946.91 Medical Assistance fraud.

(1) In this section:

(a) “Facility" means a nursing home or a community-based residential facility that is licensed under s. 50.03 and that is certified by the department of health services as a provider of aid under Medical Assistance.

(b) “Medical Assistance" means the program providing aid under subch. IV of ch. 49, except ss. 49.468 and 49.471.

(c) “Provider" means a person, corporation, limited liability company, partnership, incorporated business, or professional association, and any agent or employee thereof, who provides services under Medical Assistance.

(2) Whoever does any of the following is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in s. 939.50 (3) (h), the person may be fined not more than $25,000:

(a) Intentionally makes or causes to be made any false statement or representation of a material fact in any application for any Medical Assistance benefit or payment.

(b) Intentionally makes or causes to be made any false statement or representation of a material fact for use in determining eligibility for any Medical Assistance benefit or payment.

(c) Having knowledge of the occurrence of any event affecting the initial or continued eligibility for any Medical Assistance benefit or payment or the initial or continued eligibility for any such benefit or payment of any other individual in whose behalf he or she has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent to fraudulently secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized.

(d) Having applied to receive any Medical Assistance benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts the benefit or payment or any part thereof to a use that is not for the benefit of such other person.

(3)

(a) Whoever solicits or receives, directly, indirectly, overtly, or covertly, money, goods, services, or any other thing of value 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 Medical Assistance, or 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 Medical Assistance, is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in s. 939.50 (3) (h), the person may be fined not more than $25,000.

(b) Whoever offers or provides, directly, indirectly, overtly, or covertly, money, goods, services, or any other thing of value to any person to induce such person 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 Medical Assistance, or 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 Medical Assistance, is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in s. 939.50 (3) (h), the person may be fined not more than $25,000.

(c) This subsection does not apply to any of the following:

1. A discount or other reduction in price obtained by a provider of services or other entity under chs. 46 to 51 and 58 if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider or entity under Medical Assistance.

2. An 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.

3. Any payment made for sharing of cost savings under s. 49.45 (26g).

(4) 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 or facility in order that such institution or facility may qualify either upon initial certification or upon recertification as a hospital, skilled nursing facility, intermediate care facility, or home health agency is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in s. 939.50 (3) (h), the person may be fined not more than $25,000.

(5) Whoever knowingly imposes upon a Medical Assistance recipient charges in addition to payments received for services under ss. 49.45 to 49.471 or knowingly imposes direct charges upon a recipient in lieu of obtaining payment under ss. 49.45 to 49.471 is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in s. 939.50 (3) (h), the person may be fined not more than $25,000. This subsection does not apply under any of the following circumstances:

(a) Benefits or services are not provided under s. 49.46 (2) or 49.471 (11) and the Medical Assistance recipient is advised of this fact prior to receiving the service.

(b) An applicant is determined to be eligible retroactively under s. 49.46 (1) (b), 49.47 (4) (d), or 49.471, a provider bills the applicant directly for services and benefits rendered during the retroactive period, the provider, upon notification of the applicant's retroactive eligibility, submits a claim for payment under s. 49.45 for covered services or benefits rendered to the recipient during the retroactive period, and the provider reimburses the recipient or other person who has made prior payment to the provider for services provided to the recipient during the retroactive eligibility period, by the amount of the prior payment made upon receipt of payment under s. 49.45.

(c) Benefits or services are provided for which recipient copayment, coinsurance, or deductible is required under s. 49.45 (18), not to exceed maximum amounts allowable under 42 CFR 447.53 to 447.58, or for which recipient copayment or coinsurance is required under s. 49.471 (11).

(6) Whoever, in connection with Medical Assistance when the cost of the services provided to the patient is paid for in whole or in part by the state, intentionally charges, solicits, accepts, or receives, in addition to any amount otherwise required to be paid under Medical Assistance, 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, as a precondition of admitting a patient to a hospital, skilled nursing facility, or intermediate care facility, or as a requirement for the patient's continued stay in such a facility is guilty of a Class H felony, except that, notwithstanding the maximum fine specified in s. 939.50 (3) (h), the person may be fined not more than $25,000.

History: 2013 a. 226 ss. 13, 17, 19, 21, 23, 25, 29, 54; Stats. 2013 s. 946.91; 2015 a. 195; 2017 a. 279.