Medicare
and Medicaid
billing fraud is costing the United States an estimated
one hundred billion dollars ($100,000,000,000.00) each
year. To combat Medicaid Billing Fraud, the United States government
has amended and Texas has enacted False Claims Act Laws to encourage more
Medicaid Fraud whistleblowers to step up and blow the
whistle on Medicaid Fraud Scams. Medicaid Billing Fraud
Whistleblowers and Medicaid Payment Fraud Whistleblowers that
are the original source of specialized knowledge of
Medicaid Fraud can make substantial recoveries if they
are the first to file a successful qui tam claim under
the False Claims Acts.
For more information on a potential
Medicaid Billing Fraud Lawsuit
or Medicaid Payment Fraud Lawsuit, feel free to
contact
Texas Medicaid Billing Fraud
Whistleblower Lawyer
Jason Coomer via
e-mail message or use our
submission form to discuss a potential
Medicare billing fraud whistleblower lawsuit or Medicare
payment fraud lawsuit.
Texas Medicaid Billing Fraud Whistleblower Lawsuit
Information,
Texas Medicaid Billing Fraud Lawsuit Information, Texas Medicaid
Upcoding Fraud Lawsuit Information, and Medicaid Fraud
Lawsuit Information
Texas Medicaid Billing Fraud Whistleblowers
and Texas Medicaid Payment Fraud Whistleblowers
that provide original source information of schemes to
fraudulently bill for medical services or medical
products and fraudulently take Medicaid payments including upcoding, double billing, bill
padding, unbundling, and charging for services never
provided may recover a portion of the proceeds recovered
on the government's behalf.
Department of Justice Office of Public Affairs
FOR IMMEDIATE RELEASE Tuesday, January 4, 2011 Houston
Doctor Sentenced to 41 Months in Prison for Role in
Medicare Fraud Scheme Medical Equipment Company Manager
and Delivery Driver Also Sentenced to Prison for Roles
in Fraud Scheme
WASHINGTON – Houston-area residents
Dr. Howard Grant, Obisike Nwankwo and John Lachman were
sentenced today to 41 months in prison, 21 months in
prison, and 26 months in prison, respectively, for their
roles in a multi-million dollar durable medical
equipment (DME) Medicare fraud scheme, the Departments
of Justice and Health and Human Services (HHS) announced
today.
In addition to the prison terms, U.S.
District Court Judge Nancy Atlas in the Southern
District of Texas sentenced Grant, Nwankwo and Lachman
each to three years of supervised release. Grant was
ordered to pay $121,742 in restitution jointly and
severally with co-defendants. Nwankwo was ordered to pay
$29,052 in restitution jointly and severally with
co-defendants. Lachman was ordered to pay $1.14 million
in restitution jointly and severally with co-defendants.
Grant and Nwankwo were both convicted
by a federal jury after a two-week trial in the Southern
District of Texas in May and June 2010. Grant was
convicted of two counts of health care fraud and one
count of conspiracy to commit health care fraud and
Nwankwo was convicted of one count of conspiracy to
commit health care fraud . Lachman pleaded guilty prior
to the trial to one count of conspiracy to commit health
care fraud.
Evidence at trial established that
Onward Medical Supply, a Houston-area DME company,
billed Medicare for fraudulent DME, including power
wheelchairs and orthotic devices, beginning in 2003 and
continuing until late 2009. In addition to the three
co-conspirators sentenced today, one additional
individual was convicted at trial, and seven individuals
have pleaded guilty for their participation in various
parts of Onward’s Medicare fraud scheme, including
Onward’s owner, Doris Vinitski.
According to evidence presented at
trial, Vinitski worked with Medicare biller and
co-defendant John Nasky Okonkwo and others in late 2008
and early 2009 to submit fraudulent claims to Medicare
identifying Dr. Howard Grant as the prescribing
physician for the DME. The claims were submitted in
several groups in November 2008. Evidence presented at
trial showed that Grant learned about the fraudulent
prescriptions prior to Onward’s submission of the claims
to Medicare. Evidence at trial also showed that, upon
learning of the prescriptions, Grant asked Vinitski for
$10,000 in exchange for allowing the fraud scheme to
continue. Okonkwo agreed to plead guilty for his
participation in the scheme. Following the verdict, U.S.
District Court Judge Nancy Atlas ordered Grant to
surrender his medical license and his Drug Enforcement
Administration (DEA) number and to stop all billing to
Medicare and Medicaid.
Evidence at trial established that
Nwankwo acted as a delivery driver for Onward and
several other DME companies and that he delivered DME
such as power wheelchairs and orthotics for Onward to
beneficiaries who did not want or need the equipment.
One beneficiary testified at trial that when Nwankwo
tried to deliver a power wheelchair to her, she told him
to get off her front step or she would call the police.
Lachman managed the Onward fraud
scheme in the early years, until the end of 2006. During
that time, he created fraudulent patient files, managed
payments of kickbacks to recruiters and delivery
drivers, and operated the day-to-day business of Onward.
The sentences were announced by
Assistant Attorney General Lanny A. Breuer of the
Criminal Division; U.S. Attorney José Angel Moreno of
the Southern District of Texas; Richard C. Powers,
Special Agent-in-Charge of the FBI’s Houston office;
Special Agent-in-Charge Mike Fields of the Dallas
Regional Office of the HHS Office of Inspector General (OIG),
Office of Investigations; and Texas Attorney General
Greg Abbott on behalf of the Texas Attorney General’s
Medicaid Fraud Control Unit (MFCU).
CHRISTUS HEALTH AFFILIATES IN TEXAS PAYS U.S.
$1.36 MILLION TO SETTLE ALLEGATIONS OF MEDICARE AND
MEDICAID FRAUD
WASHINGTON, D.C. - Three San Antonio,
Texas affiliates of Christus Health of Houston have paid
the United States $1.36 million to settle claims that
the Christus affiliates defrauded Medicare and Medicaid
from 1997 through 2000, the Justice Department announced
today. The civil settlement resolves allegations that
Primary CareNet of Texas (PCN) (also known as Christus
Primary CareNet) and Health Texas Medical Group (HTMG),
on its own behalf and as successor in interest to
Solomon Anthony Clinic (SAC), defrauded the programs by
improperly charging Medicare and Medicaid for
physicians' evaluation and management services.
"This settlement again demonstrates
the United States' commitment to protecting federal
funds from fraud and abuse," said Robert D. McCallum,
Assistant Attorney General in charge of the Civil
Division. "The federal health care system operates on
the good faith and honesty of its providers, and we will
actively pursue those who misuse the system for
financial gain."
The allegations arose from a lawsuit
filed by PCN’s former Chief Financial Officer, Timothy
Ohman, under the qui tam or whistleblower provisions of
the False Claims Act, a federal law that allows private
individuals to sue on behalf of the United States. Ohman
alleged that PCN, a management and billing company, and
HTMG and SAC, two physician practice groups, improperly
charged evaluation and management services for Medicare
and Medicaid patients. As a result, HTMG and SAC
received more reimbursement from Medicare and Medicaid
than they should have.
"Medicare and Medicaid fraud and
abuse is a crime against the American taxpayer," stated
Johnny Sutton, United States Attorney, Western District
of Texas. “With vigorous enforcement actions such as
these, we help to insure the future of the Medicare and
Medicaid Trust Funds”
The civil investigation and
settlement were jointly handled by the Office of the
United States Attorney for the Western District of Texas
and the Civil Division of the Department of Justice,
with assistance of the Department of Health and Human
Services Office of Inspector General, including the
Office of Counsel and the Federal Bureau of
Investigation.
The case is entitled U.S. ex rel.
Ohman v. Primary CareNet, et al., No. SA-01-CA-150-IV (W.D.Tex.).
The cases were prosecuted by Trial
Attorneys Jennifer L. Saulino, O. Benton Curtis III and
Nicola J. Mrazek of the Criminal Division’s Fraud
Section. The cases were investigated by the FBI, HHS-OIG
and MFCU.
The cases were brought as part of the
Medicare Fraud Strike Force, supervised by the U.S.
Attorney’s Office for the Southern District of Texas and
the Criminal Division’s Fraud Section. Since their
inception in March 2007, Strike Force operations in
seven districts have obtained indictments of more than
850 individuals who collectively have falsely billed the
Medicare program for more than $2.1 billion. In
addition, HHS’s Centers for Medicare and Medicaid
Services, working in conjunction with the HHS-OIG, are
taking steps to increase accountability and decrease the
presence of fraudulent providers.
To learn more about the Health Care
Fraud Prevention and Enforcement Action Team (HEAT), go
to: www.stopmedicarefraud.gov.
HCA - THE HEALTH CARE COMPANY & SUBSIDIARIES TO
PAY $840 MILLION IN CRIMINAL FINES AND CIVIL DAMAGES AND
PENALTIES
Largest Government Fraud Settlement in U.S.
History December 2000
WASHINGTON, D.C. - HCA-The Healthcare
Company (formerly known as Columbia-HCA), the largest
for-profit hospital chain in the United States, has
agreed to plead guilty to criminal conduct and pay more
than $840 million in criminal fines, civil penalties and
damages for alleged unlawful billing practices, Attorney
General Janet Reno announced today.
Today's agreement is the largest
government fraud settlement ever reached by the Justice
Department.
"Health care fraud impacts every
American citizen. When a company defrauds our nation's
health care programs, it takes money out of the pockets
of the American taxpayers. It is wrong," said Attorney
General Reno. "This investigation has been the largest
multi-agency investigation of a health care provider
ever undertaken by the U.S. and reflects our commitment
to vigorously pursuing all types of health care fraud
schemes."
Under today's agreement, which is
subject to review by the court, HCA will pay a total of
$745 million to resolve five allegations regarding the
manner in which it bills the U.S. government and the
states for health care costs. The agreement does not
resolve allegations that HCA unlawfully charged for the
costs of running its hospitals on cost reports submitted
to the government, and that it paid kickbacks to
physicians to get Medicare and Medicaid patients
referred to its facilities.
Of the $745 million, the settlement
requires HCA to pay:
* more than $95 million to resolve
civil claims arising from the company's outpatient
laboratory billing practices, which included billing to
Medicare, Medicaid, the Defense Department's TRICARE
health care program, and the Federal Employees' Health
Benefits Program, for lab tests that were not medically
necessary, not ordered by physicians, as well as other
billing violations;
* more than $403 million to resolve
civil claims arising from "upcoding," where false
diagnosis codes were assigned to patient records in
order to increase reimbursement to the hospitals by
Medicare, Medicaid, TRICARE and the Federal Employees'
Health Benefits Program. The guilty plea includes one
count relating to this upcoding practice;
* $50 million to resolve civil claims
that the company illegally claimed non-reimbursable
marketing and advertising costs it disguised as
community education. Medicare reimburses providers for
"community education" - costs to educate the community
at large about public health issues - but not for
advertising and marketing a hospital's services;
* $90 million to resolve civil claims
that HCA illegally charged Medicare for non-reimbursable
costs incurred in the purchase of home health agencies
owned by the Olsten Corporation, as well as other
agencies in Florida, Georgia and Alabama. According to
the government, HCA devised an elaborate scheme to hide
these costs in reimbursable "management fees" paid to
third parties. In 1999, a subsidiary of Olsten
Corporation, Kimberly Quality Care, entered into
criminal plea agreements in three districts and paid
more than $10 million in criminal fines. Olsten paid
nearly $41 million as part of a civil settlement arising
from its collusion with HCA for that conduct. HCA has
now agreed to pay $90 million to settle this issue, and;
* $106 million to resolve civil
claims for billing Medicare, Medicaid and TRICARE for
home health visits for patients who did not qualify to
receive them or were not performed and for committing
other billing violations.
