713.13 Medical Assistance Fraud at the Federal Level (MAM)

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There are cases in which medical assistance fraud is processed in federal court. Pursuant to Section 1128B of the Social Security Act [42 USC 1320a-7b], an individual has committed medical assistance fraud by:

. knowingly and willfully making or causing to be made any false statement or representation of a fact in any application for any health care benefit or payment;

. knowingly and willfully making or causing to be made any false statement or representation of a fact for use in determining eligibility for any health care benefit or payment;

. concealing or failing to tell us about any knowledge of or the occurrence of any event affecting:

- the individual's own initial or continued right to any health care benefit or payment; or

- the initial or continued right to any health care benefit or payment for any other person on whose behalf the individual has applied for and/or is receiving benefits;

. converting benefits or payments for benefits, in total or in part, to a use other than intended;

. presenting or causing to be presented a claim for medical service for which payment is or could be made, knowing that the service was not provided or that the person providing the medical service is not licensed to provide the service; or

. purposely committing any other act that violates any medical assistance regulations, or any state statute relating to medical assistance programs.