Louisiana Medical Assistance Programs Integrity Act

Whistleblowers with knowledge of fraud on Louisiana medical assistance funds may bring suit on the state’s behalf and share in the recovery, under the Louisiana Medical Assistance Programs Integrity Act which was first enacted in 1997. Under 46 La. Rev. Stat. Ch. 3 § 438.3 of the Act, an individual may face civil liability for knowingly presenting or causing to be presented a false or fraudulent claim, conspiring to do so, or engaging in other fraudulent activity specified by law.

The Louisiana Medical Assistance Programs Integrity Act is modeled on the federal False Claims Act, and cases brought under one statute are often brought in conjunction with claims under the other.  However, unlike the federal law which applies to all false claims made to the federal government, the state law only applies to false claims relating to the state’s medical assistance programs.  Violation of the Louisiana Medical Assistance Programs Integrity Act exposes an individual for civil penalties up to three times the total damages to the state. Further, the Act imposes civil penalties up to $10,000 for each individual false claim in violation of the Act.

A private individual with direct knowledge of a Louisiana Medical Assistance Programs Integrity Act violation is authorized to file a suit under the Act’s qui tam provisions. The qui tam relator, often referred to as a “whistleblower,” may proceed with the action regardless of whether the government chooses to intervene.

Whistleblowers involved in successful judgments or settlements may receive up to 25 percent of the civil penalties recovered by the state government. If the state government has chosen not to intervene, the whistleblower may receive up to 35 percent of the available recovery. Further, the Act provides the whistleblower with protection against employer retaliation, offering remedies including punitive damages.

Persons with information about fraud on the state of Louisiana are urged to preserve their rights by consulting an attorney and filing a case as soon as possible. A disclosure to the Louisiana state government pursuant to 46 La. Rev. Stat. Ch. 3 § 439.1.B(2) may preserve a person’s rights as an original source of the information about fraud.

As of August 2013, the text of the state FCA statute below is believed to be a complete, current version of the statute currently in force. Nonetheless, attorneys and qui tam relators should rely on the most up to date version of the state’s laws.

Louisiana Medical Assistance Programs Integrity Law

46 La. Rev. Stat. Ch. 3 §§ 437 et seq., 438 et seq., 439 et seq., 440.3

§437.2.  Legislative intent and purpose

A.  This Part is enacted to combat and prevent fraud and abuse committed by some health care providers participating in the medical assistance programs and by other persons and to negate the adverse effects such activities have on fiscal and programmatic integrity.

B.  The legislature intends the secretary of the Department of Health and Hospitals, the attorney general, and private citizens of Louisiana to be agents of this state with the ability, authority, and resources to pursue civil monetary penalties, liquidated damages, or other remedies to protect the fiscal and programmatic integrity of the medical assistance programs from health care providers and other persons who engage in fraud, misrepresentation, abuse, or other ill practices, as set forth in this Part, to obtain payments to which these health care providers or persons are not entitled.

§437.3.  Definitions

As used in this Part the following terms shall have the following meanings:

(1)  ”Administrative adjudication” means adjudication and the adjudication process contained in the Administrative Procedure Act.

(2)  ”Agent” means a person who is employed by or has a contractual relationship with a health care provider or who acts on behalf of the health care provider.

(3)  ”Billing agent” means an agent who performs any or all of the health care provider’s billing functions.

(4)  ”Billing” or “bills” means submitting, or attempting to submit, a claim for goods, services, or supplies.

(5)  ”Claim” means any request or demand, whether under a contract or otherwise, for money or property, whether or not the state or department has title to the money or property, that is drawn in whole or in part on medical assistance programs funds that are either of the following:

(a)  Presented to an officer, employee, or agent of the state or department.

(b)  Made to a contractor, grantee, or other recipient, if the money or property is to be spent or used in any manner in any program administered by the department under the authority of federal or state law, rule, or regulation, and if the state or department does either of the following:

(i)  Provides or has provided any portion of the money or property requested or demanded.

(ii)  Reimburses the contractor, grantee, or other recipient for any portion of the money or property which is requested or demanded.

