider knew were not medicallynecessary 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 providerknew 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 customarilyprovided or performed as a single billable product or procedure into artificial components orseparate 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 forthe 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 orfederal 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.

Amended by Chapter 48, 2007 General Session

State Codes and Statutes

Statutes > Utah > Title-26 > Chapter-20 > 26-20-7

26-20-7. False claims for medical benefits prohibited.
(1) A person may not make or present or cause to be made or presented to an employeeor 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 notdelivered;
(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 generalpublic;
(e) for items or services which the person or the provider knew were not medicallynecessary 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 providerknew 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 customarilyprovided or performed as a single billable product or procedure into artificial components orseparate 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 forthe 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 orfederal 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.

Amended by Chapter 48, 2007 General Session

State Codes and Statutes

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State Codes and Statutes

Statutes > Utah > Title-26 > Chapter-20 > 26-20-7

26-20-7. False claims for medical benefits prohibited.
(1) A person may not make or present or cause to be made or presented to an employeeor 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 notdelivered;
(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 generalpublic;
(e) for items or services which the person or the provider knew were not medicallynecessary 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 providerknew 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 customarilyprovided or performed as a single billable product or procedure into artificial components orseparate 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 forthe 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 orfederal 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.

Amended by Chapter 48, 2007 General Session