What is the Texas Medicaid Fraud Prevention Act?

Jarrett Uncategorized

INTRODUCTION
Have you witnessed a person or company (government contractor) commit fraud on, or otherwise abuse, the Medicaid system? If you have, and you have evidence to prove it, you may be able to file a claim under the TMFPA. You may even have an actionable TMFPA claim if you have evidence proving the government contractor knowingly breached its contract with the State of Texas. Thus, a TMFPA whistleblower, called a Relator, does not need to show evidence of false presentment to the State. The Relator is also not necessarily required to show the State suffered economic damages as a result of the wrongful acts.

WRONGFUL ACTS

The TMFPA lists 13 wrongful acts that give rise to a claim. The are as follows:

(1) knowingly makes or causes to be made a false statement or misrepresentation of a material fact to permit a person to receive a benefit or payment under the Medicaid program that is not authorized or that is greater than the benefit or payment that is authorized;

(2) knowingly conceals or fails to disclose information that permits a person to receive a benefit or payment under the Medicaid program that is not authorized or that is greater than the benefit or payment that is authorized;

(3) knowingly 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 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 ICF-IID;
(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 pays, 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 product or the continued provision of a service or product if the cost of the service or product is paid for, in whole or in part, under the Medicaid program;

(6) knowingly 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 makes or causes to be made 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 fails to indicate the type of license and the identification number of the licensed health care provider who actually provided the service;

(9) conspires to commit a violation of Subdivision (1), (2), (3), (4), (5), (6), (7), (8), (10), (11), (12), or (13);

(10) is a managed care organization that contracts with the 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:
(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; or
(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;

(11) knowingly obstructs an investigation by the attorney general of an alleged unlawful act under this section;

(12) knowingly makes, uses, or causes the making or use of a false record or statement material to an obligation to pay or transmit money or property to this state under the Medicaid program, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to this state under the Medicaid program; or

(13) knowingly engages in conduct that constitutes a violation under Section 32.039(b).

WHAT TO DO WHEN YOU WITNESS THE ABOVE ACTS

There is no doubt you will need an attorney to help you navigate the complex procedures these cases involve. The attorneys at Ellzey & Associates have substantial experience working with State agencies as well as the Texas Attorney Generals’ office. This experience combined with our existing relationships at these entities allow use to present your case as efficiently and effectively as possible.

WHAT IS A RELATOR ENTITLED TO?

Under the TMFPA, Petitions initially remain sealed for 180 days (this time period is extended in most every case), as opposed to 60 days under the FCA, in order for the State of Texas to decide if it wants to intervene in the case. If it does so, the Relator is entitled to 15-25% of the recovery by the government, plus attorneys’ fees, expenses and costs.

In the event the Government declines to intervene in the case (which is most often the case), the TMFPA contains a provision that allows private individuals who have knowledge about fraud involving the Texas Medicaid Program to bring an action on behalf of the State of Texas for violations of the TMFPA. In the event of a recovery, the Whistleblower is entitled to 25-30% of the recovery, plus attorneys’ fees, expenses and costs.

DO I STILL HAVE A CASE IF THE GOVERNMENT DECLINES TO INTERVENE?

In short, almost always. While it is impossible for private attorneys to know every deal the government has made with contractors, such as forbearances and waivers, your case almost certainly has merit if we decided to take it. The government can have a list of reasons for declining your case. But just because the government makes that initial decision doesn’t mean it will not decide to intervene at some point in the future. We are also willing to litigate your case through trial and appeal without the government’s assistance.

What does this mean? If you have evidence of a TMFPA violation, bring it to us. You should not look at the intervention statistics and decide your case is not worth. pursuing. At a minimum, you should seek our counsel to determine what to do with the information you have.