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F.S. 409.920 on Google Scholar

F.S. 409.920 on Casetext

Amendments to 409.920


The 2022 Florida Statutes

Title XXX
SOCIAL WELFARE
Chapter 409
SOCIAL AND ECONOMIC ASSISTANCE
View Entire Chapter
F.S. 409.920 Florida Statutes and Case Law
409.920 Medicaid provider fraud.
(1) For the purposes of this section, the term:
(a) “Agency” means the Agency for Health Care Administration.
(b) “Fiscal agent” means any individual, firm, corporation, partnership, organization, or other legal entity that has contracted with the agency to receive, process, and adjudicate claims under the Medicaid program.
(c) “Item or service” includes:
1. Any particular item, device, medical supply, or service claimed to have been provided to a recipient and listed in an itemized claim for payment; or
2. In the case of a claim based on costs, any entry in the cost report, books of account, or other documents supporting such claim.
(d) “Knowingly” means that the act was done voluntarily and intentionally and not because of mistake or accident. As used in this section, the term “knowingly” also includes the word “willfully” or “willful” which, as used in this section, means that an act was committed voluntarily and purposely, with the specific intent to do something that the law forbids, and that the act was committed with bad purpose, either to disobey or disregard the law.
(e) “Managed care plans” means a health insurer authorized under chapter 624, an exclusive provider organization authorized under chapter 627, a health maintenance organization authorized under chapter 641, the Children’s Medical Services Network authorized under chapter 391, a prepaid health plan authorized under this chapter, a provider service network authorized under this chapter, a minority physician network authorized under this chapter, and an emergency department diversion program authorized under this chapter or the General Appropriations Act, providing health care services pursuant to a contract with the Medicaid program.
(2)(a) A person may not:
1. Knowingly make, cause to be made, or aid and abet in the making of any false statement or false representation of a material fact, by commission or omission, in any claim submitted to the agency or its fiscal agent or a managed care plan for payment.
2. Knowingly make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program.
3. Knowingly charge, solicit, accept, or receive anything of value, other than an authorized copayment from a Medicaid recipient, from any source in addition to the amount legally payable for an item or service provided to a Medicaid recipient under the Medicaid program or knowingly fail to credit the agency or its fiscal agent for any payment received from a third-party source.
4. Knowingly make or in any way cause to be made any false statement or false representation of a material fact, by commission or omission, in any document containing items of income and expense that is or may be used by the agency to determine a general or specific rate of payment for an item or service provided by a provider.
5. Knowingly solicit, offer, pay, or receive any remuneration, including any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in kind, 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 the Medicaid program, or in return for obtaining, purchasing, leasing, ordering, or arranging for or recommending, obtaining, purchasing, leasing, or ordering any goods, facility, item, or service, for which payment may be made, in whole or in part, under the Medicaid program. This subparagraph does not apply to any discount, payment, waiver of payment, or payment practice not prohibited by 42 U.S.C. s. 1320a-7b(b) or any regulations adopted thereunder.
6. Knowingly submit false or misleading information or statements to the Medicaid program for the purpose of being accepted as a Medicaid provider.
7. Knowingly use or endeavor to use a Medicaid provider’s identification number or a Medicaid recipient’s identification number to make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program.
(b)1. A person who violates this subsection and receives or endeavors to receive anything of value of:
a. Ten thousand dollars or less commits a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
b. More than $10,000, but less than $50,000, commits a felony of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
c. Fifty thousand dollars or more commits a felony of the first degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.
2. The value of separate funds, goods, or services that a person received or attempted to receive pursuant to a scheme or course of conduct may be aggregated in determining the degree of the offense.
3. In addition to the sentence authorized by law, a person who is convicted of a violation of this subsection shall pay a fine in an amount equal to five times the pecuniary gain unlawfully received or the loss incurred by the Medicaid program or managed care organization, whichever is greater.
(3) The repayment of Medicaid payments wrongfully obtained, or the offer or endeavor to repay Medicaid funds wrongfully obtained, does not constitute a defense to, or a ground for dismissal of, criminal charges brought under this section.
(4) Property “paid for” includes all property furnished to or intended to be furnished to any recipient of benefits under the Medicaid program, regardless of whether reimbursement is ever actually made by the program.
(5) All records in the custody of the agency or its fiscal agent which relate to Medicaid provider fraud are business records within the meaning of s. 90.803(6).