Many of the civil issues resolved as
part of today's agreement arose from lawsuits filed by
relators, commonly known as "whistleblowers," under the
False Claims Act. This law allows whistleblowers who
qualify under the statute to receive up to 25 percent of
the settlement recovery in cases the government pursues.
Under the civil settlement announced today,
whistleblower shares remain undetermined pending further
negotiations or court proceedings.
In addition to the civil settlement,
two subsidiaries of Tennessee-based HCA, Columbia
Homecare Group Inc. and Columbia Management Companies
Inc. entered into a criminal plea agreement in which
they agreed to pay $95,336,432 in criminal fines and
plead guilty to several charges involving a wide range
of criminal conduct which occurred at HCA's hospitals
nationwide. The plea agreement and the sentences are
subject to the approval of federal courts.
According to the terms of the plea
agreement, the companies will plead guilty to charges
involving cost report fraud, fraudulent billing of
Medicare for personnel who worked at home health
agencies and at wound care centers, fraudulent billing
to Medicare for patients diagnosed with pneumonia,
paying kickbacks and other remuneration to doctors to
induce referrals, paying kickbacks in connection with
the purchase and sale of home health agencies and
fraudulent billing of Medicare for fees paid to manage
those agencies. The guilty pleas will be filed in five
district courts and, with the courts' permission,
consolidated for plea and sentencing in the district
courts in the Middle District of Florida and the Western
District of Texas (El Paso).
The subsidiaries will plead guilty to
the following criminal charges, which will be filed in
five District Courts and will be consolidated for
sentencing in District Courts in Tampa and El Paso:
Southern District of Florida (Miami)
Columbia Homecare Group Inc., a subsidiary of Columbia,
will plead guilty to one count of conspiracy to defraud
the U.S. and to violate the Medicare Anti-kickback
Statute involving its fraudulent business in the
purchase and operation of home health agencies and
fraudulent billing of Medicare for management and
personnel costs. The criminal fine is $3.36 million;
Northern District of Georgia
(Atlanta) Columbia Homecare Inc. will plead guilty to
one count of violating the Medicare Anti-kickback
Statute related to purchase of home health agencies. The
criminal fine is $3.36 million;
Department of Justice Criminal Fraud
Section Another subsidiary, Columbia Management
Companies Inc., will plead guilty to one count of
conspiracy to defraud the U.S. and to make and use false
writings and documents in connection with its fraudulent
"upcoding" of bills to Medicare for patients diagnosed
with certain types of pneumonia. The criminal fine is
$27.5 million. This investigation was based in
Nashville, Tennessee;
Middle District of Florida (Tampa)
Columbia Homecare Group will plead guilty to one count
of conspiring to defraud the U.S. and one count of
conspiracy to violate the Medicare Anti-kickback Statute
in connection with the purchase and operation of home
health agencies. The criminal fine is $8.4 million.
Also, Columbia Management Companies will plead guilty to
eight counts of making false statements to the U.S. in
connection with the submission of false cost reports to
Medicare. The fine amount is $22.6 million; and,
Western District of Texas (El Paso).
Columbia Homecare Group will plead to a conspiracy to
pay kickbacks and other monetary benefits to doctors in
violation of the Medicare Anti-kickback Statute. The
criminal fine is $30,116,592.
Today's plea agreement resolves only
corporate criminal liability. The government has the
option to investigate and prosecute any individuals as
the plea agreement specifically requires the companies
to cooperate with the government in ongoing
investigations. As a further result of the plea
agreement, two subsidiaries will be excluded from
participating in the Medicare Program.
In addition to today's agreement,
Inspector General June Gibbs Brown announced that HCA is
entering into two agreements with HHS - a Corporate
Integrity Agreement and a divestiture agreement.
The Corporate Integrity Agreement,
which requires the company to engage in significant
compliance efforts over the next eight years, calls for
the health care company and independent review
organizations to conduct audits and reviews of HCA and
its hospitals' inpatient coding, laboratory billing,
hospital outpatient billing, and financial relationships
with physicians.
The agreement also requires HCA to:
* maintain a code of conduct and
compliance policies and procedures;
* conduct training of its employees
on general compliance matters and substantive federal
health care program requirements;
* ensure that certain employees and
committees are responsible for compliance at all levels
of the organization from the Board of Directors to
individual facilities;
* promptly report and pay back all
overpayments,
* maintain means for employees and
other individuals to report on suspected misconduct;
and,
* screen prospective and present
employees and contractors to ensure that they are not
excluded from federal health care programs.
"This settlement includes an
extensive corporate integrity agreement that is intended
to ensure HCA's strict compliance with the laws of doing
business with the federal health care programs," said
HHS Inspector General Brown. "The agreement will be in
force for a period of eight years and includes audit and
other compliance provisions that are unprecedented in
their scope and level of detail."
Throughout the term of the integrity
agreement, HCA will be required to report to the Office
of the Inspector General at HHS annually and with
respect to certain events.
The divestiture agreement will bar
any HCA subsidiary that is entering a guilty plea to
Medicare-related offenses from participating in Medicare
and other federal health care programs. The Inspector
General has agreed to delay the exclusion for a limited
time to allow the subsidiary to divest itself of the
hospital it operates in order to minimize the risk of
disruption to patient care.
In exchange, HCA is obligated to take
certain measures to ensure that quality services are
provided at the hospital and that the new operator is
approved by appropriate government agencies prior to
divestiture. The agreement provides the OIG with
multiple remedies other than exclusion, including
financial penalties and the right to appoint a trustee
to divest the hospital, if HCA fails to meet the
deadlines to divest the facility.
Finally, a state negotiating team
appointed by the National Association of Medicaid Fraud
Control Units consisting of representatives from
Tennessee, Nevada, Washington and Ohio, has reached an
agreement in principle with HCA to resolve related
issues with affected Medicaid programs. The Medicaid
program, which is funded by the federal and state
governments, represents approximately $36.3 million of
today's $745 million settlement; of this, the states
will receive about $13.6 million, representing their
share of Medicaid funds. The state negotiating team will
send proposed settlement agreements to 33 states and
recommend that those states become part of the
settlement.
"Today's developments stand as a
testament to our success in the fight against health
care fraud and abuse," said Attorney General Reno.
"Federal health care programs operate on the good faith
and honesty of health care providers. The government
will not tolerate misuse of the reimbursement systems
for financial gain and will hold the responsible parties
accountable for their conduct."
The Attorney General was joined in
today's announcement of the criminal and civil
agreements by Assistant Attorney General David W. Ogden
of the Civil Division; Richard Deane, U.S. Attorney in
Georgia; Donna Bucella, U.S. Attorney in Tampa; June
Gibbs Brown, Inspector General of the Department of
Health and Human Services (HHS); Thomas Kubic , Deputy
Assistant Director, Criminal Investigative Division of
the FBI; Carol Levy, Director of the Defense Criminal
Investigative Service and Assistant Inspector General
for Investigations of the Department of Defense; Patrick
McFarland, Inspector General of the Office of Personnel
Management; Dr. James Sears, TRICARE; and Barbara Zelner,
Counsel to the National Association of Medicaid Fraud
Control Units.
The Attorney General recognizes the
prosecutors in the following divisions and districts
that assisted in bringing this case to a successful
resolution: Department of Justice, Civil Division,
Commercial Litigation Branch, Fraud Section; Department
of Justice, Criminal Division, Fraud Section; Middle
District of Alabama; Eastern District of Arkansas;
Western District of Arkansas; Central District of
California; District of Colorado; District of Columbia;
Middle District of Florida; Southern District of
Florida; Middle District of Georgia; Northern District
of Georgia; Northern District of Illinois; District of
Kansas; Eastern District of Kentucky; Eastern District
of Louisiana; Middle District of Louisiana; Western
District of Louisiana; District of Massachusetts;
District of Nevada; District of New Hampshire; Eastern
District of North Carolina; Western District of North
Carolina; Northern District of Ohio; Northern District
of Oklahoma; Eastern District of Pennsylvania; District
of South Carolina; Eastern District of Tennessee; Middle
District of Tennessee; Eastern District of Texas;
Northern District of Texas; Southern District of Texas
Western District of Texas; District of Utah; Eastern
District of Virginia; Western District of Virginia; and
District of Wyoming. She also wishes to acknowledge the
extensive assistance provided by agents, investigators,
and auditors for the Federal Bureau of Investigation,
the HHS Office of the Inspector General, the Health Care
Financing Administration, the Defense Criminal
Investigative Service, the Office of Personnel
Management Inspector General, and State Medicaid Fraud
Control Units.
Medicare Fraud Strike Force Operations Lead to
Charges Against 32 Doctors and Health Care Executives
for More Than $16 Million in Alleged False Billing in
Houston Early Morning Takedown Leads to Arrests in
Houston, New York, Boston and Louisiana
WASHINGTON – Thirty-two people have
been indicted for schemes to submit more than $16
million in false Medicare claims in the continuing
operation of the Medicare Fraud Strike Force in Houston,
Deputy Attorney General David W. Ogden and Deputy
Secretary Bill Corr of the Department of Health and
Human Services (HHS) announced today. The Strike Force
in Houston is the fourth phase of a targeted criminal,
civil and administrative effort against individuals and
health care companies that fraudulently bill the
Medicare program.
While the indictments were returned
by a grand jury in Houston, individuals were arrested
today in Houston, New York, Boston and Louisiana. In
addition, Strike Force agents executed 12 search
warrants at health care businesses and homes across the
Houston area.
The joint DOJ-HHS Medicare Fraud
Strike Force is a multi-agency team of federal, state
and local investigators designed to combat Medicare
fraud through the use of Medicare data analysis
techniques and an increased focus on community policing.
The fourth phase was announced in May 2009, with agents
from FBI, HHS Office of the Inspector General (HHS-OIG),
the Texas Attorney General’s Medicaid Fraud Control Unit
(MFCU), the Drug Enforcement Administration (DEA),
Office of Personnel Management, Office of the Inspector
General (OPM-OIG) and the Office of the Inspector
General at the Railroad Retirement Board (RRB-OIG).
