Louisiana Revised Statutes 46:438.8 – Burden of proof; prima facie evidence; standard of review
Terms Used In Louisiana Revised Statutes 46:438.8
- Claim: means any request or demand, whether under a contract or otherwise, for money or property, whether or not the state or department has title to the money or property, that is drawn in whole or in part on medical assistance programs funds that are either of the following:
(a) Presented to an officer, employee, or agent of the state or department. See Louisiana Revised Statutes 46:437.3
- Conviction: A judgement of guilt against a criminal defendant.
- Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- False or fraudulent claim: means a claim which the health care provider or his billing agent submits knowing the claim to be false, fictitious, untrue, or misleading in regard to any material information. See Louisiana Revised Statutes 46:437.3
- Health care provider: means any person furnishing or claiming to furnish a good, service, or supply under the medical assistance programs, any other person defined as a health care provider by federal or state law or by rule, and a provider-in-fact. See Louisiana Revised Statutes 46:437.3
- Indictment: The formal charge issued by a grand jury stating that there is enough evidence that the defendant committed the crime to justify having a trial; it is used primarily for felonies.
- Material: means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property. See Louisiana Revised Statutes 46:437.3
- Medical assistance programs: means the Medical Assistance Program (Title XIX of the Social Security Act), commonly referred to as "Medicaid" and other programs operated by and funded in the department which provide payment to health care providers. See Louisiana Revised Statutes 46:437.3
- Nolo contendere: No contest-has the same effect as a plea of guilty, as far as the criminal sentence is concerned, but may not be considered as an admission of guilt for any other purpose.
- Order: means a final order imposed pursuant to an administrative adjudication. See Louisiana Revised Statutes 46:437.3
- Plea: In a criminal case, the defendant's statement pleading "guilty" or "not guilty" in answer to the charges, a declaration made in open court.
- Recipient: means an individual who is eligible to receive health care through the medical assistance programs. See Louisiana Revised Statutes 46:437.3
- Secretary: means the secretary of the Louisiana Department of Health, or his authorized designee. See Louisiana Revised Statutes 46:437.3
A. The burden of proof in an action instituted pursuant to this Part shall be on the medical assistance programs and by a preponderance of the evidence, except that the defendant shall carry the burden of proving that goods, services, or supplies were actually provided to an eligible recipient in the quantity and quality submitted on a claim. In all other aspects, the burden of proof shall be as set forth in the Code of Civil Procedure and other applicable laws.
B. Proof by a preponderance of the evidence of a false or fraudulent claim or illegal remuneration shall be deemed to exist under the following circumstances:
(1) If the defendant has pled guilty to, been convicted of, or entered a nolo contendere plea to a criminal charge in any federal or state court to charges arising out of the same circumstances as would be a violation of this Subpart.
(2) If an order has been rendered against a defendant finding the defendant to have violated this Subpart.
C.(1) The submission of a certified or true copy of an order, civil judgment, or criminal conviction or plea shall be prima facie evidence of the same.
(2) The submission of the bill of information or of the indictment and the minutes of the court shall be prima facie evidence as to the circumstances underlying a criminal conviction or plea.
D.(1) In determining whether a pattern of incorrect submissions exists in regard to an alleged false or fraudulent claim, the court shall give consideration as to whether the total amount of the incorrect submissions by a health care provider is material in relation to the total claims submitted by the health care provider.
(2) “Material” as used in this Subsection shall have the same meaning as defined by rules and regulation promulgated by the secretary in accordance with the Administrative Procedure Act which incorporate the same definition of “material” as recognized by the American Institute of Certified Public Accountants.
Acts 1997, No. 1373, §1.