(6) Proof that a claim was submitted to the agency or its fiscal agent which contained a false statement or a false representation of a material fact, by commission or omission, unless satisfactorily explained, gives rise to an inference that the person whose signature appears as the provider’s authorizing signature on the claim form, or whose signature appears on an agency electronic claim submission agreement submitted for claims made to the fiscal agent by electronic means, had knowledge of the false statement or false representation. This subsection applies whether the signature appears on the claim form or the electronic claim submission agreement by means of handwriting, typewriting, facsimile signature stamp, computer impulse, initials, or otherwise.
(7) Proof of submission to the agency or its fiscal agent of a document containing items of income and expense, which document is used or that may be used by the agency or its fiscal agent to determine a general or specific rate of payment and which document contains a false statement or a false representation of a material fact, by commission or omission, unless satisfactorily explained, gives rise to the inference that the person who signed the certification of the document had knowledge of the false statement or representation. This subsection applies whether the signature appears on the document by means of handwriting, typewriting, facsimile signature stamp, electronic transmission, initials, or otherwise.
(8) A person who provides the state, any state agency, any of the state’s political subdivisions, or any agency of the state’s political subdivisions with information about fraud or suspected fraudulent acts by a Medicaid provider, including a managed care organization, is immune from civil liability for libel, slander, or any other relevant tort for providing information about fraud or suspected fraudulent acts unless the person acted with knowledge that the information was false or with reckless disregard for the truth or falsity of the information. Such immunity extends to reports of fraudulent acts or suspected fraudulent acts conveyed to or from the agency in any manner, including any forum and with any audience as directed by the agency, and includes all discussions subsequent to the report and subsequent inquiries from the agency, unless the person acted with knowledge that the information was false or with reckless disregard for the truth or falsity of the information. For purposes of this subsection, the term “fraudulent acts” includes actual or suspected fraud and abuse, insurance fraud, licensure fraud, or public assistance fraud, including any fraud-related matters that a provider or health plan is required to report to the agency or a law enforcement agency.
(9) The Attorney General shall conduct a statewide program of Medicaid fraud control. To accomplish this purpose, the Attorney General shall:
(a) Investigate the possible criminal violation of any applicable state law pertaining to fraud in the administration of the Medicaid program, in the provision of medical assistance, or in the activities of providers of health care under the Medicaid program.
(b) Investigate the alleged abuse or neglect of patients in health care facilities receiving payments under the Medicaid program, in coordination with the agency.
(c) Investigate the alleged misappropriation of patients’ private funds in health care facilities receiving payments under the Medicaid program.
(d) Refer to the Office of Statewide Prosecution or the appropriate state attorney all violations indicating a substantial potential for criminal prosecution.
(e) Refer to the agency all suspected abusive activities not of a criminal or fraudulent nature.
(f) Safeguard the privacy rights of all individuals and provide safeguards to prevent the use of patient medical records for any reason beyond the scope of a specific investigation for fraud or abuse, or both, without the patient’s written consent.
(g) Publicize to state employees and the public the ability of persons to bring suit under the provisions of the Florida False Claims Act and the potential for the persons bringing a civil action under the Florida False Claims Act to obtain a monetary award.
(10) In carrying out the duties and responsibilities under this section, the Attorney General may:
(a) Enter upon the premises of any health care provider, excluding a physician, participating in the Medicaid program to examine all accounts and records that may, in any manner, be relevant in determining the existence of fraud in the Medicaid program, to investigate alleged abuse or neglect of patients, or to investigate alleged misappropriation of patients’ private funds. A participating physician is required to make available any accounts or records that may, in any manner, be relevant in determining the existence of fraud in the Medicaid program, alleged abuse or neglect of patients, or alleged misappropriation of patients’ private funds. The accounts or records of a non-Medicaid patient may not be reviewed by, or turned over to, the Attorney General without the patient’s written consent.
(b) Subpoena witnesses or materials, including medical records relating to Medicaid recipients, within or outside the state and, through any duly designated employee, administer oaths and affirmations and collect evidence for possible use in either civil or criminal judicial proceedings.
(c) Request and receive the assistance of any state attorney or law enforcement agency in the investigation and prosecution of any violation of this section.
(d) Seek any civil remedy provided by law, including, but not limited to, the remedies provided in ss. 68.081-68.092 and 812.035 and this chapter.
(e) Refer to the agency for collection each instance of overpayment to a provider of health care under the Medicaid program which is discovered during the course of an investigation.
History.s. 50, ch. 91-282; s. 6, ch. 94-251; s. 2, ch. 96-280; s. 6, ch. 96-387; s. 2, ch. 97-290; s. 6, ch. 2000-163; s. 31, ch. 2002-400; s. 8, ch. 2004-344; s. 19, ch. 2009-223; s. 4, ch. 2013-150; s. 43, ch. 2020-156.

