Pennsylvania HB 216: An Act amending the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code, in fraud and abuse control, further providing for definitions and for provider prohibited acts, criminal penalties and civil remedies.

Bill Text

PRINTER'S NO. 173
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 216
Session of
2025
INTRODUCED BY KUTZ, HAMM, JAMES, KAUFFMAN, ECKER AND GROVE,
JANUARY 22, 2025
REFERRED TO COMMITTEE ON JUDICIARY, JANUARY 22, 2025
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in fraud and abuse
control, further providing for definitions and for provider
prohibited acts, criminal penalties and civil remedies.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. Section 1401 of the act of June 13, 1967 (P.L.31,
No.21), known as the Human Services Code, is amended by adding a
definition to read:
Section 1401. Definitions.--The following words and phrases
when used in this article shall have, unless the context clearly
indicates otherwise, the meanings given to them in this section:
* * *
"Representation" means a communication that is used to
identify goods or services for which reimbursement is sought
under the medical assistance program or that is or may be used
to determine a rate of reimbursement under the medical
assistance program.
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* * *
Section 2. Section 1407 of the act is amended to read:
Section 1407. [Provider] Prohibited Acts, Criminal Penalties
and Civil Remedies.--(a) It shall be unlawful for any person
to:
(1) [Knowingly or intentionally present for allowance or
payment any false or fraudulent claim or cost report for
furnishing services or merchandise under medical assistance, or
to knowingly present for allowance or payment any claim or cost
report for medically unnecessary services or merchandise under
medical assistance, or to knowingly submit false information,
for the purpose of obtaining greater compensation than that to
which he is legally entitled for furnishing services or
merchandise under medical assistance, or to knowingly submit
false information for the purpose of obtaining authorization for
furnishing services or merchandise under medical assistance.]
Make or cause to be made a materially false, fraudulent or
misleading statement, claim or representation in a document or
record in any format, including written or electronic, used by
any person in connection with providing goods or services to any
recipient under the medical assistance program.
(1.1) Submit or cause to be submitted false information for
the purpose of obtaining greater compensation than that to which
the person is legally entitled for furnishing goods or services
under the medical assistance program.
(1.2) Submit or cause to be submitted a claim for medically
unnecessary or inadequate services or merchandise provided to a
recipient under the medical assistance program.
(2) Solicit or receive or to offer or pay any remuneration,
including any kickback, bribe or rebate, directly or indirectly,
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in cash or in kind from or to any person in connection with the
furnishing of services or merchandise for which payment may be
in whole or in part under the medical assistance program or in
connection with referring an individual to a person for the
furnishing or arranging for the furnishing of any services or
merchandise for which payment may be made in whole or in part
under the medical assistance program.
(3) Submit or cause to be submitted a duplicate claim for
services, supplies or equipment for which [the provider] a
person has already received or claimed reimbursement from any
source.
(4) Submit or cause to be submitted a claim for services,
supplies or equipment which were not rendered to a recipient.
(5) Submit or cause to be submitted a claim for services,
supplies or equipment which includes costs or charges not
related to such services, supplies or equipment rendered to the
recipient.
(6) Submit or cause to be submitted a claim or refer a
recipient to another provider by referral, order or
prescription, for services, supplies or equipment which:
(i) are not documented in the record in the prescribed
manner and are of little or no benefit to the recipient[,];
(ii) are below the accepted medical treatment standards[,
or]; or
(iii) are unneeded by the recipient.
(7) Submit or cause to be submitted a claim which
misrepresents the description of services, supplies or equipment
dispensed or provided; the dates of services; the identity of
the recipient; the identity of the attending, prescribing or
referring practitioner; or the identity of the actual
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[provider.] person dispensing or providing services, supplies or
equipment .
(8) Submit or cause to be submitted a claim for
reimbursement for a service, charge or item at a fee or charge
which is higher than the [provider's] person's usual and
customary charge to the g