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| THE GENERAL ASSEMBLY OF PENNSYLVANIA |
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| HOUSE BILL |
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| INTRODUCED BY DAVIS, DeLUCA, BARRAR, CARROLL, D. COSTA, FABRIZIO, HORNAMAN, JOSEPHS, W. KELLER, KOTIK, MANN, MATZIE, MUNDY, M. O'BRIEN, PASHINSKI, SANTARSIERO, M. SMITH AND STURLA, FEBRUARY 14, 2011 |
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| REFERRED TO COMMITTEE ON JUDICIARY, FEBRUARY 14, 2011 |
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| AN ACT |
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1 | Amending Title 18 (Crimes and Offenses) of the Pennsylvania |
2 | Consolidated Statutes, providing for health care program |
3 | fraud. |
4 | The General Assembly of the Commonwealth of Pennsylvania |
5 | hereby enacts as follows: |
6 | Section 1. Title 18 of the Pennsylvania Consolidated |
7 | Statutes is amended by adding a section to read: |
8 | § 7332. Health care program fraud. |
9 | (a) Prohibitions.--A person shall not: |
10 | (1) Knowingly make, cause to be made or aid and abet in |
11 | the making of a false statement or false representation of a |
12 | material fact, by commission or omission, in a claim |
13 | submitted to the agency or its fiscal agent or a managed care |
14 | plan for payment. |
15 | (2) Knowingly make, cause to be made or aid and abet in |
16 | the making of a claim for items or services that are not |
17 | authorized to be reimbursed by the Medicaid or other health |
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1 | care program. |
2 | (3) Knowingly charge, solicit, accept or receive |
3 | anything of value, other than an authorized copayment from a |
4 | Medicaid or other health care program recipient, from a |
5 | source in addition to the amount payable for an item or |
6 | service provided to a Medicaid or other health care program |
7 | recipient under the Medicaid or other health care program or |
8 | knowingly fail to credit the agency or its fiscal agent for a |
9 | payment received from a third-party source. |
10 | (4) Knowingly make or cause to be made a false statement |
11 | or false representation of a material fact, by commission or |
12 | omission, in a document containing items of income and |
13 | expense that is or may be used by the agency to determine a |
14 | general or specific rate of payment for an item or service |
15 | provided by a provider. |
16 | (5) Knowingly solicit, offer, pay or receive |
17 | remuneration, including a kickback, bribe or rebate, directly |
18 | or indirectly, overtly or covertly, in cash or in kind, in |
19 | return for referring an individual to a person for the |
20 | furnishing or arranging for the furnishing of an item or |
21 | service for which payment may be made, in whole or in part, |
22 | under the Medicaid or other health care program, or in return |
23 | for obtaining, purchasing, leasing, ordering or arranging for |
24 | or recommending, obtaining, purchasing, leasing or ordering a |
25 | good, facility, item or service, for which payment may be |
26 | made, in whole or in part, under the Medicaid or other health |
27 | care program. |
28 | (6) Knowingly submit false or misleading information or |
29 | statements to the Medicaid or other health care program for |
30 | the purpose of being accepted as a Medicaid or health care |
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1 | provider. |
2 | (7) Knowingly use or attempt to use a Medicaid or health |
3 | care provider's identification number or a Medicaid or |
4 | recipient's identification number to make, cause to be made |
5 | or aid and abet in the making of a claim for items or |
6 | services that are not authorized to be reimbursed by the |
7 | Medicaid or other health care program. |
8 | (b) Penalties.--A person who violates this subsection and |
9 | receives or attempts to receive something with a value of: |
10 | (1) $10,000 or less commits a felony of the third |
11 | degree. |
12 | (2) More than $10,000, but less than $50,000, commits a |
13 | felony of the second degree. |
14 | (3) $50,000 or more commits a felony of the first |
15 | degree. |
16 | (c) Aggregation.--The value of separate funds, goods or |
17 | services that a person received or attempted to receive under a |
18 | scheme or course of conduct may be aggregated in determining the |
19 | degree of the offense. |
20 | (d) Fine.--In addition to the sentence authorized by law, a |
21 | person who is convicted of a violation of this section shall pay |
22 | a fine in an amount equal to five times the pecuniary gain |
23 | unlawfully received or the loss incurred by the Medicaid or |
24 | other health care program or managed care organization, |
25 | whichever is greater. |
26 | (e) Effect of repayment.--The repayment of Medicaid or |
27 | health care program payments wrongfully obtained, or the offer |
28 | or endeavor to repay Medicaid or health care program funds |
29 | wrongfully obtained, does not constitute a defense to, or a |
30 | ground for dismissal of, criminal charges brought under this |
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1 | section. |
2 | (f) Records.--Records in the custody of the agency or its |
3 | fiscal agent which relate to Medicaid or health care program |
4 | provider fraud are business records within the meaning of 42 |
5 | Pa.C.S. § 6108 (relating to business records). |
6 | (g) Claims with false statements.--Proof that a claim was |
