Missouri Health Care Payment Fraud and Abuse Act
The Missouri statute applies only to fraud involving the state’s Medicaid program. Known as the Health Care Payment Fraud and Abuse Act, this statute is not a qui tam statute as it does not allow a whistleblower to bring a private action on behalf of the state. However, any person who is the original source of the information used by the attorney general to bring an action for violations of this statute shall receive 10% of any recovery in the case. “Original source of information” means that the information has not been previously disclosed to or known by the government or public. Whistleblowers are also protected against retaliation for engaging in protected activity.
The Missouri Health Care Payment Fraud and Abuse Act, Mo. Rev. Stat. §§ 191.900, et seq., states that:
- 1. No health care provider shall knowingly make or cause to be made a false statement or false representation of a material fact in order to receive a health care payment, including but not limited to:
- (1) Knowingly presenting to a health care payer a claim for a health care payment that falsely represents that the health care for which the health care payment is claimed was medically necessary, if in fact it was not;
- (2) Knowingly concealing the occurrence of any event affecting an initial or continued right under a medical assistance program to have a health care payment made by a health care payer for providing health care;
- (3) Knowingly concealing or failing to disclose any information with the intent to obtain a health care payment to which the health care provider or any other health care provider is not entitled, or to obtain a health care payment in an amount greater than that which the health care provider or any other health care provider is entitled;
- (4) Knowingly presenting a claim to a health care payer that falsely indicates that any particular health care was provided to a person or persons, if in fact health care of lesser value than that described in the claim was provided.
- 2. No person shall knowingly solicit or receive any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind in return for:
- (1) Referring another person to a health care provider for the furnishing or arranging for the furnishing of any health care; or
- (2) Purchasing, leasing, ordering or arranging for or recommending purchasing, leasing or ordering any health care.
- 3. No person shall knowingly offer or pay 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 to refer another person to a health care provider for the furnishing or arranging for the furnishing of any health care.
- 4. No person shall knowingly abuse a person receiving health care.
A person who violates subsections 1 to 3 of this section shall be liable for a civil penalty of $5,000 - $10,000 for each violation, plus three times the amount of damages which the state and federal government sustained because of the act of that person.
A person who violates subsections 1 to 3 of this section is guilty of a class D felony upon his or her first conviction, and shall be guilty of a class B felony upon his or her second and subsequent convictions. A person who violates subsection 6 of this section shall also be guilty of a class D felony, unless the act involves no physical, sexual or emotional harm or injury and the value of the property involved is less than $500, in which event a violation of subsection 6 of this section is a class A misdemeanor.
Violators shall be required to make restitution to the federal and state governments, in an amount at least equal to that unlawfully paid to or by the person, and shall be required to reimburse the reasonable costs attributable to the investigation and prosecution pursuant to sections 191.900 to 191.910. This is in addition to any fines, penalties or sentences imposed by law, as described above.