§ 40-8.2-3 - Prohibited acts.
SECTION 40-8.2-3
§ 40-8.2-3 Prohibited acts. – (a) It shall be unlawful for any person intentionally to:
(1) Present or cause to be presented for preauthorization orpayment to the Rhode Island Medicaid program:
(i) Any materially false or fraudulent claim or cost reportfor the furnishing of services or merchandise; or
(ii) Present or cause to be presented for preauthorization orpayment, any claim or cost report for medically unnecessary services ormerchandise; or
(iii) To submit or cause to be submitted materially false orfraudulent information, for the intentional purpose(s) of obtaining greatercompensation than that to which the provider is legally entitled for thefurnishing of services or merchandise; or
(iv) Submit or cause to be submitted materially falseinformation for the purpose of obtaining authorization for furnishing servicesor merchandise; or
(v) Submit or cause to be submitted any claim or cost reportor other document which fails to make full disclosure of material information.
(2) Solicit, receive, offer, or pay any remuneration,including any kickback, bribe, or rebate, directly or indirectly, in cash or inkind, to induce referrals from or to any person in return for furnishing ofservices or merchandise or in return for referring an individual to a personfor the furnishing of any services or merchandise for which payment may bemade, in whole or in part, under the Rhode Island Medicaid program.
(ii) Provided, however, that in any prosecution under thissubsection, it shall not be necessary for the state to prove that theremuneration returned was taken from any particular expenditure made by aperson.
(3) Submit or cause to be submitted a duplicate claim forservices, supplies, or merchandise to the Rhode Island Medicaid program forwhich the provider has already received or claimed reimbursement from anysource, unless the duplicate claim is filed
(i) For payment of more than one type of service ormerchandise furnished or rendered to a recipient for which the use of more thanone type of claim is necessary; or
(ii) Because of a lack of a response from or a request by theRhode Island Medicaid program; provided, however, in such instance a duplicateclaim will clearly be identified as such, in writing, by the provider; or
(iii) Simultaneous with a claim submission to another sourceof payment when the provider has knowledge that the other payor will not paythe claim.
(4) Submit or cause to be submitted to the Rhode IslandMedicaid program a claim for service or merchandise which was not rendered to arecipient.
(5) Submit or cause to be submitted to the Rhode IslandMedicaid program a claim for services or merchandise which includes costs orcharges not related to the provision or rendering of services or merchandise tothe recipient.
(6) Submit or cause to be submitted a claim or refer arecipient to a person for services or merchandise under the Rhode IslandMedicaid program which are intentionally not documented in the provider'srecord and/or are medically unnecessary as that term is defined by §40-8.2-2(7).
(7) Submit or cause to be submitted to the Rhode IslandMedicaid program a claim which materially misrepresents:
(i) The description of services or merchandise rendered orprovided to a recipient;
(ii) The cost of the services or merchandise rendered orprovided to a recipient;
(iii) The dates that the services or merchandise wererendered or provided to a recipient;
(iv) The identity of the recipient(s) of the services ormerchandise; or
(v) The identity of the attending, prescribing, or referringpractitioner or the identity of the actual provider.
(8) Submit a claim for reimbursement to the Rhode IslandMedicaid program for service(s) or merchandise at a fee or charge, whichexceeds the provider's lowest fee or charge for the provision of the service ormerchandise to the general public.
(9) Submit or cause to be submitted to the Rhode IslandMedicaid program a claim for a service or merchandise which was not rendered bythe provider, unless the claim is submitted on behalf of:
(i) A bona fide provider employee of such provider; or
(ii) An affiliated provider entity owned or controlled by theprovider; or
(iii) Is submitted on behalf of a provider by a third partybilling service under a written agreement with the provider, and the claims aresubmitted in a manner which does not otherwise violate the provisions of thischapter.
(10) Render or provide services or merchandise under theRhode Island Medicaid program unless otherwise authorized by the regulations ofthe Rhode Island Medicaid program without a provider's written order and therecipient's consent, or submit or cause to be submitted a claim for services ormerchandise, except in emergency situations or when the recipient is a minor oris incompetent to give consent. The type of consent to be required hereundercan include verbal acquiescence of the recipient and need not require a signedconsent form or the recipient's signature, except where otherwise required bythe regulations of the Rhode Island Medicaid program.
(11) Charge any recipient or person acting on behalf of arecipient, money or other consideration in addition to, or in excess of therates of remuneration established under the Rhode Island Medicaid program.
(12) Enter into an agreement, combination or conspiracy withany party other than the Rhode Island Medicaid program to obtain or aid anotherto obtain reimbursement or payments from the Rhode Island Medicaid program towhich the person, recipient, or provider seeking reimbursement or payment isnot entitled.
(13) Make a material false statement in the application forenrollment as a provider under the Rhode Island Medicaid program.
(14) Refuse to provide representatives of the Medicaid fraudcontrol unit upon reasonable request, access to information and data pertainingto services or merchandise rendered to eligible recipients, and/or formerrecipients while recipients under the Rhode Island Medicaid program.
(15) Obtain any monies by false pretenses through the use ofany artifice, scheme, or design prohibited by this section.
(16) Seek or obtain employment with or as a provider afterhaving actual or constructive knowledge of a then existing exclusion issuedunder the authority of 42 U.S.C. § 1320a-7.
(17) Grant or offer to grant employment in violation of athen existing exclusion issued under the authority of 42 U.S.C. § 1320a-7,having actual or constructive knowledge of the existence of such exclusion.
(18) File a false document to gain employment in a Medicaidfunded facility or with a provider.
(b) A provider or person who violates any provision ofsubsection (a), excepting subsection (a)(14), (a)(16), or (a)(18), is guilty ofa felony for each violation, and upon conviction therefor, shall be sentencedto a term of imprisonment not exceeding ten (10) years, nor fined more than tenthousand dollars ($10,000), or both.
(2) A provider or person who violates the provisions ofsubsection (a)(14), (a)(16), or (a)(18), shall be guilty of a misdemeanor foreach violation and, upon conviction, be fined not more than five hundreddollars ($500).
(3) Any provider who knowingly and willfully participates inany offense either as a principal or as an accessory, or conspirator shall besubject to the same penalty as if the provider had committed the substantiveoffense.
(c) The provisions of subsection (a)(2) shall not apply to:
(1) A discount or other reduction in price obtained by aperson or provider of services or merchandise under the Rhode Island Medicaidprogram, if the reduction in price is properly disclosed and appropriatelyreflected in the costs claimed or charges made by the person or provider underthe Rhode Island Medicaid program.
(2) Any amount paid by an employer to an employee, who has abona fide employment relationship with the employer, for employment in theprovision of covered services or merchandise furnished under the Rhode IslandMedicaid program.
(3) Any amounts paid by a vendor of services or merchandiseto a person authorized to act as a purchasing agent for a group of individualsor entities who are furnishing services or merchandise which are reimbursed bythe Rhode Island Medicaid program, as long as:
(i) The purchasing agent has a written agreement with eachindividual or entity in the group that specifies the amount the agent will bepaid by each vendor (where the sum may be a fixed sum or a fixed percentage ofthe value of the purchases made from the vendor by the group under the contractbetween the vendor and the purchasing agent); and
(ii) In the case of an entity that is a provider of servicesto the Rhode Island Medicaid program, the agent discloses in writing to theindividual or entity in accordance with regulations to be promulgated by thedepartment, and to the department upon request, the amount received from eachvendor with respect to purchases made by or on behalf of the entity.