Utah Code 26B-3-1106. False claims for medical benefits prohibited
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(1) A person may not make or present or cause to be made or presented to an employee or officer of the state a claim for a medical benefit:
Terms Used In Utah Code 26B-3-1106
- Benefit: means the receipt of money, goods, or any other thing of pecuniary value. See Utah Code 26B-3-1101
- Claim: means any request or demand for money or property:(2)(a) made to any:(2)(a)(i) employee, officer, or agent of the state;(2)(a)(ii) contractor with the state; or(2)(a)(iii) grantee or other recipient, whether or not under contract with the state; and(2)(b) if:(2)(b)(i) any portion of the money or property requested or demanded was issued from or provided by the state; or(2)(b)(ii) the state will reimburse the contractor, grantee, or other recipient for any portion of the money or property. See Utah Code 26B-3-1101
- Medical benefit: means a benefit paid or payable to:
(6)(a) a health care provider; or(6)(b) a recipient or a provider under a program administered by the state under:(6)(b)(i) Titles V and XIX of the federal Social Security Act;(6)(b)(ii) Title X of the federal Public Health Services Act;(6)(b)(iii) the federal Child Nutrition Act of 1966 as amended by Pub. See Utah Code 26B-3-1101- Person: means an individual, corporation, unincorporated association, professional corporation, partnership, or other form of business association. See Utah Code 26B-3-1101
- Recipient: means a person who has received medical assistance under the Medicaid program. See Utah Code 26B-3-101
- State: when applied to the different parts of the United States, includes a state, district, or territory of the United States. See Utah Code 68-3-12.5
(1)(a) which is wholly or partially false, fictitious, or fraudulent;(1)(b) for services which were not rendered or for items or materials which were not delivered;(1)(c) which misrepresents the type, quality, or quantity of items or services rendered;(1)(d) representing charges at a higher rate than those charged by the provider to the general public;(1)(e) for items or services which the person or the provider knew were not medically necessary in accordance with professionally recognized standards;(1)(f) which has previously been paid;(1)(g) for services also covered by one or more private sources when the person or provider knew of the private sources without disclosing those sources on the claim; or(1)(h) where a provider:(1)(h)(i) unbundles a product, procedure, or group of procedures usually and customarily provided or performed as a single billable product or procedure into artificial components or separate procedures; and(1)(h)(ii) bills for each component of the product, procedure, or group of procedures:(1)(h)(ii)(A) as if they had been provided or performed independently and at separate times; and(1)(h)(ii)(B) the aggregate billing for the components exceeds the amount otherwise billable for the usual and customary single product or procedure.(2) In addition to the prohibitions in Subsection (1), a person may not:(2)(a) fail to credit the state for payments received from other sources;(2)(b) recover or attempt to recover payment in violation of the provider agreement from:(2)(b)(i) a recipient under a medical benefit program; or(2)(b)(ii) the recipient’s family;(2)(c) falsify or alter with intent to deceive, any report or document required by state or federal law, rule, or Medicaid provider agreement;(2)(d) retain any unauthorized payment as a result of acts described by this section; or(2)(e) aid or abet the commission of any act prohibited by this section. - Medical benefit: means a benefit paid or payable to: