AN ACT
RELATING TO MEDICAID; PRESCRIBING THE
DUTIES OF THE MEDICAID FRAUD CONTROL UNIT.
BE IT ENACTED BY THE LEGISLATURE OF
THE STATE OF NEW MEXICO:
Section 1. Section 30-44-7 NMSA 1978 (being Laws 1989,
Chapter 286, Section 7, as amended) is amended to read:
"30-44-7. MEDICAID
FRAUD--DEFINED--INVESTIGATION--PENALTIES.--
A. Medicaid fraud consists of:
(1) paying, soliciting, offering or receiving:
(a) a kickback or bribe in connection with the
furnishing of treatment, services or goods for which payment is or may be made
in whole or in part under the program, including an offer or promise to, or a
solicitation or acceptance by, a health care official of anything of value with
intent to influence a decision or commit a fraud affecting a state or federally
funded or mandated managed health care plan;
(b) a rebate of a fee or charge made to a
provider for referring a recipient to a provider;
(c) anything of value, intending to retain it and
knowing it to be in excess of amounts authorized under the program, as a
precondition of providing treatment, care, services or goods or as a
requirement for continued provision of treatment, care, services or goods; or
(d) anything of value, intending to retain it and
knowing it to be in excess of the rates established under the program for the
provision of treatment, services or goods;
(2) providing with intent that a claim be relied
upon for the expenditure of public money:
(a) treatment, services or goods that have not
been ordered by a treating physician;
(b) treatment that is substantially
inadequate when compared to generally
recognized standards within the discipline or industry; or
(c) merchandise that has been adulterated,
debased or mislabeled or is outdated;
(3) presenting or causing to be presented for
allowance or payment with intent that a claim be relied upon for the
expenditure of public money any false, fraudulent, excessive, multiple or
incomplete claim for furnishing treatment, services or goods; or
(4) executing or conspiring to execute a plan or
action to:
(a) defraud a state or federally funded or
mandated managed health care plan in connection with the delivery of or payment
for health care benefits, including engaging in any intentionally deceptive
marketing practice in connection with proposing, offering, selling, soliciting
or providing any health care service in a state or federally funded or mandated
managed health care plan; or
(b) obtain by means of false or fraudulent
representation or promise anything of value in connection with the delivery of
or payment for health care benefits that are in whole or in part paid for or
reimbursed or subsidized by a state or federally funded or mandated managed
health care plan. This includes representations
or statements of financial information, enrollment claims, demographic
statistics, encounter data, health services available or rendered and the
qualifications of persons rendering health care or ancillary services.
B. Except as otherwise provided for in this
section regarding the payment of fines by an entity, whoever commits medicaid
fraud as described in Paragraph (1) or (3) of Subsection A of this section is
guilty of a fourth degree felony and shall be sentenced pursuant to the
provisions of Section 31-18-15 NMSA 1978.
C. Except as otherwise provided for in this
section regarding the payment of fines by an entity, whoever commits medicaid
fraud as described in Paragraph (2) or (4) of Subsection A of this section when
the value of the benefit, treatment, services or goods improperly provided is:
(1) not more than one hundred dollars ($100) is
guilty of a petty misdemeanor and shall be sentenced pursuant to the provisions
of Section 31-19-1 NMSA 1978;
(2) more than one hundred dollars ($100) but not
more than two hundred fifty dollars ($250) is guilty of a misdemeanor and shall
be sentenced pursuant to the provisions of Section 31-19-1 NMSA 1978;
(3) more than two hundred fifty dollars ($250)
but not more than two thousand five hundred dollars ($2,500) is guilty of a
fourth degree felony and shall be sentenced pursuant to the provisions of
Section 31-18-15 NMSA 1978;
(4) more than two thousand five hundred dollars
($2,500) but not more than twenty thousand dollars ($20,000) shall be guilty of
a third degree felony and shall be sentenced pursuant to the provisions of
Section 31-18-15 NMSA 1978; and
(5) more than twenty thousand dollars ($20,000)
shall be guilty of a second degree felony and shall be sentenced pursuant to
the provisions of Section 31-18-15 NMSA 1978.
D. Except as otherwise provided for in this
section regarding the payment of fines by an entity, whoever commits medicaid
fraud when the fraud results in physical harm or psychological harm to a
recipient is guilty of a fourth degree felony and shall be sentenced pursuant
to the provisions of Section 31-18-15 NMSA 1978.
E. Except as otherwise provided for in this
section regarding the payment of fines by an entity, whoever commits medicaid
fraud when the fraud results in great physical harm or great psychological harm
to a recipient is guilty of a third degree felony and shall be sentenced
pursuant to the provisions of Section 31-18-15 NMSA 1978.
F. Except as otherwise provided for in this
section regarding the payment of fines by an entity, whoever commits medicaid
fraud when the fraud results in death to a recipient is guilty of a second
degree felony and shall be sentenced pursuant to the provisions of Section
31-18-15 NMSA 1978.
G. If the person who commits medicaid fraud is
an entity rather than an individual, the entity shall be subject to a fine of
not more than fifty thousand dollars ($50,000) for each misdemeanor and not
more than two hundred fifty thousand dollars ($250,000) for each felony.
H. The unit shall coordinate with the human
services department, department of health and children, youth and families
department to develop a joint protocol establishing responsibilities and
procedures, including prompt and appropriate referrals and necessary action
regarding allegations of program fraud, to ensure prompt investigation of
suspected fraud upon the medicaid program by any provider. These departments shall participate in the
joint protocol and enter into a memorandum of understanding defining procedures
for coordination of investigations of fraud by medicaid providers to eliminate
duplication and fragmentation of resources.
The memorandum of understanding shall further provide procedures for
reporting to the legislative finance committee the results of all
investigations every calendar quarter.
The unit shall report to the legislative finance committee a detailed
disposition of recoveries and distribution of proceeds every calendar
quarter."
Section 2. EFFECTIVE DATE.--The effective date of the
provisions of this act is July 1, 2003.
HB 668
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