7 | submitted to the agency or its fiscal agent which contained a |
8 | false statement or a false representation of a material fact, by |
9 | commission or omission, unless satisfactorily explained, gives |
10 | rise to an inference that the person whose signature appears as |
11 | the provider's authorizing signature on the claim form, or whose |
12 | signature appears on an agency's electronic claim submission |
13 | agreement submitted for claims made to the fiscal agent by |
14 | electronic means, had knowledge of the false statement or false |
15 | representation. This subsection applies whether the signature |
16 | appears on the claim form or the electronic claim submission |
17 | agreement by means of handwriting, typewriting, facsimile |
18 | signature stamp, computer impulse, initials or otherwise. |
19 | (h) Other claims with false statements.--Proof of submission |
20 | to the agency or its fiscal agent of a document containing items |
21 | of income and expense, which document is used or that may be |
22 | used by the agency or its fiscal agent to determine a general or |
23 | specific rate of payment and which document contains a false |
24 | statement or a false representation of a material fact, by |
25 | commission or omission, unless satisfactorily explained, gives |
26 | rise to the inference that the person who signed the |
27 | certification of the document had knowledge of the false |
28 | statement or representation. This subsection applies whether the |
29 | signature appears on the document by means of handwriting, |
30 | typewriting, facsimile signature stamp, electronic transmission, |
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1 | initials or otherwise. |
2 | (i) Immunity.--A person who provides the Commonwealth, a |
3 | Commonwealth agency, a political subdivision or an agency of a |
4 | political subdivision with information about fraud or suspected |
5 | fraud by a Medicaid or health care program provider, including a |
6 | managed care organization, is immune from civil liability for |
7 | providing the information unless the person acted fraudulently |
8 | or in bad faith. |
9 | (j) Definitions.--As used in this section, the following |
10 | words and phrases shall have the meanings given to them in this |
11 | subsection unless the context clearly indicates otherwise: |
12 | "Adult basic program." The program created under Chapter 13 |
13 | of the act of June 26, 2001 (P.L.755, No.77), known as the |
14 | Tobacco Settlement Act. |
15 | "Agency." An executive agency of the Commonwealth that |
16 | administers, manages or finances a health care services program |
17 | on behalf of the residents of this Commonwealth. |
18 | "Children's Health Insurance Program." The children's health |
19 | care program established under Article XXIII of the act of May |
20 | 17, 1921 (P.L.682, No.284), known as The Insurance Company Law |
21 | of 1921. |
22 | "Fiscal agent." An individual, firm, corporation, |
23 | partnership, organization or other legal entity that has |
24 | contracted with the agency to receive, process and adjudicate |
25 | claims under the Medicaid or other agency program. |
26 | "Health care program." A health care program administered, |
27 | managed or financed through an executive agency of the |
28 | Commonwealth, including the Medicaid program, the Children's |
29 | Health Insurance Program and the adultBasic Program. |
30 | "Item or service." Includes: |
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1 | (1) a particular item, device, medical supply or service |
2 | claimed to have been provided to a recipient and listed in an |
3 | itemized claim for payment; or |
4 | (2) in the case of a claim based on costs, an entry in |
5 | the cost report, books of account or other documents |
6 | supporting the claim. |
7 | "Knowingly." Describes an act done voluntarily and |
8 | intentionally and not because of mistake or accident. The term |
9 | includes the term "willful" or "willfully" which means that an |
10 | act was committed voluntarily and purposely, with the specific |
11 | intent to do something that the law forbids, and that the act |
12 | was committed with bad purpose, either to disobey or disregard |
13 | the law. |
14 | "Managed care plan." A company or health insurance entity |
15 | licensed under the act of May 17, 1921 (P.L.682, No.284), known |
16 | as The Insurance Company Law of 1921, to issue an individual or |
17 | group health, sickness or accident policy or subscriber contract |
18 | or certificate or plan that provides medical or health care |
19 | coverage by a health care facility or licensed health care |
20 | provider that is offered or governed under this section or the |
21 | following: |
22 | (1) The act of December 29, 1972 (P.L.1701, No.364), |
23 | known as the Health Maintenance Organization Act. |
24 | (2) The act of May 18, 1976 (P.L.123, No.54), known as |
25 | the Individual Accident and Sickness Insurance Minimum |
26 | Standards Act. |
27 | (3) 40 Pa.C.S. Ch. 61 (relating to hospital plan |
28 | corporations) or 63 (relating to professional health services |
29 | plan corporations). |
30 | (4) Article XXIV of The Insurance Company Law of 1921. |
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1 | "Medicaid" or "Medical assistance." The program of medical |
2 | assistance established under the act of June 13, 1967 (P.L.31, |
3 | No.21), known as the Public Welfare Code. |
4 | Section 2. This act shall take effect in 60 days. |
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