"Our Medicare Strike Force is
striking back against health care fraud in all its forms
and wherever it occurs. We will stop fraud as its
happening, using real-time data analysis of Medicare
billing records," said Deputy Attorney General David W.
Ogden. "Those who commit health care fraud will not be
allowed to steal money from American taxpayers. Anyone
operating or considering operating a health care fraud
scheme around the country should take notice that they
will be held accountable."
"When criminals rip off Medicare
beneficiaries, we all pay the price. These false
Medicare schemes and scams are costing the taxpayers
millions of dollars, harming Medicare beneficiaries and
driving up the cost of health care, but thanks to this
new innovative partnership and the hard work of our
staff on the ground, we are starting to fight back
against fraud in a big way. The Administration’s HEAT
initiative and our Strike Forces are making a big
difference in a very short amount of time, returning
millions back to the Medicare Trust in just a few
months," said Bill Corr, Deputy Secretary of Health and
Human Services and the top HHS official on the HEAT
Team. "We are also working together across the federal
government on important new innovations in the way we do
business on the front end, to try and prevent crime like
this from happening in the first place."
The Strike Force operations in
Houston are another important step of the Health Care
Fraud Prevention & Enforcement Action Team (HEAT), a
joint initiative announced in May 2009 between the
Department of Justice and HHS to focus their joint
efforts to reduce and prevent Medicare and Medicaid
fraud through enhanced cooperation. The HEAT taskforce,
co-chaired by Deputy Attorney Ogden and Deputy Secretary
Corr, is made up of top-level law enforcement agents,
prosecutors and staff from both Departments and their
operating divisions. In the May 2009 announcement,
Attorney General Eric Holder and Secretary Kathleen
Sebelius announced the expansion of the Strike Force
into Detroit and Houston to build upon existing
partnerships between the agencies in a heightened effort
to reduce fraud and recover taxpayer dollars.
Charges were unsealed today against
32 individuals who are accused of various Medicare fraud
offenses, including conspiracy to defraud the Medicare
program, and criminal false claims. The Strike Force
operations in Houston have identified the primary fraud
schemes as those related to false billing for "arthritis
kits," power wheelchairs and enteral feeding supplies.
According to the indictments, the
defendants charged today participated in schemes to
submit claims to Medicare for products that were in fact
medically unnecessary and oftentimes, never provided. In
some cases, indictments allege that beneficiaries were
deceased at the time they allegedly received the items.
Collectively, the physicians, company owners and
executives charged in the indictments are accused of
conspiring to submit more than $16 million in false
claims to the Medicare program.
"Americans deserve quality healthcare
and have the right to expect that money expended on
Medicare is not wasted," said U.S. Attorney Tim Johnson.
"We will prosecute anyone who fraudulently obtains
Medicare benefits at the expense of the truly needy."
"We will protect the Medicare program
and its beneficiaries by stopping those who falsely bill
for power wheelchairs, orthotic devices and other
supplies that are not needed," said Daniel R. Levinson,
Inspector General of the Department of Health & Human
Services. "Today’s arrests demonstrate the significant
impact of the new HEAT strike force on combating fraud
and abuse in the Houston area."
"We will continue to work together to
combat those who corrupt the system and wish to line
their pockets with taxpayer dollars," said Special Agent
in Charge Richard C. Powers, FBI Houston Field Office.
"Healthcare fraud strikes at the heart of our health
care system and our economy."
Texas Attorney General Greg Abbott
added: "Today’s arrests reflect a concerted effort to
crack down on those who defraud Texas taxpayers. We will
continue working with our federal partners to uncover
waste, fraud, and abuse in the Medicare and Medicaid
systems."
Since the inception of Strike Force
operations in March 2007 with phase one in South
Florida, phase two in Los Angeles in May 2008, and phase
three in Detroit in March 2009, the Strike Force has
obtained indictments of more than 293 individuals and
organizations that collectively have billed the Medicare
program for more than $674 million. In addition, HHS’s
Centers for Medicare and Medicaid Services, working in
conjunction with the HHS-OIG, is taking steps to
increase accountability and decrease the presence of
fraudulent providers.
Each of the three Houston Strike
Force teams is led by a federal prosecutor from the U.S.
Attorney’s Office in Houston or the Criminal Division’s
Fraud Section. Each team has an agent from the FBI,
HHS-OIG and the Texas Attorney General’s MFCU. DEA,
OPM-OIG and RRB-OIG also have agents on the teams.
The cases are being prosecuted by
attorneys from the U.S. Attorney’s Office, including
Assistant U.S. Attorney Jennifer Lowery and Special
Assistant U.S. Attorney Justin Blan, on detail from
HHS-OIG, as well as from the Criminal Division’s Fraud
Section, including Assistant Chief John S. (Jay) Darden
and Trial Attorneys Charles Reed, Katherine Houston,
Anthony Burba and John Cunningham.
An indictment is merely an
allegation, and defendants are presumed innocent until
and unless proven guilty.
Texas False Claims Act
Texas Human Resources Code
Chapter 32. Medical Assistance Program
Subchapters B. Administrative Provisions
§32.039. Damages and Penalties
(a) In this section:
(1) "Claim" means an application for
payment of health care services under Title XIX of the
federal Social Security Act that is submitted by a
person who is under a contract or provider agreement
with the department.
(2) "Managed care organization" means
any entity or person that is authorized or otherwise
permitted by law to arrange for or provide a managed
care plan.
(3) "Managed care plan" means a plan
under which a person undertakes to provide, arrange for,
pay for, or reimburse any part of the cost of any health
care service. A part of the plan must consist of
arranging for or providing health care services as
distinguished from indemnification against the cost of
those services on a prepaid basis through insurance or
otherwise. The term does not include a plan that
indemnifies a person for the cost of health care
services through insurance.
(4) A person "should know" or "should
have known" information to be false if the person acts
in deliberate ignorance of the truth or falsity of the
information or in reckless disregard of the truth or
falsity of the information, and proof of the person's
specific intent to defraud is not required.
(b) A person commits a violation if
the person:
(1) presents or causes to be
presented to the department a claim that contains a
statement or representation the person knows or should
know to be false; or
(2) is a managed care organization
that contracts with the department to provide or arrange
to provide health care benefits or services to
individuals eligible for medical assistance and:
(A) fails to provide to an individual
a health care benefit or service that the organization
is required to provide under the contract with the
department;
(B) fails to provide to the
department information required to be provided by law,
department rule, or contractual provision;
(C) engages in a fraudulent activity
in connection with the enrollment in the organization's
managed care plan of an individual eligible for medical
assistance or in connection with marketing the
organization's services to an individual eligible for
medical assistance; or
(D) engages in actions that indicate
a pattern of:
(i) wrongful denial of payment for a
health care benefit or service that the organization is
required to provide under the contract with the
department; or
(ii) wrongful delay of at least 45
days or a longer period specified in the contract with
the department, not to exceed 60 days, in making payment
for a health care benefit or service that the
organization is required to provide under the contract
with the department.
(c) A person who commits a violation
under Subsection (b) is liable to the department for:
(1) the amount paid, if any, as a
result of the violation and interest on that amount
determined at the rate provided by law for legal
judgments and accruing from the date on which the
payment was made; and
(2) payment of an administrative
penalty of an amount not to exceed twice the amount
paid, if any, as a result of the violation, plus an
amount:
(A) not less than $5,000 or more than
$15,000 for each violation that results in injury to an
elderly person, as defined by Section 48.002(1), a
disabled person, as defined by Section 48.002(8)(A), or
a person younger than 18 years of age; or
(B) not more than $10,000 for each
violation that does not result in injury to a person
described by Paragraph (A).
(d) Unless the provider submitted
information to the department for use in preparing a
voucher that the provider knew or should have known was
false or failed to correct information that the provider
knew or should have known was false when provided an
opportunity to do so, this section does not apply to a
claim based on the voucher if the department calculated
and printed the amount of the claim on the voucher and
then submitted the voucher to the provider for the
provider's signature. In addition, the provider's
signature on the voucher does not constitute fraud. The
department shall adopt rules that establish a grace
period during which errors contained in a voucher
prepared by the department may be corrected without
penalty to the provider.
(e) In determining the amount of the
penalty to be assessed under Subsection (c)(2), the
department shall consider:
(1) the seriousness of the violation;
(2) whether the person had previously
committed a violation; and
(3) the amount necessary to deter the
person from committing future violations.
(f) If after an examination of the
facts the department concludes that the person committed
a violation, the department may issue a preliminary
report stating the facts on which it based its
conclusion, recommending that an administrative penalty
under this section be imposed and recommending the
amount of the proposed penalty.
(g) The department shall give written
notice of the report to the person charged with
committing the violation. The notice must include a
brief summary of the facts, a statement of the amount of
the recommended penalty, and a statement of the person's
right to an informal review of the alleged violation,
the amount of the penalty, or both the alleged violation
and the amount of the penalty.
(h) Not later than the 10th day after
the date on which the person charged with committing the
violation receives the notice, the person may either
give the department written consent to the report,
including the recommended penalty, or make a written
request for an informal review by the department.
(i) If the person charged with
committing the violation consents to the penalty
recommended by the department or fails to timely request
an informal review, the department shall assess the
penalty. The department shall give the person written
notice of its action. The person shall pay the penalty
not later than the 30th day after the date on which the
person receives the notice.
(j) If the person charged with
committing the violation requests an informal review as
provided by Subsection (h), the department shall conduct
the review. The department shall give the person written
notice of the results of the review.
(k) Not later than the 10th day after
the date on which the person charged with committing the
violation receives the notice prescribed by Subsection
(j), the person may make to the department a written
request for a hearing. The hearing must be conducted in
accordance with Chapter 2001, Government Code.
(l) If, after informal review, a
person who has been ordered to pay a penalty fails to
request a formal hearing in a timely manner, the
department shall assess the penalty. The department
shall give the person written notice of its action. The
person shall pay the penalty not later than the 30th day
after the date on which the person receives the notice.
(m) Within 30 days after the date on
which the board's order issued after a hearing under
Subsection (k) becomes final as provided by Section
2001.144, Government Code, the person shall:
(1) pay the amount of the penalty;
(2) pay the amount of the penalty and
file a petition for judicial review contesting the
occurrence of the violation, the amount of the penalty,
or both the occurrence of the violation and the amount
of the penalty; or
(3) without paying the amount of the
penalty, file a petition for judicial review contesting
the occurrence of the violation, the amount of the
penalty, or both the occurrence of the violation and the
amount of the penalty.
