TITLE 31

Welfare

In General

CHAPTER 10. FRAUDULENT ACTS


The General Assembly finds and declares it to be in the public interest and for the protection of the health and welfare of the residents of the State that proper provisions be instituted to regulate abuses in the payment of funds under the State's public assistance programs.

65 Del. Laws, c. 345, § 2.;

When used in this chapter, the following words shall have the meaning herein defined. To the extent that the terms are not defined herein, the words are to have their commonly accepted meaning.

(1) "Department" shall mean the Department of Health and Social Services.

(2) "Facility" shall mean any facility required to be licensed under Chapters 10 and 11 of Title 16, including any such facility operated by or for the State.

(3) "Person" shall mean a human being and, where appropriate, a public or private corporation, an unincorporated association, a partnership, a government or a governmental instrumentality.

(4) "Provider" shall mean a person who is enrolled and who renders goods or services for which payment is made, in whole or in part, under a public assistance program.

(5) "Public assistance program" shall mean the medical assistance program of the State.

65 Del. Laws, c. 345, § 2.;

It shall be unlawful for any provider, by means of a false statement or representation, or by concealment of, or failure to disclose any material fact, or by any other fraudulent scheme or device on behalf of the provider or others to obtain or attempt to obtain payments or any other property, under any public assistance program established by the State to which the provider is not entitled, in whole or in part.

65 Del. Laws, c. 345, § 2; 70 Del. Laws, c. 186, § 1.;

It shall be unlawful for any provider to:

(1) Falsify any report, statement or document required to be filed in connection with any public assistance program;

(2) Include in any cost report or reports for reimbursement any amount or item which the provider knew or should have known was not used in providing service to the recipient for which the amount is paid or to be paid;

(3) Make or cause to be made a statement or representation for use in qualifying as a provider of goods or service under any public assistance program, knowing that statement or representation to be false, in whole or in part by commission or omission; or

(4) Make or cause to be made a false statement or representation of a material fact with respect to the conditions or operation of a provider or facility in order that such provider or facility may qualify or remain qualified to provide assistance under any public assistance program.

65 Del. Laws, c. 345, § 2; 70 Del. Laws, c. 186, § 1.;

(a) It shall be unlawful for any person to solicit or receive any remuneration (including kickback, bribe or rebate) directly or indirectly, overtly or covertly, in cash or in kind:

(1) In return for referring an individual to a provider for the furnishing or arranging for the furnishing of any medical care or medical assistance for which payment may be made in whole or in part under any public assistance program; or

(2) In return for purchasing, leasing, ordering or arranging for or recommending purchasing, leasing, or ordering any property, facility, service or item of medical care or medical assistance for which payment may be made in whole or in part under any public assistance program.

(b) It shall be unlawful for any person to offer or pay any remuneration (including any kickback, bribe or rebate) directly or indirectly, in cash or in kind to induce any other person:

(1) To refer an individual to a provider for the furnishing or arranging for the furnishing of any medical care or medical assistance for which payment may be made in whole or in part under any public assistance program; or

(2) To purchase, lease, order or arrange for or recommend purchasing, leasing or ordering any property, facility, service, or item of medical care or medical assistance for which payment may be made in whole or in part under any public assistance program.

(c) It shall be unlawful for any provider to:

(1) Charge, solicit, accept or receive for any service provided to a recipient, money or other consideration in addition to or at a rate in excess of the rates established by the State for such item or service; or

(2) Charge, solicit or receive, in addition to any amount otherwise required to be paid by the State, 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 to 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, when the cost of services provided therein to the patient is paid for, in whole or in part, by the State.

(d) Subsections (a), (b) and (c) of this section shall not apply to:

(1) A discount or other reduction to price obtained by a provider under this chapter if the reduction in price is properly disclosed and appropriately reflected in the costs claimed or charges made by the provider; or

(2) Wages paid by an employer to an employee as part of a bona fide employment relationship; or

(3) Contracts between the State and a public or private agency where part of the agency's responsibility is referral of a person to a provider;

(4) Dividends based exclusively on a legitimate ownership interest;

(5) Fees for services actually rendered, provided that the fees are not made to induce referrals to the provider.

65 Del. Laws, c. 345, § 2.;

It shall be unlawful for any provider to convert any benefit or payment received from any public assistance program for use other than the use and benefit for the person named in the application for assistance.

65 Del. Laws, c. 345, § 2.;

(a) Whoever knowingly violates §§ 1003, 1004(2) and 1006 of this title shall be guilty of a class A misdemeanor; provided, that, where the value of assistance benefits, payments or other property is $500 or more, but less than $10,000, the violator shall be guilty of a class E felony; further provided, that, where the value of assistance, benefits, payments or other property is $10,000 or more, the violator shall be guilty of a class C felony.

(b) Whoever violates § 1004(1) of this title, shall be guilty of a class A misdemeanor.

(c) Whoever violates §§ 1004(3) and (4) and 1005 of this title, shall be guilty of a class E felony.

(d) In addition to the penalties provided herein, every provider convicted under this chapter shall make full restitution of the money, goods or services or the value of those goods or services unlawfully received, plus interest on that amount at the rate of 1.5% per month, for the period from the date upon which payment was made to the date upon which repayment is made to the State.

(e) Upon conviction under this chapter, such provider shall not be eligible for any further participation in the Delaware Public Assistance Program; provided, however, that where the community interest would be adversely affected, the Secretary of the Department of Health and Social Services, or the Secretary's designee, shall, upon petition of the provider, conduct a hearing on the record, to determine the need for a comparable provider to render the needed services to the community, and whether this provider's continued participation in the program is in the best interest of the State. Where this is established, the provider may continue in the program under such conditions as the Secretary may impose.

65 Del. Laws, c. 345, § 2; 70 Del. Laws, c. 186, § 1.;

(a) Any provider who violates this chapter, in addition to any other penalties provided by law, shall be liable for the following civil penalties:

(1) Payment of an amount equal to 3 times the amount of excess payments; and

(2) Payment of a civil penalty of up to the sum of $2,000 for each deceptive claim or falsification; and

(3) All reasonable expenses which the court determines may have been incurred by the State in the enforcement of this section.

(b) No criminal action or indictment need be brought against any provider as a condition for establishing civil liability hereunder.

(c) Any provider, who, without intent to violate this chapter, obtains benefits or payments in excess of the amount to which the provider is entitled, shall be liable for the payment of a civil assessment as provided in subsection (a) of this section which may be sought and recovered in an administrative proceeding by the Department to which the claim was submitted, or by the Attorney General.

65 Del. Laws, c. 345, § 2; 70 Del. Laws, c. 186, § 1; 74 Del. Laws, c. 358, § 1.;

The Superior Court shall have original and exclusive jurisdiction over violations of this chapter.

65 Del. Laws, c. 345, § 2.;