26B-3-1106. False claims for medical benefits prohibited.
(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:
(a)
made to any:
(i)
employee, officer, or agent of the state;
(ii)
contractor with the state; or
(iii)
grantee or other recipient, whether or not under contract with the state; and
(b)
if:
(i)
any portion of the money or property requested or demanded was issued from or provided by the state; or
(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:
(a)
a health care provider; or
(b)
a recipient or a provider under a program administered by the state under:
(i)
Titles V and XIX of the federal Social Security Act;
(ii)
Title X of the federal Public Health Services Act;
(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
(a)
which is wholly or partially false, fictitious, or fraudulent;
(b)
for services which were not rendered or for items or materials which were not delivered;
(c)
which misrepresents the type, quality, or quantity of items or services rendered;
(d)
representing charges at a higher rate than those charged by the provider to the general public;
(e)
for items or services which the person or the provider knew were not medically necessary in accordance with professionally recognized standards;
(f)
which has previously been paid;
(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
(h)
where a provider:
(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
(ii)
bills for each component of the product, procedure, or group of procedures:
(A)
as if they had been provided or performed independently and at separate times; and
(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:
(a)
fail to credit the state for payments received from other sources;
(b)
recover or attempt to recover payment in violation of the provider agreement from:
(i)
a recipient under a medical benefit program; or
(ii)
the recipient’s family;
(c)
falsify or alter with intent to deceive, any report or document required by state or federal law, rule, or Medicaid provider agreement;
(d)
retain any unauthorized payment as a result of acts described by this section; or
(e)
aid or abet the commission of any act prohibited by this section.
Renumbered and Amended by Chapter 306, 2023 General Session