(n) A person who acts under
Subsection (m)(3) within the 30-day period may:
(1) stay enforcement of the penalty
by:
(A) paying the amount of the penalty
to the court for placement in an escrow account; or
(B) giving to the court a supersedeas
bond that is approved by the court for the amount of the
penalty and that is effective until all judicial review
of the department's order is final; or
(2) request the court to stay
enforcement of the penalty by:
(A) filing with the court a sworn
affidavit of the person stating that the person is
financially unable to pay the amount of the penalty and
is financially unable to give the supersedeas bond; and
(B) giving a copy of the affidavit to
the commissioner by certified mail.
(o) If the commissioner receives a
copy of an affidavit under Subsection (n)(2), the
commissioner may file with the court, within five days
after the date the copy is received, a contest to the
affidavit. The court shall hold a hearing on the facts
alleged in the affidavit as soon as practicable and
shall stay the enforcement of the penalty on finding
that the alleged facts are true. The person who files an
affidavit has the burden of proving that the person is
financially unable to pay the amount of the penalty and
to give a supersedeas bond.
(p) If the person charged does not
pay the amount of the penalty and the enforcement of the
penalty is not stayed, the department may forward the
matter to the attorney general for enforcement of the
penalty and interest as provided by law for legal
judgments. An action to enforce a penalty order under
this section must be initiated in a court of competent
jurisdiction in Travis County or in the county in which
the violation was committed.
(q) Judicial review of a department
order or review under this section assessing a penalty
is under the substantial evidence rule. A suit may be
initiated by filing a petition with a district court in
Travis County, as provided by Subchapter G, Chapter
2001, Government Code.
(r) If a penalty is reduced or not
assessed, the department shall remit to the person the
appropriate amount plus accrued interest if the penalty
has been paid or shall execute a release of the bond if
a supersedeas bond has been posted. The accrued interest
on amounts remitted by the department under this
subsection shall be paid at a rate equal to the rate
provided by law for legal judgments and shall be paid
for the period beginning on the date the penalty is paid
to the department under this section and ending on the
date the penalty is remitted.
(s) A damage, cost, or penalty
collected under this section is not an allowable expense
in a claim or cost report that is or could be used to
determine a rate or payment under the medical assistance
program.
(t) All funds collected under this
section shall be deposited in the State Treasury to the
credit of the General Revenue Fund.
(u) A person found liable for a
violation under Subsection (c) that resulted in injury
to an elderly person, as defined by Section 48.002(1), a
disabled person, as defined by Section 48.002(8)(A), or
a person younger than 18 years of age may not provide or
arrange to provide health care services under the
medical assistance program for a period of 10 years. The
department by rule may provide for a period of
ineligibility longer than 10 years. The period of
ineligibility begins on the date on which the
determination that the person is liable becomes final.
This subsection does not apply to a person who operates
a nursing facility or an ICF-MR facility.
(v) A person found liable for a
violation under Subsection (c) that did not result in
injury to an elderly person, as defined by Section
48.002(1), a disabled person, as defined by Section
48.002(8)(A), or a person younger than 18 years of age
may not provide or arrange to provide health care
services under the medical assistance program for a
period of three years. The department by rule may
provide for a period of ineligibility longer than three
years. The period of ineligibility begins on the date on
which the determination that the person is liable
becomes final. This subsection does not apply to a
person who operates a nursing facility or an ICF-MR
facility.
Added by Acts 1987, 70th Leg., ch.
1052, § 2.04, eff. Sept. 1, 1987.
Amended by Acts 1995, 74th Leg., ch.
76, § 5.95(49), (53), eff. Sept. 1, 1995; Acts 1997,
75th Leg., ch. 1153, § 3.01(a), eff. Sept. 1, 1997; Acts
1999, 76th Leg., ch. 12, §§ 1, 2, eff. Sept. 1, 1999.
CHAPTER 36. MEDICAID FRAUD PREVENTION
SUBCHAPTER A. GENERAL PROVISIONS
§ 36.001. Definitions
In this chapter:
(1) "Claim" means a written or
electronically submitted request or demand that:
(A) is signed by a provider or a
fiscal agent and that identifies a product or service
provided or purported to have been provided to a
Medicaid recipient as reimbursable under the Medicaid
program, without regard to whether the money that is
requested or demanded is paid; or
(B) states the income earned or
expense incurred by a provider in providing a product or
a service and that is used to determine a rate of
payment under the Medicaid program.
(2) "Documentary material" means a
record, document, or other tangible item of any form,
including:
(A) a medical document or X ray
prepared by a person in relation to the provision or
purported provision of a product or service to a
Medicaid recipient;
(B) a medical, professional, or
business record relating to:
(i) the provision of a product or
service to a Medicaid recipient; or
(ii) a rate or amount paid or claimed
for a product or service, including a record relating to
a product or service provided to a person other than a
Medicaid recipient as needed to verify the rate or
amount;
(C) a record required to be kept by
an agency that regulates health care providers; or
(D) a record necessary to disclose
the extent of services a provider furnishes to Medicaid
recipients.
(3) "Fiscal agent" means:
(A) a person who, through a
contractual relationship with the Texas Department of
Human Services, the Texas Department of Health, or
another state agency, receives, processes, and pays a
claim under the Medicaid program; or
(B) the designated agent of a person
described by Paragraph (A).
(4) "Health care practitioner" means
a dentist, podiatrist, psychologist, physical therapist,
chiropractor, registered nurse, or other provider
licensed to provide health care services in this state.
(5) "Managed care organization" has
the meaning assigned by Section 32.039(a).
(6) "Medicaid program" means the
state Medicaid program.
(7) "Medicaid recipient" means an
individual on whose behalf a person claims or receives a
payment from the Medicaid program or a fiscal agent,
without regard to whether the individual was eligible
for benefits under the Medicaid program.
(8) "Physician" means a physician
licensed to practice medicine in this state.
(9) "Provider" means a person who
participates in or who has applied to participate in the
Medicaid program as a supplier of a product or service
and includes:
(A) a management company that
manages, operates, or controls another provider;
(B) a person, including a medical
vendor, that provides a product or service to a provider
or to a fiscal agent;
(C) an employee of a provider; and
(D) a managed care organization.
(10) "Service" includes care or
treatment of a Medicaid recipient.
(11) "Signed" means to have affixed a
signature directly or indirectly by means of
handwriting, typewriting, signature stamp, computer
impulse, or other means recognized by law.
(12) "Unlawful act" means an act
declared to be unlawful under Section 36.002.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Amended by Acts 1997, 75th
Leg., ch. 1153, § 4.02, eff. Sept. 1, 1997.
§ 36.002. Unlawful Acts
A person commits an unlawful act if
the person:
(1) knowingly or intentionally makes
or causes to be made a false statement or
misrepresentation of a material fact:
(A) on an application for a contract,
benefit, or payment under the Medicaid program; or
(B) that is intended to be used to
determine a person's eligibility for a benefit or
payment under the Medicaid program;
(2) knowingly or intentionally
conceals or fails to disclose an event:
(A) that the person knows affects the
initial or continued right to a benefit or payment under
the Medicaid program of:
(i) the person; or
(ii) another person on whose behalf
the person has applied for a benefit or payment or is
receiving a benefit or payment; and
(B) to permit a person to receive a
benefit or payment that is not authorized or that is
greater than the payment or benefit that is authorized;
(3) knowingly or intentionally
applies for and receives a benefit or payment on behalf
of another person under the Medicaid program and
converts any part of the benefit or payment to a use
other than for the benefit of the person on whose behalf
it was received;
(4) knowingly or intentionally makes,
causes to be made, induces, or seeks to induce the
making of a false statement or misrepresentation of
material fact concerning:
(A) the conditions or operation of a
facility in order that the facility may qualify for
certification or recertification required by the
Medicaid program, including certification or
recertification as:
(i) a hospital;
(ii) a nursing facility or skilled
nursing facility;
(iii) a hospice;
(iv) an intermediate care facility
for the mentally retarded;
(v) an assisted living facility; or
(vi) a home health agency; or
(B) information required to be
provided by a federal or state law, rule, regulation, or
provider agreement pertaining to the Medicaid program;
(5) except as authorized under the
Medicaid program, knowingly or intentionally charges,
solicits, accepts, or receives, in addition to an amount
paid under the Medicaid program, a gift, money, a
donation, or other consideration as a condition to the
provision of a service or continued service to a
Medicaid recipient if the cost of the service provided
to the Medicaid recipient is paid for, in whole or in
part, under the Medicaid program;
(6) knowingly or intentionally
presents or causes to be presented a claim for payment
under the Medicaid program for a product provided or a
service rendered by a person who:
(A) is not licensed to provide the
product or render the service, if a license is required;
or
(B) is not licensed in the manner
claimed;
(7) knowingly or intentionally makes
a claim under the Medicaid program for:
(A) a service or product that has not
been approved or acquiesced in by a treating physician
or health care practitioner;
(B) a service or product that is
substantially inadequate or inappropriate when compared
to generally recognized standards within the particular
discipline or within the health care industry; or
(C) a product that has been
adulterated, debased, mislabeled, or that is otherwise
inappropriate;
(8) makes a claim under the Medicaid
program and knowingly or intentionally fails to indicate
the type of license and the identification number of the
licensed health care provider who actually provided the
service;
(9) knowingly or intentionally enters
into an agreement, combination, or conspiracy to defraud
the state by obtaining or aiding another person in
obtaining an unauthorized payment or benefit from the
Medicaid program or a fiscal agent; or
(10) is a managed care organization
that contracts with the Health and Human Services
Commission or other state agency to provide or arrange
to provide health care benefits or services to
individuals eligible under the Medicaid program and
knowingly or intentionally:
(A) fails to provide to an individual
a health care benefit or service that the organization
is required to provide under the contract;
(B) fails to provide to the
commission or appropriate state agency information
required to be provided by law, commission or agency
rule, or contractual provision;
(C) engages in a fraudulent activity
in connection with the enrollment of an individual
eligible under the Medicaid program in the
organization's managed care plan or in connection with
marketing the organization's services to an individual
eligible under the Medicaid program; or
(D) obstructs an investigation by the
attorney general of an alleged unlawful act under this
section.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Amended by Acts 1997, 75th
Leg., ch. 1153, § 4.03, eff. Sept. 1, 1997; Acts 1999,
76th Leg., ch. 233, § 4, eff. Sept. 1, 1999.
§ 36.003. Documentary Material in
Possession of State Agency
(a) A state agency, including the
Health and Human Services Commission, the Texas
Department of Human Services, the Texas Department of
Health, the Texas Department of Mental Health and Mental
Retardation, or the Department of Protective and
Regulatory Services, shall provide the attorney general
access to all documentary materials of persons and
Medicaid recipients under the Medicaid program to which
that agency has access. Documentary material provided
under this subsection is provided to permit
investigation of an alleged unlawful act or for use or
potential use in an administrative or judicial
proceeding.