Statutes updated from Official Statutes on: August 29, 2022
F.S. 409.920 on Google Scholar

F.S. 409.920 on Casetext

Amendments to 409.920


Arrestable Offenses / Crimes under Fla. Stat. 409.920
Level: Degree
Misdemeanor/Felony: First/Second/Third

409.920 2a1 - FRAUD-FALSE STATEMENT - FALSE MEDICAID CLAIM 10K DOLS OR LESS - F: T
409.920 2a1 - FRAUD-FALSE STATEMENT - FALSE MEDICAID CLAIM MORE 10K LESS 50K DOLS - F: S
409.920 2a1 - FRAUD-FALSE STATEMENT - FALSE MEDICAID CLAIM 50K DOLS OR MORE - F: F
409.920 2a2 - FRAUD - UNAUTH MEDICAID CLAIM 10K DOLS OR LESS - F: T
409.920 2a2 - FRAUD - UNAUTH MEDICAID CLAIM MORE 10K LESS 50K DOLS - F: S
409.920 2a2 - FRAUD - UNAUTH MEDICAID CLAIM 50K DOLS OR MORE - F: F
409.920 2a3 - FRAUD - ADDED PAY FROM 3RD PARTY 10K DOLS OR LESS - F: T
409.920 2a3 - FRAUD - ADDED PAY FROM 3RD PARTY MORE 10K LESS 50K DOL - F: S
409.920 2a3 - FRAUD - ADDED PAY FROM 3RD PARTY 50K DOLS OR MORE - F: F
409.920 2a4 - FRAUD-FALSE STATEMENT - ON MEDICAID PAY DOCUMENTS 10K DOLS OR LESS - F: T
409.920 2a4 - FRAUD-FALSE STATEMENT - ON MEDICAID PAY DOCS MORE 10K LESS 50K DOLS - F: S
409.920 2a4 - FRAUD-FALSE STATEMENT - ON MEDICAID PAY DOCUMENTS 50K DOLS OR MORE - F: F
409.920 2a5 - FRAUD - PAY FOR MEDICAID REFERRAL 10K DOLS OR LESS - F: T
409.920 2a5 - FRAUD - PAY FOR MEDICAID REFER MORE 10K LESS 50K DOLS - F: S
409.920 2a5 - FRAUD - PAY FOR MEDICAID REFERRAL 50K DOLS OR MORE - F: F
409.920 2a6 - FRAUD-FALSE STATEMENT - ON PROVIDER INFO 10K DOLS OR LESS - F: T
409.920 2a6 - FRAUD-FALSE STATEMENT - ON PROVIDER INFO MORE 10K LESS 50K DOLS - F: S
409.920 2a6 - FRAUD-FALSE STATEMENT - ON PROVIDER INFO 50K DOLS OR MORE - F: F
409.920 2a7 - FRAUD - UNAUTH USE OF PROVIDER ID 10K DOLS OR LESS - F: T
409.920 2a7 - FRAUD - UNAUTH USE PROVIDER ID MORE 10K LESS 50K DOLS - F: S
409.920 2a7 - FRAUD - UNAUTH USE OF PROVIDER ID 50K DOLS OR MORE - F: F
409.920 2b1a - FRAUD - MEDICAID PROVIDER FRAUD 10K DOLS OR LESS - F: T
409.920 2b1b - FRAUD - MEDICAID PROVIDER FRAUD MORE 10K LESS 50K DOLS - F: S
409.920 2b1c - FRAUD - MEDICAID PROVIDER FRAUD 50K DOLS OR MORE - F: F