  A claim may be based on costs or projected costs and includes any entry or omission in a cost report or similar document, book of account, or any other document which supports, or attempts to support, the claim.  A claim may be made through electronic means if authorized by the department.  Each claim may be treated as a separate claim or several claims may be combined to form one claim.

(6)  ”Department” means the Department of Health and Hospitals.

(7)  ”False or fraudulent claim” means a claim which the health care provider or his billing agent submits knowing the claim to be false, fictitious, untrue, or misleading in regard to any material information.  ”False or fraudulent claim” shall include a claim which is part of a pattern of incorrect submissions in regard to material information or which is otherwise part of a pattern in violation of applicable federal or state law or rule.

(8)  ”Good, service, or supply” means any good, item, device, supply, or service for which a claim is made, or is attempted to be made, in whole or part.

(9)  ”Health care provider” means any person furnishing or claiming to furnish a good, service, or supply under the medical assistance programs, any other person defined as a health care provider by federal or state law or by rule, and a provider-in-fact.

(10)  ”Ineligible recipient” means an individual who is not eligible to receive health care through the medical assistance programs.

(11)  ”Knowing” or “knowingly” means that the person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information.

(12)  ”Managing employee” means a person who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of a health care provider. “Managing employee” shall include but is not limited to a chief executive officer, president, general manager, business manager, administrator, or director.

(13)  ”Material” means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.

(14)  ”Medical assistance programs” means the Medical Assistance Program (Title XIX of the Social Security Act), commonly referred to as “Medicaid”, and other programs operated by and funded in the department which provide payment to health care providers.

(15)  ”Misrepresentation” means the knowing failure to truthfully or fully disclose any and all information required, or the concealment of any and all information required on a claim or a provider agreement or the making of a false or misleading statement to the department relative to the medical assistance programs.

(16)  ”Obligation”  means an established duty, whether or not fixed, arising from an express or implied contractual, grantor, grantee, or licensor-licensee relationship, from a free-based or similar relationship, from statute or regulation, or from the retention of any overpayment.

(17)  ”Order” means a final order imposed pursuant to an administrative adjudication.

(18)  ”Ownership interest” means the possession, directly or indirectly, of equity in the capital or the stock, or the right to share in the profits, of a health care provider.

(19)  ”Payment” means the payment to a health care provider from medical assistance programs funds pursuant to a claim, or the attempt to seek payment for a claim.

(20)  ”Property” means any and all property, movable and immovable, corporeal and incorporeal.

(21)  ”Provider agreement” means a document which is required as a condition of enrollment or participation as a health care provider under the medical assistance programs.

(22)  ”Provider-in-fact” means an agent who directly or indirectly participates in management decisions, has an ownership interest in the health care provider, or other persons defined as a provider-in-fact by federal or state law or by rule.

(23)  ”Recipient” means an individual who is eligible to receive health care through the medical assistance programs.

(24)  ”Recoupment” means recovery through the reduction, in whole or in part, of payment to a health care provider.

(25)  ”Recovery” means the recovery of overpayments, damages, fines, penalties, costs, expenses, restitution, attorney fees, or interest or settlement amounts.

(26)  ”Rule” means any rule or regulation promulgated by the department in accordance with the Administrative Procedure Act and any federal rule or regulation promulgated by the federal government in accordance with federal law.

(27)  ”Sanction” shall include but is not limited to any or all of the following:

(a)  Recoupment.

(b)  Posting of bond, other security, or a combination thereof.

(c)  Exclusion as a health care provider.

(d)  A monetary penalty.

(28)  ”Secretary” means the secretary of the Department of Health and Hospitals, or his authorized designee.

(29)  ”Secretary or attorney general” means that either party is authorized to institute a proceeding or take other authorized action as provided in this Part pursuant to a memorandum of understanding between the two so as to notify the public as to whether the secretary or the attorney general is the deciding or controlling party in the proceeding or other authorized matter.

(30)  ”Withhold payment” means to reduce or adjust the amount, in whole or in part, to be paid to a health care provider for a pending or future claim during the time of a criminal, civil, or departmental investigation or proceeding or claims review of the health care provider.

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