(b) Except as ordered by a court for
good cause shown, the office of the attorney general may
not produce for inspection or copying or otherwise
disclose the contents of documentary material obtained
under this section to a person other than:
(1) an authorized employee of the
attorney general;
(2) an agency of this state, the
United States, or another state;
(3) a criminal district attorney,
district attorney, or county attorney of this state;
(4) the United States attorney
general; or
(5) a state or federal grand jury.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.007 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(a) eff. Sept. 1, 1997.
§ 36.004. Immunity
Notwithstanding any other law, a
person is not civilly or criminally liable for providing
access to documentary material under this chapter to:
(1) an authorized employee of the
attorney general;
(2) an agency of this state, the
United States, or another state;
(3) a criminal district attorney,
district attorney, or county attorney of this state;
(4) the United States attorney
general; or
(5) a state or federal grand jury.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.008 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
§ 36.005. Suspension or Revocation of
Agreement; Professional Discipline
(a) The commissioner of human
services, the commissioner of public health, the
commissioner of mental health and mental retardation,
the executive director of the Department of Protective
and Regulatory Services, or the executive director of
another state health care regulatory agency:
(1) shall suspend or revoke:
(A) a provider agreement between the
department or agency and a person, other than a person
who operates a nursing facility or an ICF-MR facility,
found liable under Section 36.052; and
(B) a permit, license, or
certification granted by the department or agency to a
person, other than a person who operates a nursing
facility or an ICF-MR facility, found liable under
Section 36.052; and
(2) may suspend or revoke:
(A) a provider agreement between the
department or agency and a person who operates a nursing
facility or an ICF-MR facility and who is found liable
under Section 36.052; or
(B) a permit, license, or
certification granted by the department or agency to a
person who operates a nursing facility or an ICF-MR
facility and who is found liable under Section 36.052.
(b) A person found liable under
Section 36.052 for an unlawful act may not provide or
arrange to provide health care services under the
Medicaid program for a period of 10 years. The board of
a state agency that operates part of the Medicaid
program may by rule provide for a period of
ineligibility longer than 10 years. The period of
ineligibility begins on the date on which the
determination that the person is liable becomes final.
This subsection does not apply to a person who operates
a nursing facility or an ICF-MR facility.
(c) A person licensed by a state
regulatory agency who commits an unlawful act is subject
to professional discipline under the applicable
licensing law or rules adopted under that law.
(d) For purposes of this section, a
person is considered to have been found liable under
Section 36.052 if the person is found liable in an
action brought under Subchapter C.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.009 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(a), eff. Sept. 1, 1997. Amended by Acts
1997, 75th Leg., ch. 1153, § 4.06, eff. Sept. 1, 1997.
§ 36.006. Application of Other Law
The application of a civil remedy
under this chapter does not preclude the application of
another common law, statutory, or regulatory remedy,
except that a person may not be liable for a civil
remedy under this chapter and civil damages or a penalty
under Section 32.039 if the civil remedy and civil
damages or penalty are assessed for the same act.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.010 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
§ 36.007. Recovery of Costs, Fees,
and Expenses
The attorney general may recover
fees, expenses, and costs reasonably incurred in
obtaining injunctive relief or civil remedies or in
conducting investigations under this chapter, including
court costs, reasonable attorney's fees, witness fees,
and deposition fees.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.011 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
§ 36.008. Use of Money Recovered
The legislature, in appropriating
money recovered under this chapter, shall consider the
requirements of the attorney general and other affected
state agencies in investigating Medicaid fraud and
enforcing this chapter.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.012 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(a), eff. Sept. 1, 1997.
SUBCHAPTER B. ACTION BY ATTORNEY
GENERAL
§ 36.051. Injunctive Relief
(a) If the attorney general has
reason to believe that a person is committing, has
committed, or is about to commit an unlawful act, the
attorney general may institute an action for an
appropriate order to restrain the person from committing
or continuing to commit the act.
(b) An action under this section
shall be brought in a district court of Travis County or
of a county in which any part of the unlawful act
occurred, is occurring, or is about to occur.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.003 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(b), eff. Sept. 1, 1997.
§ 36.052. Civil Remedies
(a) Except as provided by Subsection
(c), a person who commits an unlawful act is liable to
the state for:
(1) restitution of the value of any
payment or monetary or in-kind benefit provided under
the Medicaid program, directly or indirectly, as a
result of the unlawful act;
(2) interest on the value of the
payment or benefit described by Subdivision (1) at the
prejudgment interest rate in effect on the day the
payment or benefit was received or paid, for the period
from the date the benefit was received or paid to the
date that restitution is paid to the state;
(3) a civil penalty of:
(A) not less than $5,000 or more than
$15,000 for each unlawful act committed by the person
that results in injury to an elderly person, as defined
by Section 48.002(1), a disabled person, as defined by
Section 48.002(8)(A), or a person younger than 18 years
of age; or
(B) not less than $1,000 or more than
$10,000 for each unlawful act committed by the person
that does not result in injury to a person described by
Paragraph (A); and
(4) two times the value of the
payment or benefit described by Subdivision (1).
(b) In determining the amount of the
civil penalty described by Subsection (a)(3), the trier
of fact shall consider:
(1) whether the person has previously
violated the provisions of this chapter;
(2) the seriousness of the unlawful
act committed by the person, including the nature,
circumstances, extent, and gravity of the unlawful act;
(3) whether the health and safety of
the public or an individual was threatened by the
unlawful act;
(4) whether the person acted in bad
faith when the person engaged in the conduct that formed
the basis of the unlawful act; and
(5) the amount necessary to deter
future unlawful acts.
(c) The trier of fact may assess a
total of not more than two times the value of a payment
or benefit described by Subsection (a)(1) if the trier
of fact finds that:
(1) the person furnished the attorney
general with all information known to the person about
the unlawful act not later than the 30th day after the
date on which the person first obtained the information;
and
(2) at the time the person furnished
all the information to the attorney general, the
attorney general had not yet begun an investigation
under this chapter.
(d) An action under this section
shall be brought in Travis County or in a county in
which any part of the unlawful act occurred.
(e) The attorney general may:
(1) bring an action for civil
remedies under this section together with a suit for
injunctive relief under Section 36.051; or
(2) institute an action for civil
remedies independently of an action for injunctive
relief.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.004 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(b), eff. Sept. 1, 1997. Amended by Acts
1997, 75th Leg., ch. 1153, § 4.04, eff. Sept. 1, 1997.
§ 36.053. Investigation
(a) The attorney general may take
action under Subsection (b) if the attorney general has
reason to believe that:
(1) a person has information or
custody or control of documentary material relevant to
the subject matter of an investigation of an alleged
unlawful act;
(2) a person is committing, has
committed, or is about to commit an unlawful act; or
(3) it is in the public interest to
conduct an investigation to ascertain whether a person
is committing, has committed, or is about to commit an
unlawful act.
(b) In investigating an unlawful act,
the attorney general may:
(1) require the person to file on a
prescribed form a statement in writing, under oath or
affirmation, as to all the facts and circumstances
concerning the alleged unlawful act and other
information considered necessary by the attorney
general;
(2) examine under oath a person in
connection with the alleged unlawful act; and
(3) execute in writing and serve on
the person a civil investigative demand requiring the
person to produce the documentary material and permit
inspection and copying of the material under Section
36.054.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.005 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(b), eff. Sept. 1, 1997. Amended by Acts
1997, 75th Leg., ch. 1153, § 4.05, eff. Sept. 1, 1997.
§ 36.054. Civil Investigative Demand
(a) An investigative demand must:
(1) state the rule or statute under
which the alleged unlawful act is being investigated and
the general subject matter of the investigation;
(2) describe the class or classes of
documentary material to be produced with reasonable
specificity to fairly indicate the documentary material
demanded;
(3) prescribe a return date within
which the documentary material is to be produced; and
(4) identify an authorized employee
of the attorney general to whom the documentary material
is to be made available for inspection and copying.
(b) A civil investigative demand may
require disclosure of any documentary material that is
discoverable under the Texas Rules of Civil Procedure.
(c) Service of an investigative
demand may be made by:
(1) delivering an executed copy of
the demand to the person to be served or to a partner,
an officer, or an agent authorized by appointment or by
law to receive service of process on behalf of that
person;
(2) delivering an executed copy of
the demand to the principal place of business in this
state of the person to be served; or
(3) mailing by registered or
certified mail an executed copy of the demand addressed
to the person to be served at the person's principal
place of business in this state or, if the person has no
place of business in this state, to a person's principal
office or place of business.
(d) Documentary material demanded
under this section shall be produced for inspection and
copying during normal business hours at the office of
the attorney general or as agreed by the person served
and the attorney general.
(e) Except as ordered by a court for
good cause shown, the office of the attorney general may
not produce for inspection or copying or otherwise
disclose the contents of documentary material obtained
under this section to a person other than an authorized
employee of the attorney general without the consent of
the person who produced the documentary material. The
attorney general shall prescribe reasonable terms and
conditions allowing the documentary material to be
available for inspection and copying by the person who
produced the material or by an authorized representative
of that person. The attorney general may use the
documentary material or copies of it as the attorney
general determines necessary in the enforcement of this
chapter, including presentation before a court.
(f) A person may file a petition,
stating good cause, to extend the return date for the
demand or to modify or set aside the demand. A petition
under this section shall be filed in a district court of
Travis County and must be filed before the earlier of:
(1) the return date specified in the
demand; or
(2) the 20th day after the date the
demand is served.
(g) Except as provided by court
order, a person on whom a demand has been served under
this section shall comply with the terms of an
investigative demand.
(h) A person who has committed an
unlawful act in relation to the Medicaid program in this
state has submitted to the jurisdiction of this state
and personal service of an investigative demand under
this section may be made on the person outside of this
state.
(i) This section does not limit the
authority of the attorney general to conduct
investigations or to access a person's documentary
materials or other information under another state or
federal law, the Texas Rules of Civil Procedure, or the
Federal Rules of Civil Procedure.
(j) If a person fails to comply with
an investigative demand, or if copying and reproduction
of the documentary material demanded cannot be
satisfactorily accomplished and the person refuses to
surrender the documentary material, the attorney general
may file in a district court of Travis County a petition
for an order to enforce the investigative demand.
(k) If a petition is filed under
Subsection (j), the court may determine the matter
presented and may enter an order to implement this
section.
(l) Failure to comply with a final
order entered under Subsection (k) is punishable by
contempt.
(m) A final order issued by a
district court under Subsection (k) is subject to appeal
to the supreme court.
Added by Acts 1995, 74th Leg., ch.
824, § 1, eff. Sept. 1, 1995. Renumbered from V.T.C.A.,
Human Resources Code § 36.006 by Acts 1997, 75th Leg.,
ch. 1153, § 4.01(b), eff. Sept. 1, 1997.
§ 36.055. Attorney General as Relator
in Federal Action
To the extent permitted by 31 U.S.C.
Sections 3729–3733, the attorney general may bring an
action as relator under 31 U.S.C. Section 3730 with
respect to an act in connection with the Medicaid
program for which a person may be held liable under 31
U.S.C. Section 3729. The attorney general may contract
with a private attorney to represent the state under
this section.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.07(a), eff. Sept. 1, 1997.