Civil Citations / Citable Offenses under S409.920
R or S next to points is Mandatory Revocation or Suspension

Current data shows no reason a civil citation or a suspension or revocation of license should have been issued under Florida Statute 409.920.


Annotations, Discussions, Cases:

  1. State v. Harden

    938 So. 2d 480 (Fla. 2006)   Cited 29 times   1 Legal Analyses
    After hearing argument from the parties, the circuit court entered an order granting the defendants' motion to dismiss. The circuit court concluded that the State's attempt to prosecute the defendants under the unlawful remuneration provision of section 409.920(2)(e) was preempted by federal law and thus unconstitutional under the Supremacy Clause. The circuit court also held that the mens rea requirement in section 409.920(1)(d) was preempted by federal law and unconstitutional under the Supremacy Clause. Additionally, the circuit court agreed with the defendants' alternative argument that the State's construction of section 409.920(2)(e) as a criminal ban on the solicitation of commercial business would, absent an intent to defraud requirement not contained in the statute, violate the First Amendment and render the statute unconstitutionally vague as applied.
    PAGE 484
  2. State v. Rubio

    917 So. 2d 383 (Fla. Dist. Ct. App. 2005)   Cited 5 times
    Unlike the statute prohibiting patient brokering, section 409.920 involves only Medicaid provider fraud. Congress has mandated a knowing and willful standard for Medicaid fraud violations. Prosecuting health care providers in Florida for mere negligence in filing claims may cause providers to simply refuse to treat Medicaid patients. Thus Florida's lesser intent requirement clearly "stands as an obstacle to execution and accomplishment of the objectives and purpose" of the Medicaid program. We agree with the trial court that the prior definition of "knowingly" in section 409.920(1)(d) rendered section 409.920(2)(a) unconstitutional and counts 3-55 were properly dismissed.
    PAGE 392
  3. State v. Harden

    873 So. 2d 352 (Fla. Dist. Ct. App. 2004)   Cited 13 times
    Thus, the trial court applied implied conflict preemption analysis and found that section 409.920(2), Florida Statutes (2000), was unconstitutional. Additionally, the trial court found that the mens rea requirement in section 409.920(1)(d), Florida Statutes (2000), was preempted by federal law and also unconstitutional. The trial court subsequently entered dismissal orders as to the other defendants. The State's appeal follows.
    PAGE 354
  4. State v. Wolland

