Pennsylvania Code & Bulletin

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 1032 (February 24, 2024).

55 Pa. Code § 1101.74. Provider fraud.

§ 1101.74. Provider fraud.

 If, after investigation, the Department determines that a provider has submitted or has caused to be submitted claims for payments which the provider is not otherwise entitled to receive, the Department will, in addition to the administrative action described in § §  1101.82—1101.84 (relating to administrative procedures), refer the case record to the Medicaid Fraud Control Unit of the Department of Justice for further investigation and possible referral for prosecution under Federal, State and local laws. Providers who are convicted by a Federal court of willfully defrauding the Medicaid program are subject to a $25,000 fine or up to five years imprisonment or both.

Cross References

   This section cited in 55 Pa. Code §  51.27 (relating to misuse and abuse of funds and damage of participants property); 55 Pa. Code §  5221.43 (relating to quality assurance and utilization review); and 55 Pa. Code §  6100.744 (relating to additional conditions and sanctions).

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