SUBCHAPTER C. ACTION BY PRIVATE
PERSONS
§ 36.101. Action by Private Person
Authorized
(a) A person may bring a civil action
for a violation of Section 36.002 for the person and for
the state. The action shall be brought in the name of
the person and of the state.
(b) In an action brought under this
subchapter, a person who violates Section 36.002 is
liable as provided by Section 36.052.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.102. Initiation of Action
(a) A person bringing an action under
this subchapter shall serve a copy of the petition and a
written disclosure of substantially all material
evidence and information the person possesses on the
attorney general in compliance with the Texas Rules of
Civil Procedure.
(b) The petition shall be filed in
camera and shall remain under seal until at least the
60th day after the date the petition is filed. The
petition may not be served on the defendant until the
court orders service on the defendant.
(c) The state may elect to intervene
and proceed with the action not later than the 60th day
after the date the attorney general receives the
petition and the material evidence and information.
(d) The state may, for good cause
shown, move the court to extend the time during which
the petition remains under seal under Subsection (b). A
motion under this subsection may be supported by
affidavits or other submissions in camera.
(e) An action under this subchapter
may be dismissed before the end of the period prescribed
by Subsection (b), as extended as provided by Subsection
(d), if applicable, only if the court and the attorney
general consent in writing to the dismissal and state
their reasons for consenting.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.103. Answer by Defendant
A defendant is not required to file
an answer to a petition filed under this subchapter
until the 20th day after the date the petition is
unsealed and served on the defendant in compliance with
the Texas Rules of Civil Procedure.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.104. Continuation or Dismissal
of Action Based on State Decision
(a) Not later than the last day of
the period prescribed by Section 36.102(c), the state
shall:
(1) proceed with the action; or
(2) notify the court that the state
declines to take over the action.
(b) If the state declines to take
over the action, the court shall dismiss the action.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.105. Representation of State by
Private Attorney
The attorney general may contract
with a private attorney to represent the state in an
action under this subchapter with which the state elects
to proceed.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.106. Intervention by Other
Parties Prohibited
A person other than the state may not
intervene or bring a related action based on the facts
underlying a pending action brought under this
subchapter.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.107. Rights of Parties if State
Continues Action
(a) If the state proceeds with the
action, the state has the primary responsibility for
prosecuting the action and is not bound by an act of the
person bringing the action. The person bringing the
action has the right to continue as a party to the
action, subject to the limitations set forth by this
section.
(b) The state may dismiss the action
notwithstanding the objections of the person bringing
the action if:
(1) the attorney general notifies the
person that the state has filed a motion to dismiss; and
(2) the court provides the person
with an opportunity for a hearing on the motion.
(c) The state may settle the action
with the defendant notwithstanding the objections of the
person bringing the action if the court determines,
after a hearing, that the proposed settlement is fair,
adequate, and reasonable under all the circumstances. On
a showing of good cause, the hearing may be held in
camera.
(d) On a showing by the state that
unrestricted participation during the course of the
litigation by the person bringing the action would
interfere with or unduly delay the state's prosecution
of the case, or would be repetitious, irrelevant, or for
purposes of harassment, the court may impose limitations
on the person's participation, including:
(1) limiting the number of witnesses
the person may call;
(2) limiting the length of the
testimony of witnesses called by the person;
(3) limiting the person's
cross-examination of witnesses; or
(4) otherwise limiting the
participation by the person in the litigation.
(e) On a showing by the defendant
that unrestricted participation during the course of the
litigation by the person bringing the action would be
for purposes of harassment or would cause the defendant
undue burden or unnecessary expense, the court may limit
the participation by the person in the litigation.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.108. Stay of Certain Discovery
(a) On a showing by the state that
certain actions of discovery by the person bringing the
action would interfere with the state's investigation or
prosecution of a criminal or civil matter arising out of
the same facts, the court may stay the discovery for a
period not to exceed 60 days.
(b) The court shall hear a motion to
stay discovery under this section in camera.
(c) The court may extend the period
prescribed by Subsection (a) on a further showing in
camera that the state has pursued the criminal or civil
investigation or proceedings with reasonable diligence
and that any proposed discovery in the civil action will
interfere with the ongoing criminal or civil
investigation or proceedings.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.109. Pursuit of Alternate Remedy
by State
(a) Notwithstanding Section 36.101,
the state may elect to pursue the state's claim through
any alternate remedy available to the state, including
any administrative proceeding to determine an
administrative penalty. If an alternate remedy is
pursued in another proceeding, the person bringing the
action has the same rights in the other proceeding as
the person would have had if the action had continued
under this subchapter.
(b) A finding of fact or conclusion
of law made in the other proceeding that has become
final is conclusive on all parties to an action under
this subchapter. For purposes of this subsection, a
finding or conclusion is final if:
(1) the finding or conclusion has
been finally determined on appeal to the appropriate
court;
(2) no appeal has been filed with
respect to the finding or conclusion and all time for
filing an appeal has expired; or
(3) the finding or conclusion is not
subject to judicial review.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.110. Award to Private Plaintiff
(a) If the state proceeds with an
action under this subchapter, the person bringing the
action is entitled, except as provided by Subsection
(b), to receive at least 10 percent but not more than 25
percent of the proceeds of the action, depending on the
extent to which the person substantially contributed to
the prosecution of the action.
(b) If the court finds that the
action is based primarily on disclosures of specific
information, other than information provided by the
person bringing the action, relating to allegations or
transactions in a criminal or civil hearing, in a
legislative or administrative report, hearing, audit, or
investigation, or from the news media, the court may
award the amount the court considers appropriate but not
more than seven percent of the proceeds of the action.
The court shall consider the significance of the
information and the role of the person bringing the
action in advancing the case to litigation.
(c) A payment to a person under this
section shall be made from the proceeds of the action. A
person receiving a payment under this section is also
entitled to receive an amount for reasonable expenses
that the court finds to have been necessarily incurred,
plus reasonable attorney's fees and costs. Expenses,
fees, and costs shall be awarded against the defendant.
(d) In this section, "proceeds of the
action" includes proceeds of a settlement of the action.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.111. Reduction of Award
(a) If the court finds that the
action was brought by a person who planned and initiated
the violation of Section 36.002 on which the action was
brought, the court may, to the extent the court
considers appropriate, reduce the share of the proceeds
of the action the person would otherwise receive under
Section 36.110, taking into account the person's role in
advancing the case to litigation and any relevant
circumstances pertaining to the violation.
(b) If the person bringing the action
is convicted of criminal conduct arising from the
person's role in the violation of Section 36.002, the
court shall dismiss the person from the civil action and
the person may not receive any share of the proceeds of
the action. A dismissal under this subsection does not
prejudice the right of the state to continue the action.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.112. Award to Defendant for
Frivolous Action
Chapter 105, Civil Practice and
Remedies Code, applies in an action under this
subchapter with which the state proceeds.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.113. Certain Actions Barred
(a) A person may not bring an action
under this subchapter that is based on allegations or
transactions that are the subject of a civil suit or an
administrative penalty proceeding in which the state is
already a party.
(b) A person may not bring an action
under this subchapter that is based on the public
disclosure of allegations or transactions in a criminal
or civil hearing, in a legislative or administrative
report, hearing, audit, or investigation, or from the
news media, unless the person bringing the action is an
original source of the information. In this subsection,
"original source" means an individual who has direct and
independent knowledge of the information on which the
allegations are based and has voluntarily provided the
information to the state before filing an action under
this subchapter that is based on the information.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.114. State Not Liable for
Certain Expenses
The state is not liable for expenses
that a person incurs in bringing an action under this
subchapter.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.115. Retaliation by Employer
Against Person Bringing Suit Prohibited
(a) A person who is discharged,
demoted, suspended, threatened, harassed, or in any
other manner discriminated against in the terms of
employment by the person's employer because of a lawful
act taken by the person in furtherance of an action
under this subchapter, including investigation for,
initiation of, testimony for, or assistance in an action
filed or to be filed under this subchapter, is entitled
to:
(1) reinstatement with the same
seniority status the person would have had but for the
discrimination; and
(2) not less than two times the
amount of back pay, interest on the back pay, and
compensation for any special damages sustained as a
result of the discrimination, including litigation costs
and reasonable attorney's fees.
(b) A person may bring an action in
the appropriate district court for the relief provided
in this section.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.116. Sovereign Immunity Not
Waived
Except as provided by Section 36.112,
this subchapter does not waive sovereign immunity.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
§ 36.117. Attorney General
Compensation
The office of the attorney general
may retain a reasonable portion of recoveries under this
subchapter, not to exceed amounts specified in the
General Appropriations Act, for the administration of
this subchapter.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.08, eff. Sept. 1, 1997.
SUBCHAPTER D. CRIMINAL PENALTIES AND
REVOCATION OF CERTAIN OCCUPATIONAL LICENSES
§ 36.131. Criminal Offense
(a) A person commits an offense if
the person commits an unlawful act under Section 36.002.
(b) An offense under this section is:
(1) a Class C misdemeanor if the
value of any payment or monetary or in-kind benefit
provided under the Medicaid program, directly or
indirectly, as a result of the unlawful act is less than
$50;
(2) a Class B misdemeanor if the
value of any payment or monetary or in-kind benefit
provided under the Medicaid program, directly or
indirectly, as a result of the unlawful act is $50 or
more but less than $500;
(3) a Class A misdemeanor if the
value of any payment or monetary or in-kind benefit
provided under the Medicaid program, directly or
indirectly, as a result of the unlawful act is $500 or
more but less than $1,500;
(4) a state jail felony if the value
of any payment or monetary or in-kind benefit provided
under the Medicaid program, directly or indirectly, as a
result of the unlawful act is $1,500 or more but less
than $20,000;
(5) a felony of the third degree if
the value of any payment or monetary or in-kind benefit
provided under the Medicaid program, directly or
indirectly, as a result of the unlawful act is $20,000
or more but less than $100,000;
(6) a felony of the second degree if
the value of any payment or monetary or in-kind benefit
provided under the Medicaid program, directly or
indirectly, as a result of the unlawful act is $100,000
or more but less than $200,000; or
(7) a felony of the first degree if
the value of any payment or monetary or in-kind benefit
provided under the Medicaid program, directly or
indirectly, as a result of the unlawful act is $200,000
or more.
(c) If conduct constituting an
offense under this section also constitutes an offense
under another provision of law, including a provision in
the Penal Code, the actor may be prosecuted under either
this section or the other provision.
(d) When multiple payments or
monetary or in-kind benefits are provided under the
Medicaid program as a result of one scheme or continuing
course of conduct, the conduct may be considered as one
offense and the amounts of the payments or monetary or
in-kind benefits aggregated in determining the grade of
the offense.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.09, eff. Sept. 1, 1997.
