(1) A person shall not make or present or cause to be made or presented to a health care corporation or health care insurer a claim for payment of health care benefits knowing the claim to be false.

(2) A person shall not make or present or cause to be made or presented to a health care corporation or health care insurer a claim for payment of health care benefits which he or she knows falsely represents that the goods or services were medically necessary in accordance with professionally accepted standards. Each claim which violates this subsection shall constitute a separate offense. A health facility or agency shall not be liable under this subsection unless the health facility or agency, pursuant to a conspiracy, combination, or collusion with a physician or other provider, falsely represents the medical necessity of the particular goods or services for which the claim was made.

Terms Used In Michigan Laws 752.1003

  • Claim: means any attempt to cause a health care corporation or health care insurer to make the payment of a health care benefit. See Michigan Laws 752.1002
  • Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
  • False: means wholly or partially untrue or deceptive. See Michigan Laws 752.1002
  • Felony: A crime carrying a penalty of more than a year in prison.
  • Health care benefit: means the right under a contract or a certificate or policy of insurance to have a payment made by a health care corporation or health care insurer for a specified health care service. See Michigan Laws 752.1002
  • Health care corporation: means a nonprofit dental care corporation incorporated under Act No. See Michigan Laws 752.1002
  • Health care insurer: means any insurance company authorized to provide health insurance in this state or any legal entity which is self-insured and providing health care benefits to its employees. See Michigan Laws 752.1002
  • Health facility or agency: means a health facility or agency, as defined in section 20106 of the public health code, Act No. See Michigan Laws 752.1002
  • knowingly: means that a person is in possession of facts under which he or she is aware or should be aware of the nature of his or her conduct and that his or her conduct is substantially certain to cause the payment of a health care benefit. See Michigan Laws 752.1002
  • Person: means an individual, corporation, partnership, association, or any other legal entity. See Michigan Laws 752.1002

(3) A person shall not knowingly make or cause to be made a false statement or false representation of a material fact to a health care corporation or health care insurer for use in determining rights to health care benefits. Each claim which violates this subsection shall constitute a separate violation.

(4) A person who, having knowledge of the occurrence of an event affecting his or her initial or continued right to receive a health care benefit, or the continued right of any other person on whose behalf he or she has applied for or is receiving a health care benefit, shall not conceal or fail to disclose that event with intent to obtain a health care benefit to which the person or any other person is not entitled, or to obtain a health care benefit in an amount greater than that to which the person or any other person is entitled.

(5) A person who violates this section is guilty of a felony punishable by imprisonment for not more than 4 years, or by a fine of not more than $50,000.00, or both.

(6) This section does not apply to statements made on an application for coverage under a certificate or policy of insurance issued by a health care insurer or coverage under a certificate issued by a health care corporation.