Title 40
Human Services

Chapter 8.2
Medical Assistance Fraud

§ 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 or payment to the Rhode Island Medicaid program:

(i) Any materially false or fraudulent claim or cost report for the furnishing of services or merchandise; or

(ii) Present, or cause to be presented, for preauthorization or payment, any claim or cost report for medically unnecessary services or merchandise; or

(iii) To submit, or cause to be submitted, materially false or fraudulent information for the intentional purpose(s) of obtaining greater compensation than that to which the provider is legally entitled for the furnishing of services or merchandise; or

(iv) Submit, or cause to be submitted, materially false information for the purpose of obtaining authorization for furnishing services or merchandise; or

(v) Submit, or cause to be submitted, any claim or cost report or other document that fails to make full disclosure of material information.

(2)(i) Solicit, receive, offer, or pay any remuneration, including any kickback, bribe, or rebate, directly or indirectly, in cash or in kind, to induce referrals from or to any person in return for furnishing of services or merchandise, or in return for referring an individual to a person for the furnishing of any services or merchandise, for which payment may be made, in whole or in part, under the Rhode Island Medicaid program.

(ii) Provided, however, that in any prosecution under this subsection, it shall not be necessary for the state to prove that the remuneration returned was taken from any particular expenditure made by a person.

(3) Submit, or cause to be submitted, a duplicate claim for services, supplies, or merchandise to the Rhode Island Medicaid program for which the provider has already received or claimed reimbursement from any source, unless the duplicate claim is filed:

(i) For payment of more than one type of service or merchandise furnished or rendered to a recipient for which the use of more than one type of claim is necessary; or

(ii) Because of a lack of a response from, or a request by, the Rhode Island Medicaid program; provided, however, in such instance, a duplicate claim will clearly be identified as such, in writing, by the provider; or

(iii) Simultaneous with a claim submission to another source of payment when the provider has knowledge that the other payor will not pay the claim.

(4) Submit, or cause to be submitted, to the Rhode Island Medicaid program a claim for service or merchandise that was not rendered to a recipient.

(5) Submit, or cause to be submitted, to the Rhode Island Medicaid program a claim for services or merchandise that includes costs or charges not related to the provision or rendering of services or merchandise to the recipient.

(6) Submit, or cause to be submitted, a claim or refer a recipient to a person for services or merchandise under the Rhode Island Medicaid program that are intentionally not documented in the provider’s record 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 Island Medicaid program a claim that materially misrepresents:

(i) The description of services or merchandise rendered or provided to a recipient;

(ii) The cost of the services or merchandise rendered or provided to a recipient;

(iii) The dates that the services or merchandise were rendered or provided to a recipient;

(iv) The identity of the recipient(s) of the services or merchandise; or

(v) The identity of the attending, prescribing, or referring practitioner or the identity of the actual provider.

(8) Submit a claim for reimbursement to the Rhode Island Medicaid program for service(s) or merchandise at a fee or charge that exceeds the provider’s lowest fee or charge for the provision of the service or merchandise to the general public.

(9) Submit, or cause to be submitted, to the Rhode Island Medicaid program a claim for a service or merchandise that was not rendered by the provider, unless the claim is submitted on behalf of:

(i) A bona fide provider employee of the provider; or

(ii) An affiliated provider entity owned or controlled by the provider; or

(iii) A provider by a third-party billing service under a written agreement with the provider, and the claims are submitted in a manner that does not otherwise violate the provisions of this chapter.

(10) Render or provide services or merchandise under the Rhode Island Medicaid program, unless otherwise authorized by the regulations of the Rhode Island Medicaid program, without a provider’s written order and the recipient’s consent, or submit, or cause to be submitted, a claim for services or merchandise, except in emergency situations or when the recipient is a minor or is incompetent to give consent. The type of consent to be required hereunder can include verbal acquiescence of the recipient and need not require a signed consent form or the recipient’s signature, except where otherwise required by the regulations of the Rhode Island Medicaid program.

(11) Charge any recipient, or person acting on behalf of a recipient, money or other consideration in addition to, or in excess of, the rates of remuneration established under the Rhode Island Medicaid program.

(12) Enter into an agreement, combination, or conspiracy with any party other than the Rhode Island Medicaid program to obtain or aid another to obtain reimbursement or payments from the Rhode Island Medicaid program to which the person, recipient, or provider seeking reimbursement or payment is not entitled.

(13) Make a material false statement in the application for enrollment as a provider under the Rhode Island Medicaid program.

(14) Refuse to provide representatives of the Medicaid fraud control unit, upon reasonable request, access to information and data pertaining to services or merchandise rendered to eligible recipients and/or former recipients while recipients under the Rhode Island Medicaid program.

(15) Obtain any monies by false pretenses through the use of any artifice, scheme, or design prohibited by this section.

(16) Seek or obtain employment with or as a provider after having actual or constructive knowledge of a then-existing exclusion issued under the authority of 42 U.S.C. § 1320a-7.

(17) Grant, or offer to grant, employment in violation of a then-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 Medicaid-funded facility or with a provider.

(b)(1) A provider or person who violates any provision of subsection (a), excepting subsection (a)(14), (a)(16), or (a)(18), is guilty of a felony for each violation, and upon conviction therefor, shall be sentenced to a term of imprisonment not exceeding ten (10) years, nor fined more than ten thousand dollars ($10,000), or both.

(2) A provider or person who violates the provisions of subsection (a)(14), (a)(16), or (a)(18), shall be guilty of a misdemeanor for each violation and, upon conviction, be fined not more than five hundred dollars ($500).

(3) Any provider who knowingly and willfully participates in any offense, either as a principal or as an accessory or conspirator, shall be subject to the same penalty as if the provider had committed the substantive offense.

(c) The provisions of subsection (a)(2) shall not apply to:

(1) A discount or other reduction in price obtained by a person or provider of services or merchandise under the Rhode Island Medicaid program if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the person or provider under the Rhode Island Medicaid program.

(2) Any amount paid by an employer to an employee, who has a bona fide employment relationship with the employer, for employment in the provision of covered services or merchandise furnished under the Rhode Island Medicaid program.

(3) Any amounts paid by a vendor of services or merchandise to a person authorized to act as a purchasing agent for a group of individuals or entities furnishing services or merchandise that are reimbursed by the Rhode Island Medicaid program, as long as:

(i) The purchasing agent has a written agreement with each individual or entity in the group that specifies the amount the agent will be paid by each vendor (where the sum may be a fixed sum or a fixed percentage of the value of the purchases made from the vendor by the group under the contract between the vendor and the purchasing agent); and

(ii) In the case of an entity that is a provider of services to the Rhode Island Medicaid program, the agent discloses in writing to the individual or entity, in accordance with regulations to be promulgated by the executive office, and to the office of program integrity upon request, the amount received from each vendor with respect to purchases made by or on behalf of the entity.