26B-3-1106. False claims for medical benefits prohibited.

347 words·~2 min read·/ut/title-26b/chapter-3/26b-3-1106

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Effective 5/3/2023

(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:

(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