§ 36.132. Revocation of Licenses
(a) In this section:
(1) "License" means a license,
certificate, registration, permit, or other
authorization that:
(A) is issued by a licensing
authority;
(B) is subject before expiration to
suspension, revocation, forfeiture, or termination by an
issuing licensing authority; and
(C) must be obtained before a person
may practice or engage in a particular business,
occupation, or profession.
(2) "Licensing authority" means:
(A) the Texas State Board of Medical
Examiners;
(B) the State Board of Dental
Examiners;
(C) the Texas State Board of
Examiners of Psychologists;
(D) the Texas State Board of Social
Worker Examiners;
(E) the Board of Nurse Examiners;
(F) the Board of Vocational Nurse
Examiners;
(G) the Texas Board of Physical
Therapy Examiners;
(H) the Texas Board of Occupational
Therapy Examiners; or
(I) another state agency authorized
to regulate a provider who receives or is eligible to
receive payment for a health care service under the
Medicaid program.
(b) A licensing authority shall
revoke a license issued by the authority to a person if
the person is convicted of a felony under Section
36.131. In revoking the license, the licensing authority
shall comply with all procedures generally applicable to
the licensing authority in revoking licenses.
Added by Acts 1997, 75th Leg., ch.
1153, § 4.09, eff. Sept. 1, 1997.
TEXAS GOVERNMENT CODE
CHAPTER 531. HEALTH AND HUMAN
SERVICES COMMISSION
SUBCHAPTER C. MEDICAID AND OTHER
WELFARE FRAUD, ABUSE, OR OVERCHARGES
§ 531.101. Award for Reporting
Medicaid Fraud, Abuse, or Overcharges
(a) The commission may grant an award
to an individual who reports activity that constitutes
fraud or abuse of funds in the state Medicaid program or
reports overcharges in the program if the commission
determines that the disclosure results in the recovery
of an overcharge or in the termination of the fraudulent
activity or abuse of funds.
(b) The commission shall determine
the amount of an award. The award must be equal to not
less than 10 percent of the savings to this state that
result from the individual's disclosure. In determining
the amount of the award, the commission shall consider
how important the disclosure is in ensuring the fiscal
integrity of the program.
(c) An award under this section is
subject to appropriation. The award must be paid from
money appropriated to or otherwise available to the
commission, and additional money may not be appropriated
to the commission for the purpose of paying the award.
(d) Payment of an award under this
section from federal funds is subject to the permissible
use under federal law of funds for this purpose.
(e) A person who brings an action
under Subchapter C, Chapter 36, Human Resources Code, is
not eligible for an award under this section.
Added by Acts 1997, 75th Leg., ch.
165, § 14.16, eff. Sept. 1, 1997; Acts 1997, 75th Leg.,
ch. 1153, § 1.06(a), eff. Sept. 1, 1997.
§ 531.102. Investigations and
Enforcement Office
(a) The commission, through the
commission's office of investigations and enforcement,
is responsible for the investigation of fraud in the
provision of health and human services and the
enforcement of state law relating to the provision of
those services.
(b) The commission shall set clear
objectives, priorities, and performance standards for
the office that emphasize:
(1) coordinating investigative
efforts to aggressively recover money;
(2) allocating resources to cases
that have the strongest supportive evidence and the
greatest potential for recovery of money; and
(3) maximizing opportunities for
referral of cases to the office of the attorney general.
(c) The commission shall train office
staff to enable the staff to pursue priority Medicaid
and welfare fraud and abuse cases as necessary.
(d) The commission may require
employees of health and human services agencies to
provide assistance to the commission in connection with
the commission's duties relating to the investigation of
fraud in the provision of health and human services.
(e) The commission by rule shall set
specific claims criteria that, when met, require the
office to begin an investigation.
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. June 20, 1997.
Amended by Acts 1999, 76th Leg., ch.
1289, § 3, eff. Sept. 1, 1999.
§ 531.103. Interagency Coordination
(a) The commission and the office of
the attorney general shall enter into a memorandum of
understanding to develop and implement joint written
procedures for processing cases of suspected fraud,
waste, or abuse under the state Medicaid program. The
memorandum of understanding shall require:
(1) the commission and the office of
the attorney general to set priorities and guidelines
for referring cases to appropriate state agencies for
investigation to enhance deterrence of fraud, waste, or
abuse in the program and maximize the imposition of
penalties, the recovery of money, and the successful
prosecution of cases;
(2) the commission to keep detailed
records for cases processed by the commission or the
office of the attorney general, including information on
the total number of cases processed and, for each case:
(A) the agency and division to which
the case is referred for investigation;
(B) the date on which the case is
referred; and
(C) the nature of the suspected
fraud, waste, or abuse;
(3) the commission to notify each
appropriate division of the office of the attorney
general of each case referred by the commission;
(4) the office of the attorney
general to ensure that information relating to each case
investigated by that office is available to each
division of the office with responsibility for
investigating suspected fraud, waste, or abuse;
(5) the office of the attorney
general to notify the commission of each case the
attorney general declines to prosecute or prosecutes
unsuccessfully;
(6) representatives of the commission
and of the office of the attorney general to meet not
less than quarterly to share case information and
determine the appropriate agency and division to
investigate each case; and
(7) the commission and the office of
the attorney general to submit information requested by
the comptroller about each resolved case for the
comptroller's use in improving fraud detection.
(b) An exchange of information under
this section between the office of the attorney general
and the commission or a health and human services agency
does not affect whether the information is subject to
disclosure under Chapter 552.
(c) The commission and the office of
the attorney general shall jointly prepare and submit a
semiannual report to the governor, lieutenant governor,
and speaker of the house of representatives concerning
the activities of those agencies in detecting and
preventing fraud, waste, and abuse under the state
Medicaid program. The report may be consolidated with
any other report relating to the same subject matter the
commission or office of the attorney general is required
to submit under other law.
(d) The commission and the office of
the attorney general may not assess or collect
investigation and attorney's fees on behalf of any state
agency unless the office of the attorney general or
other state agency collects a penalty, restitution, or
other reimbursement payment to the state.
(e) The commission shall refer a case
of suspected fraud, waste, or abuse under the state
Medicaid program to the appropriate district attorney,
county attorney, city attorney, or private collection
agency if the attorney general fails to act within 30
days of referral of the case to the office of the
attorney general. A failure by the attorney general to
act within 30 days constitutes approval by the attorney
general under Section 2107.003.
(f) The district attorney, county
attorney, city attorney, or private collection agency
may collect and retain costs associated with the case
and 20 percent of the amount of the penalty,
restitution, or other reimbursement payment collected.
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. Sept. 1, 1997.
§ 531.104. Assisting Investigations
by Attorney General
(a) The commission and the attorney
general shall execute a memorandum of understanding
under which the commission shall provide investigative
support as required to the attorney general in
connection with cases under Subchapter B, Chapter 36,
Human Resources Code. Under the memorandum of
understanding, the commission shall assist in performing
preliminary investigations and ongoing investigations
for actions prosecuted by the attorney general under
Subchapter C, Chapter 36, Human Resources Code.
(b) The memorandum of understanding
must provide that the commission is not required to
provide investigative support in more than 100 open
investigations in a fiscal year.
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. Sept. 1, 1997.
§ 531.105. Fraud Detection Training
(a) The commission shall develop and
implement a program to provide annual training to
contractors who process Medicaid claims and appropriate
staff of the Texas Department of Health and the Texas
Department of Human Services in identifying potential
cases of fraud, waste, or abuse under the state Medicaid
program. The training provided to the contractors and
staff must include clear criteria that specify:
(1) the circumstances under which a
person should refer a potential case to the commission;
and
(2) the time by which a referral
should be made.
(b) The Texas Department of Health
and the Texas Department of Human Services, in
cooperation with the commission, shall periodically set
a goal of the number of potential cases of fraud, waste,
or abuse under the state Medicaid program that each
agency will attempt to identify and refer to the
commission. The commission shall include information on
the agencies' goals and the success of each agency in
meeting the agency's goal in the report required by
Section 531.103(c).
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. Sept. 1, 1997.
§ 531.106. Learning or Neural Network
Technology
(a) The commission shall use learning
or neural network technology to identify and deter fraud
in the Medicaid program throughout this state.
(b) The commission shall contract
with a private or public entity to develop and implement
the technology. The commission may require the entity it
contracts with to install and operate the technology at
locations specified by the commission, including
commission offices.
(c) The data used for neural network
processing shall be maintained as an independent subset
for security purposes.
(d) The commission shall require each
health and human services agency that performs any
aspect of the state Medicaid program to participate in
the implementation and use of the technology.
(e) The commission shall maintain all
information necessary to apply the technology to claims
data covering a period of at least two years.
(f) The commission shall refer cases
identified by the technology to the commission's office
of investigations and enforcement or the office of the
attorney general, as appropriate.
(g) Each month, the learning or
neural network technology implemented under this section
must match bureau of vital statistics death records with
Medicaid claims filed by a provider. If the commission
determines that a provider has filed a claim for
services provided to a person after the person's date of
death, as determined by the bureau of vital statistics
death records, the commission shall refer the case for
investigation to the commission's office of
investigations and enforcement.
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. June 20, 1997.
Amended by Acts 1999, 76th Leg., ch.
215, § 2, eff. Sept. 1, 1999.
§ 531.1061. Fraud Investigation
Tracking System
(a) The commission shall use an
automated fraud investigation tracking system through
the commission's office of investigations and
enforcement to monitor the progress of an investigation
of suspected fraud, abuse, or insufficient quality of
care under the state Medicaid program.
(b) For each case of suspected fraud,
abuse, or insufficient quality of care identified by the
learning or neural network technology required under
Section 531.106, the automated fraud investigation
tracking system must:
(1) receive electronically
transferred records relating to the identified case from
the learning or neural network technology;
(2) record the details and monitor
the status of an investigation of the identified case,
including maintaining a record of the beginning and
completion dates for each phase of the case
investigation;
(3) generate documents and reports
related to the status of the case investigation; and
(4) generate standard letters to a
provider regarding the status or outcome of an
investigation.
(c) The commission shall require each
health and human services agency that performs any
aspect of the state Medicaid program to participate in
the implementation and use of the automated fraud
investigation tracking system.
Added by Acts 1999, 76th Leg., ch.
206, § 1, eff. Sept. 1, 1999.
§ 531.1062. Recovery Monitoring
System
(a) The commission shall use an
automated recovery monitoring system to monitor the
collections process for a settled case of fraud, abuse,
or insufficient quality of care under the state Medicaid
program.
(b) The recovery monitoring system
must:
(1) monitor the collection of funds
resulting from settled cases, including:
(A) recording monetary payments
received from a provider who has agreed to a monetary
payment plan; and
(B) recording deductions taken
through the recoupment program from subsequent Medicaid
claims filed by the provider; and
(2) provide immediate notice of a
provider who has agreed to a monetary payment plan or to
deductions through the recoupment program from
subsequent Medicaid claims who fails to comply with the
settlement agreement, including providing notice of a
provider who does not make a scheduled payment or who
pays less than the scheduled amount.
