Louisiana Revised Statutes 46:438.3 – False or fraudulent claim; misrepresentation
Terms Used In Louisiana Revised Statutes 46:438.3
- 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
- Contract: A legal written agreement that becomes binding when signed.
- Damages: Money paid by defendants to successful plaintiffs in civil cases to compensate the plaintiffs for their injuries.
- 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
- knowingly: means that the person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information. See Louisiana Revised Statutes 46:437.3
- 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
- Misrepresentation: means the knowing failure to truthfully or fully disclose any and all information required, or the concealment of any and all information required on a claim or a provider agreement or the making of a false or misleading statement to the department relative to the medical assistance programs. See Louisiana Revised Statutes 46:437.3
- Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period.
- Obligation: means an established duty, whether or not fixed, arising from an express or implied contractual, grantor, grantee, or licensor-licensee relationship, from a free-based or similar relationship, from statute or regulation, or from the retention of any overpayment. See Louisiana Revised Statutes 46:437.3
- Payment: means the payment to a health care provider from medical assistance programs funds pursuant to a claim, or the attempt to seek payment for a claim. See Louisiana Revised Statutes 46:437.3
- Property: means any and all property, movable and immovable, corporeal and incorporeal. See Louisiana Revised Statutes 46:437.3
- 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. No person shall knowingly present or cause to be presented a false or fraudulent claim.
B. No person shall knowingly engage in misrepresentation or make, use, or cause to be made or used, a false record or statement material to a false or fraudulent claim.
C. No person shall knowingly make, use, or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the medical assistance programs, or to knowingly conceal, avoid, or decrease an obligation to pay or transmit money or property to the medical assistance programs.
D. No person shall conspire to defraud, or attempt to defraud, the medical assistance programs through misrepresentation or by obtaining, or attempting to obtain, payment for a false or fraudulent claim.
E.(1) No person shall knowingly submit a claim for goods, services, or supplies which were medically unnecessary or which were of substandard quality or quantity.
(2) If a managed care health care provider or a health care provider operating under a voucher system under the medical assistance programs fails to provide medically necessary goods, services, or supplies or goods, services, or supplies which are of substandard quality or quantity to a recipient, and those goods, services, or supplies are covered under the managed care contract or voucher contract with the medical assistance programs, such failure shall constitute a violation of Paragraph (1) of this Subsection.
(3) “Substandard quality” in reference to services applicable to medical care as used in this Subsection shall mean substandard as to the appropriate standard of care as used to determine medical malpractice, including but not limited to the standard of care provided in La. Rev. Stat. 9:2794.
F. Each violation of this Section may be treated as a separate violation or may be combined into one violation at the option of the secretary or the attorney general.
G. No action shall be brought under this Section unless the amount of alleged actual damages is one thousand dollars or more.
H. No action brought pursuant to this Section shall be instituted later than ten years after the date upon which the alleged violation occurred.
Acts 1997, No. 1373, §1; Acts 2007, No. 14, §1, eff. June 18, 2007; Acts 2009, No. 426, §1; Acts 2011, No. 185, §1.