SEC. 1128B.
[42 U.S.C. 1320a-7b] (a)
Whoever—
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(1) knowingly and willfully makes or causes to be made any false
statement or representation of a material fact in any
application for any benefit or payment under a Federal health
care program (as defined in subsection (f)),
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(2) at any time knowingly and willfully makes or causes to be
made any false statement or representation of a material fact
for use in determining rights to such benefit or payment,
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(3) having knowledge of the occurrence of any event affecting
(A) his initial or continued right to any such benefit or
payment, or (B) the initial or continued right to any such
benefit or payment of any other individual in whose behalf he
has applied for or is receiving such benefit or payment,
conceals or fails to disclose such event with an intent
fraudulently to secure such benefit or payment either in a
greater amount or quantity than is due or when no such benefit
or payment is authorized,
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(4) having made application to receive any such benefit or
payment for the use and benefit of another and having received
it, knowingly and willfully converts such benefit or payment or
any part thereof to a use other than for the use and benefit of
such other person,
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(5) presents or causes to be presented a claim for a physician's
service for which payment may be made under a Federal health
care program and knows that the individual who furnished the
service was not licensed as a physician, or
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(6) for a fee knowingly and willfully counsels or assists an
individual to dispose of assets (including by any transfer in
trust) in order for the individual to become eligible for
medical assistance under a State plan under title XIX, if
disposing of the assets results in the imposition of a period of
ineligibility for such assistance under section 1917(c),
shall (i) in the case of such a statement, representation,
concealment, failure, or conversion by any person in connection
with the furnishing (by that person) of items or services for
which payment is or may be made under the program, be guilty of
a felony and upon conviction thereof fined not more than $25,000
or imprisoned for not more than five years or both, or (ii) in
the case of such a statement, representation, concealment,
failure, conversion, or provision of counsel or assistance by
any other person be guilty of a misdemeanor and upon conviction
thereof fined not more than $10,000 or imprisoned for not more
than one year, or both. In addition, in any case where an
individual who is otherwise eligible for assistance under a
Federal health care program is convicted of an offense under the
preceding provisions of this subsection, the administrator of
such program may at its option (notwithstanding any other
provision of such program) limit, restrict, or suspend the
eligibility of that individual for such period (not exceeding
one year) as it deems appropriate; but the imposition of a
limitation, restriction, or suspension with respect to the
eligibility of any individual under this sentence shall not
affect the eligibility of any other person for assistance under
the plan, regardless of the relationship between that individual
and such other person.
(b)(1)
Whoever knowingly and willfully solicits or receives any
remuneration (including any kickback, bribe, or rebate) directly
or indirectly, overtly or covertly, in cash or in kind—
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(A) in return for referring an individual to a person for the
furnishing or arranging for the furnishing of any item or
service for which payment may be made in whole or in part under
a Federal health care program, or
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(B) in return for purchasing, leasing, ordering, or arranging
for or recommending purchasing, leasing, or ordering any good,
facility, service, or item for which payment may be made in
whole or in part under Federal health care program,
shall be guilty of a felony and upon conviction thereof, shall
be fined not more than $25,000 or imprisoned for not more than
five years, or both.
(2) Whoever knowingly and willfully offers or pays any
remuneration (including any kickback, bribe, or rebate) directly
or indirectly, overtly or covertly, in cash or in kind to any
person to induce such person—
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(A) to refer an individual to a person for the furnishing or
arranging for the furnishing of any item or service for which
payment may be made in whole or in part under a Federal health
care program, or
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(B) to purchase, lease, order, or arrange for or recommend
purchasing, leasing, or ordering any good, facility, service, or
item for which payment may be made in whole or in part under a
Federal health care program,
shall be guilty of a felony and upon conviction thereof, shall
be fined not more than $25,000 or imprisoned for not more than
five years, or both.