Added by Acts 1999, 76th Leg., ch.
206, § 1, eff. Sept. 1, 1999.
§ 531.107. Medicaid and Public
Assistance Fraud Oversight Task Force
(a) The Medicaid and Public
Assistance Fraud Oversight Task Force advises and
assists the commission and the commission's office of
investigations and enforcement in improving the
efficiency of fraud investigations and collections.
(b) The task force is composed of a
representative of the:
(1) attorney general's office,
appointed by the attorney general;
(2) comptroller's office, appointed
by the comptroller;
(3) Department of Public Safety,
appointed by the public safety director;
(4) state auditor's office, appointed
by the state auditor;
(5) commission, appointed by the
commissioner of health and human services;
(6) Texas Department of Human
Services, appointed by the commissioner of human
services; and
(7) Texas Department of Insurance,
appointed by the commissioner of insurance.
(c) The comptroller or the
comptroller's designee serves as the presiding officer
of the task force. The task force may elect any other
necessary officers.
(d) The task force shall meet at
least once each fiscal quarter at the call of the
presiding officer.
(e) The appointing agency is
responsible for the expenses of a member's service on
the task force. Members of the task force receive no
additional compensation for serving on the task force.
(f) At least once each fiscal
quarter, the commission's office of investigations and
enforcement shall provide to the task force:
(1) information detailing:
(A) the number of fraud referrals
made to the office and the origin of each referral;
(B) the time spent investigating each
case;
(C) the number of cases investigated
each month, by program and region;
(D) the dollar value of each fraud
case that results in a criminal conviction; and
(E) the number of cases the office
rejects and the reason for rejection, by region; and
(2) any additional information the
task force requires.
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. Sept. 1, 1997.
§ 531.108. Fraud Prevention
(a) The commission's office of
investigations and enforcement shall compile and
disseminate accurate information and statistics relating
to:
(1) fraud prevention; and
(2) post-fraud referrals received and
accepted or rejected from the commission's case
management system or the case management system of a
health and human services agency.
(b) The commission shall:
(1) aggressively publicize successful
fraud prosecutions and fraud-prevention programs through
all available means, including the use of statewide
press releases issued in coordination with the Texas
Department of Human Services; and
(2) ensure that a toll-free hotline
for reporting suspected fraud in programs administered
by the commission or a health and human services agency
is maintained and promoted, either by the commission or
by a health and human services agency.
(c) The commission shall develop a
cost-effective method of identifying applicants for
public assistance in counties bordering other states and
in metropolitan areas selected by the commission who are
already receiving benefits in other states. If
economically feasible, the commission may develop a
computerized matching system.
(d) The commission shall:
(1) verify automobile information
that is used as criteria for eligibility; and
(2) establish a computerized matching
system with the Texas Department of Criminal Justice to
prevent an incarcerated individual from illegally
receiving public assistance benefits administered by the
commission.
(e) The commission shall submit to
the governor and Legislative Budget Board a semiannual
report on the results of computerized matching of
commission information with information from neighboring
states, if any, and information from the Texas
Department of Criminal Justice. The report may be
consolidated with any other report relating to the same
subject matter the commission is required to submit
under other law.
Added by Acts 1997, 75th Leg., ch.
1153, § 1.06(a), eff. Sept. 1, 1997
Original and Specialized Information of
Medicaid Billing Fraud or Medicaid Payment Fraud
is Essential for a Medicaid Billing Fraud
Whistleblower Lawsuit or a Medicaid Payment Fraud Whistleblower
Lawsuit
As insiders it is common for a
variety of health care professionals, health care
executives, and health care administrators to have
specialized knowledge of Medicare Billing Fraud or
Medicare Payment Fraud. As such, it is important for
these health care administration whistleblowers and
health care executive to obtain and preserve evidence of the
Medicare fraud. Whether this evidence is in
e-mail messages, memos, accounting documents, coding
instructions, recordings, or other documents, it is
important for the whistleblower to have evidence of the
Medicare fraud. It is also often helpful to have
fellow whistleblowers that can help build the Medicare
Billing
Fraud or Medicare Payment Fraud case.
Being the First to File on the Medicaid Billing Fraud
Scheme is
Essential for Recovery Under the False Claims Act and
can Prevent Potential Criminal Liability for Concealing
a Medicaid Payment Fraud Scam
Remember Medicaid Billing Fraud Whistleblowers and
Medicaid Payment Fraud Whistleblowers not only can avoid
potential criminal liability if they expose Medicaid
Billing Fraud Schemes, but can get an economic incentive for
exposing Medicaid Billing Fraud, if they
are an original source with special knowledge of fraud
and are the first to file, they receive a portion of the
money that the government recovers. Depending on
the extent of the fraud, qui tam recoveries for the
government can be in the billions of dollars and
whistleblower recoveries can be in the hundreds of
millions of dollars.
There are several keys to a
successful Medicaid False Claims Act Qui Tam Whistleblower action
including 1) obtaining original and specialized
information of the fraud, 2) being the first to file
regarding the specific fraud, and 3) protecting the
whistleblower for retaliation.
It is also essential to not delay in
coming forward with a False Claim Act Qui Tam Action as
the first whistleblower to file is eligible to be a
relator and make a large recovery for exposing the
fraud. Additionally, when the fraudulent scheme is
exposed, the people that kept the fraud secret can
sometimes be found liable for criminal activity for not
exposing the fraud that was being committed and further
be held liable for continuing criminal activity.
Hospital Administrator Medicaid Billing Fraud
Whistleblower
Protection,
Nursing Home Medicaid Payment Fraud Whistleblower
Protection, and other
Medicaid Fraud False Claims Act Whistleblower
Protections
It is also important to understand
potential whistleblower protections under the False
Claims Act and to discuss with an attorney how to
prepare for potential retaliation or aggressive attacks
by the employer or contractor. For more
information on this topic please go to the following web
page on
False Claims Act Lawsuit Whistleblower Protections.
Medicare Payment Fraud Whistleblower Lawyers,
Texas Medicare Payment Fraud Lawyers, Texas Medicare Billing
Fraud Lawyers, and Medicare Billing Fraud Whistleblower
Lawyers
Medicare is Different from Medicaid, but both
Medicare Billing Fraud Whistleblowers and Medicaid
Billing Fraud Whistleblowers are needed to File Medical
Billing Fraud Lawsuits
In 2009, the Medicare program covered
an estimated 45 million persons and this number is
expected to grow as about 7,000 people a day are
reaching retirement age. As millions of people are
added to the Medicare budget each year, the cost of the
Medicare budget is expected to grow.
The Medicare program consists of four
distinct parts which are funded differently:
-
Part A (Hospital Insurance, or
HI) covers inpatient hospital services, skilled
nursing care, and home health and hospice care. The
HI trust fund is mainly funded by a dedicated
payroll tax of 2.9% of earnings, shared equally
between employers and workers.
-
Part B (Supplementary Medical
Insurance, or SMI) covers physician services,
outpatient services, and home health and preventive
services. The SMI trust fund is funded through
beneficiary premiums (set at 25% of estimated
program costs for the aged) and general revenues
(the remaining amount, approximately 75%).
-
Part C (Medicare Advantage, or
MA) is a private plan option for beneficiaries that
covers all Part A and B services, except hospice.
Individuals choosing to enroll in Part C must also
enroll in Part B. Part C is funded through the HI
and SMI trust funds.
-
Part D covers prescription drug
benefits. Funding is included in the SMI trust fund
and is financed through beneficiary premiums (about
25%) and general revenues (about 75%).[27]
Spending on Medicare and Medicaid is
projected to grow dramatically in coming decades. While
the same demographic trends that affect Social Security
also affect Medicare, rapidly rising medical prices
appear to be a more important cause of projected
spending increases.
For more Medicare Billing Fraud
Whistelblower Lawsuit Information, please go to the
following webpage on
Medicare Payment Fraud
Lawsuits.
Medicaid Billing Fraud Lawsuit Information, Medicaid
Whistleblower Lawsuit Information, and the Increase in Medicare and
Medicaid Spending
Medicaid is a public health care
problem in the United States that provides health care,
dental care, and orthodontic care for eligible
individuals and families with low incomes and resources.
The Medicaid Program is jointly funded by state and
federal governments, but is managed by the states.
Medicaid is the largest source of funding for medical
and health-related services for people with limited
income in the United States and the Medicaid program has
been increasing. The fastest growing aspect of Medicaid
is nursing home coverage and this is expected to
continue as the Baby Boomer generation begins to reach
nursing home age.
For more information on Medicaid
Billing Fraud Whistleblower Lawsuits, please go to the
following webpage,
CHIP Fraud Whistleblower Lawsuit and Medicaid Billing
Fraud Whistleblower Lawsuit Information.
Government Contractor Fraud Qui Tam
Whistleblower Lawsuit Information (False Claims Act
Whistleblower Qui Tam Action Information)
For more information on Medicare
Fraud, Tricare Fraud, Medicaid Fraud, Defense Contractor
Fraud, Off Label Fraud, Road Construction Fraud, and
other types of False Claims Act Whistleblower Claims,
please go to the
Qui Tam, Whistleblower, and Federal Federal False Claims
Act Information Center.
Texas Medicaid Billing Fraud Whistleblower Lawyer,
Texas Medicaid Double Billing Fraud Lawyer, Texas Medicaid
Upcoding Fraud Lawyer, and Medicaid Illegal Kickback Lawyer
Texas Medicaid Billing Fraud
Whistleblower Lawyer, Jason S. Coomer, works with San
Antonio Medicaid Billing Fraud Lawyers, Dallas Medicaid
Billing Fraud Whistleblower Lawyers, Houston Medicaid
Billing Fraud Lawyers, and other Texas Medicaid Health
Care Fraud Lawyers as well as with Health Care and
Hospital Whistleblower Lawyers throughout the nation to
blow the whistle on fraud that hurts the United States.
If you are a health care executive,
health care administrator, medical device
marketing representative, medical device marketing
executive, medical doctor, or other pharmaceutical or
medical device professional with original source
knowledge of Medicare Billing Fraud,
Hospital Medicare Fraud,
Nursing Home Medicare Fraud, or Medicaid Billing
Fraud it is important that you
are the first to step forward to blow the
whistle on the Medicare Billing fraud. If you are a
Medicaid Billing Fraud Whistleblower that is aware of fraudulent
upcoding, double billing, bill padding, unbundling,
charging for services never provided, illegal Medicaid kickbacks,
or other Medicaid fraud, feel free to
contact
Texas Medicaid Billing Fraud
Whistleblower Lawyer Jason Coomer via e-mail message
or our
submission form.