    902 So. 2d 278 (Fla. Dist. Ct. App. 2005)   Cited 4 times
    Shortly after Wolland filed her motion, this Court issued State v. Harden, 873 So.2d 352 (Fla. 3d DCA 2004), affirming a trial court's order finding subsection 409.920(2)(e), the anti-kickback provision of Florida's Medicaid provider fraud statute, to be unconstitutional. In Harden we decided that subsection 409.920(2)(e) impliedly conflicted with the federal anti-kickback statute, and thus was preempted under the Supremacy Clause. This conclusion rested on two grounds. First, we concluded that as to subsection 409.920(2)(e), federal legislation was in place which protected the particular behavior at issue but because the Florida provision accorded no similar safe harbor, it obstructed the objectives and purposes of the federal act. Harden, 873 So.2d at 355 (citation omitted). Second, we concluded that because subsection 409.920(2)(e) criminalized only knowing conduct, whereas the federal act criminalized conduct that was both knowing and willful, enforcement of Florida's law would act as an obstacle to the purposes and goals of the federal act:
    PAGE 281
  5. State v. Rubio

    967 So. 2d 768 (Fla. 2007)   Cited 11 times
    This is known as the anti-kickback provision of the statute. The same definition of "knowingly" in section 409.920(1)(d) applies to both sections 409.920(2)(a) and 409.920(2)(e).
    PAGE 772
  6. State v. Scharlepp

    292 So. 3d 872 (Fla. Dist. Ct. App. 2020)
    Here, we confront the long-standing question of how much of a role an administrative agency may play in establishing the elements of a crime. Section 409.920(2)(b), Florida Statutes, grants the State the authority to punish those who commit Medicaid fraud. The statute states that a person may not "[k]nowingly make, cause to be made, or aid and abet in the making of a claim for items or services that are not authorized to be reimbursed by the Medicaid program." § 409.920(2)(a) 2., Fla. Stat. (2015). "Knowingly" means
    PAGE 874
  7. State v. Harden

    No. SC04-613 (Fla. May. 18, 2006)
    After hearing argument from the parties, the circuit court entered an order granting the defendants' motion to dismiss. The circuit court concluded that the State's attempt to prosecute the defendants under the unlawful remuneration provision of section 409.920(2)(e) was preempted by federal law and thus unconstitutional under the Supremacy Clause. The circuit court also held that the mens rea requirement in section 409.920(1)(d) was preempted by federal law and unconstitutional under the Supremacy Clause. Additionally, the circuit court agreed with the defendants' alternative argument that the State's construction of section 409.920(2)(e) as a criminal ban on the solicitation of commercial business would, absent an intent to defraud requirement not contained in the statute, violate the First Amendment and render the statute unconstitutionally vague as applied.
  8. State v. Kigar

    279 So. 3d 217 (Fla. Dist. Ct. App. 2019)   1 Legal Analyses
    In Harden , our supreme court held that the anti-kickback provision of a different Florida statute, namely section 409.920(2)(e), Florida Statutes (2000), was unconstitutional in part because it did not include a "willfulness" requirement. Id. at 491-93. In reaching that holding, the supreme court stated that the "knowingly and willfully" requirement in 42 U.S.C. section 1320a-7b(b) requires proof that "the defendant acted with an evil-meaning mind, that is to say, that he acted with knowledge that his conduct was unlawful." Id. at 491 (citation omitted). A second intertwined reason for the supreme court's holding that section 409.920(2)(e) was unconstitutional was because section 409.920(2)(e) contained no "safe harbor" exemptions. Id. at 492.
    PAGE 224
  9. Butterworth v. X Hospital

    763 So. 2d 467 (Fla. Dist. Ct. App. 2000)   Cited 2 times
    The Florida Attorney General is authorized to conduct a statewide program of Medicaid Fraud Control[.] Fla. Stat. § 409.920 (1997). The office of the Attorney General investigates alleged instances of Medicaid fraud through the Medicaid Fraud Control Unit. As part of the Medicaid Fraud Control Program, the Attorney General has the authority to issue subpoenas for witnesses or materials throughout the state of Florida. Fla. Stat. § 409.920(8)(b).
    PAGE 468
  10. Comm. Healthcare Centerone v. State

    852 So. 2d 322 (Fla. Dist. Ct. App. 2003)
    (k) The Medicaid Fraud Control Unit in the Department of Legal Affairs pursuant to s. 409.920.
    PAGE 324