(3) Paragraphs (1) and (2) shall not apply to—
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(A) a discount or other reduction in price obtained by a
provider of services or other entity under title XVIII or a
State health care program if the reduction in price is properly
disclosed and appropriately reflected in the costs claimed or
charges made by the provider or entity under title XVIII or a
State health care program;
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(B) any amount paid by an employer to an employee (who has a
bona fide employment relationship with such employer) for
employment in the provision of covered items or services;
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(C) any amount paid by a vendor of goods or services to a person
authorized to act as a purchasing agent for a group of
individuals or entities who are furnishing services reimbursed
under title XVIII or a State health care program if—
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(i) the person has a written contract, with each such individual
or entity, which specifies the amount to be paid the person,
which amount may be a fixed amount or a fixed percentage of the
value of the purchases made by each such individual or entity
under the contract, and
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(ii) in the case of an entity that is a provider of services (as
defined in section 1861(u)), the person discloses (in such form
and manner as the Secretary requires) to the entity and, upon
request, to the Secretary the amount received from each such
vendor with respect to purchases made by or on behalf of the
entity;
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(D) a waiver of any coinsurance under part B of title XVIII by a
Federally qualified health care center with respect to an
individual who qualifies for subsidized services under a
provision of the Public Health Service Act[48];
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(E) any payment practice specified by the Secretary in
regulations promulgated pursuant to section 14(a) of the
Medicare and Medicaid Patient and Program Protection Act of
1987[49]; and
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(F) any remuneration between an organization and an individual
or entity providing items or services, or a combination thereof,
pursuant to a written agreement between the organization and the
individual or entity if the organization is an eligible
organization under section 1876 or if the written agreement,
through a risk-sharing arrangement, places the individual
or entity at substantial financial risk for the cost or
utilization of the items or services, or a combination thereof,
which the individual or entity is obligated to provide.[50]
(c)
Whoever knowingly and willfully makes or causes to be made, or
induces or seeks to induce the making of, any false statement or
representation of a material fact with respect to the conditions
or operation of any institution, facility, or entity in order
that such institution, facility, or entity may qualify (either
upon initial certification or upon recertification) as a
hospital, critical access hospital, skilled nursing facility,
nursing facility, intermediate care facility for the mentally
retarded, or other entity (including an eligible organization
under section 1876(b)) for which certification is required under
title XVIII or a State health care program (as defined in
section 1128(h)), or with respect to information required to be
provided under section 1124A, shall be guilty of a felony and
upon conviction thereof shall be fined not more than $25,000 or
imprisoned for not more than five years, or both.
(d)
Whoever knowingly and willfully—
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(1) charges, for any service provided to a patient under a State
plan approved under title XIX, money or other consideration at a
rate in excess of the rates established by the State, (or, in
the case of services provided to an individual enrolled with a
medicaid managed care organization under title XIX under a
contract under section 1903(m) or under a contractual, referral,
or other arrangement under such contract, at a rate in excess of
the rate permitted under such contract), or
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(2) charges, solicits, accepts, or receives, in addition to any
amount otherwise required to be paid under a State plan approved
under title XIX, any gift, money, donation, or other
consideration (other than a charitable, religious, or
philanthropic contribution from an organization or from a person
unrelated to the patient)—
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(A) as a precondition of admitting a patient to a hospital,
nursing facility, or intermediate care facility for the mentally
retarded, or
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(B) as a requirement for the patient's continued stay in such a
facility,
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when the cost of the services provided therein to the patient is
paid for (in whole or in part) under the State plan,
shall be guilty of a felony and upon conviction thereof shall be
fined not more than $25,000 or imprisoned for not more than five
years, or both.
(e)
Whoever accepts assignments described in section 1842(b)(3)(B)(ii) or agrees to be a participating physician or
supplier under section 1842(h)(1) and knowingly, willfully, and
repeatedly violates the term of such assignments or agreement,
shall be guilty of a misdemeanor and upon conviction thereof
shall be fined not more than $2,000 or imprisoned for not more
than six months, or both.
(f)
For purposes of this section, the term “Federal health
care program” means—
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(1) any plan or program that provides health benefits, whether
directly, through insurance, or otherwise, which is funded
directly, in whole or in part, by the United States Government
(other than the health insurance program under chapter 89 of
title 5, United States Code); or
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(2) any State health care program, as defined in section 1128(h).