§438.3. False or fraudulent claim; misrepresentation; unlawful acts

            A. No person shall knowingly present or cause to be presented a false or fraudulent claim for payment or approval.

            B. No person shall knowingly engage in misrepresentation or knowingly make, use, or cause to be made or used, a false record or statement material to a false or fraudulent claim.

            C. No person shall knowingly make, use, or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the medical assistance programs, or knowingly conceal or knowingly and improperly avoid or decrease an obligation to pay or transmit money or property to the medical assistance programs.

            D. No person shall conspire to defraud the medical assistance programs or conspire to commit a violation of this Part.

            E.(1) No person shall knowingly submit a claim for goods, services, or supplies which were medically unnecessary or which were of substandard quality or quantity.

            (2) If a managed care health care provider or a health care provider operating under a voucher system under the medical assistance programs fails to provide medically necessary goods, services, or supplies or goods, services, or supplies which are of substandard quality or quantity to a recipient, and those goods, services, or supplies are covered under the managed care contract or voucher contract with the medical assistance programs, such failure shall constitute a violation of Paragraph (1) of this Subsection.

            (3) "Substandard quality" in reference to services applicable to medical care as used in this Subsection shall mean substandard as to the appropriate standard of care as used to determine medical malpractice, including but not limited to the standard of care provided in R.S. 9:2794.

            F. No person shall knowingly make or cause to be made a claim under the medical assistance programs for any of the following:

            (1) A service or product that has not been approved or prescribed by a treating physician or health care practitioner.

            (2) 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.

            (3) A product that has been adulterated, debased, mislabeled, or is otherwise inappropriate.

            G. No person shall knowingly make, cause to be made, induce, or seek to induce the making of a false statement or misrepresentation of material fact concerning any of the following:

            (1) The condition or operation of a facility in order that the facility may qualify for certification or recertification required by the medical assistance programs including but not limited to certification or recertification of any of the following:

            (a) A hospital.

            (b) A nursing facility or skilled nursing facility.

            (c) A hospice.

            (d) An intermediate care facility for people with developmental disabilities.

            (e) An assisted living facility.

            (f) A home health agency.

            (2) Information the person is required to produce to the department by federal or state law, rule, regulation, or provider agreement.

            H. No provider or provider-in-fact shall fail to provide to the department, attorney general, legislative auditor, or other appropriate state agency information required to be provided by law, rule, or contractual provision.

            I. No person shall defraud or attempt to defraud the medical assistance programs through misrepresentation.

            J. No person shall obtain or attempt to obtain payment for a false or fraudulent claim.

            K. It shall be unlawful for a managed care organization or a subcontractor to a managed care organization that contracts with the department or other state agency to provide or arrange to provide health care benefits or services to individuals eligible under the medical assistance programs and knowingly do any of the following:

            (1) Fail to provide an individual a healthcare benefit or service that the organization is required to provide under the contract with the department.

            (2) Fail to provide to the department, attorney general, legislative auditor, or other appropriate state agency information required to be provided by law, rule, or contractual provision.

            (3) Engage in fraudulent activity in connection with the enrollment of an individual eligible under the medical assistance programs or in connection with marketing the organization's services to an individual eligible under the medical assistance programs.

            L. No person shall make a claim under the medical assistance programs and knowingly misrepresent the identification of the healthcare provider who actually provided the service when such identification is necessary to obtain payment for the claim.

            M. Each violation of this Section may be treated as a separate violation or may be combined into one violation at the option of the secretary or the attorney general.

            N. No action brought pursuant to this Section shall be instituted later than ten years after the date upon which the alleged violation occurred.

            Acts 1997, No. 1373, §1; Acts 2007, No. 14, §1, eff. June 18, 2007; Acts 2009, No. 426, §1; Acts 2011, No. 185, §1; Acts 2025, No. 206, §1.