Sanctions for False or Fraudulent Claims for MO HealthNet Services - Mo. Code Regs. Ann. tit. 13, § 70-3.030

Sanctions may be imposed on providers by the state’s Medicaid agency for any of the following reasons:

1. Presenting a false or fraudulent claim for payment by the Medicaid program;
2. Submitting false information to the Medicaid program for the purpose of obtaining greater compensation under Medicaid (e.g. upcoding, etc);
3. Submitting false information to meet prior authorization requirements;
4. Failing to make available or disclosing to the state’s Medicaid agency, all records related to services provided under the Medicaid program.  All Medicaid records must be kept by Medicaid participating providers for a minimum of five years.  Failure to keep the records for five years, or failure to make the records available to the Medicaid agency in a timely manner constitutes a violation that is sanctionable. 
5. Failure to maintain and provide quality services for Medicaid beneficiaries within acceptable medical community standards;
6. Breaching the terms of the Medicaid provider contract;
7. Utilizing or abusing the Medicaid program by inappropriately requiring care that results in overutilization of the system;
8. Accepting or charging fees in violation of the Medicaid system;
9. Submission of a false or fraudulent provider application that misrepresents material facts;
10. Violating any law or code of ethics that governs professional standards or licensing;
11. Unlawful referrals;
12. Suspension from the Medicare program or any other federal program;
13. Criminal fraud;
14. Failure to adequately maintain records.

For any of the above named reasons, the following sanctions may be applied:

1. Withholding of future payments;
2. Termination from participation in Medicaid for 60 days to ten years;
3. Suspension of participation in Medicaid for a specified amount of time;
4. Suspension or withholding of payments to a provider for a specific amount of time;
5. Referral to peer review committees;
6. Recoupment from future payments;
7. Referral to the state licensing board.