NMSA 1978, § 30-44-1 Short title
30-44-1. Short title
Chapter 30, Article 44 NMSA 1978 may be cited as the "Medicaid Fraud Act".
Laws 1989, ch. 286, § 1; 1997, ch. 98, § 1.
Medicaid Fraud
NMSA 1978 ch. 30, art. 44
in effectNMSA 1978, § 30-44-2 Definitions
30-44-2. Definitions
As used in the Medicaid Fraud Act:
A. "benefit" means money, treatment, services, goods or anything of value authorized under the program;
B. "claim" means any communication, whether oral, written, electronic or magnetic, that identifies a treatment, good or service as reimbursable under the program;
C. "cost document" means any cost report or similar document that states income or expenses and is used to determine a cost reimbursement based rate of payment for a provider under the program;
D. "covered person" means an individual who is entitled to receive health care benefits from a managed health care plan;
E. "department" means the human services department [health care authority department];
F. "entity" means a person other than an individual and includes corporations, partnerships, associations, joint-stock companies, unions, trusts, pension funds, unincorporated organizations, governments and political subdivisions thereof and nonprofit organizations;
G. "great physical harm" means physical harm of a type that causes physical loss of a bodily member or organ or functional loss of a bodily member or organ for a prolonged period of time;
H. "great psychological harm" means psychological harm that causes mental or emotional incapacitation for a prolonged period of time or that causes extreme behavioral change or severe physical symptoms or that requires psychological or psychiatric care;
I. "health care official" means:
(1) an administrator, officer, trustee, fiduciary, custodian, counsel, agent or employee of a managed care health plan;
(2) an officer, counsel, agent or employee of an organization that provides, proposes to or contracts to provide services to a managed health care plan; or
(3) an official, employee or agent of a state or federal agency with regulatory or administrative authority over a managed health care plan;
J. "managed health care plan" means a government-sponsored health benefit plan that requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use health care providers managed, owned, under contract with or employed by a health care insurer or provider service network. A "managed health care plan" includes the health care services offered by a health maintenance organization, preferred provider organization, health care insurer, provider service network, entity or person that contracts to provide or provides goods or services that are reimbursed by or are a required benefit of a state or federally funded health benefit program, or any person or entity who contracts to provide goods or services to the program;
K. "person" includes individuals, corporations, partnerships and other associations;
L. "physical harm" means an injury to the body that causes pain or incapacitation;
M. "program" means the medical assistance program authorized under Title XIX of the federal Social Security Act, 42 U.S.C. 1396, et seq. and implemented under Section 27-2-12 NMSA 1978;
N. "provider" means any person who has applied to participate or who participates in the program as a supplier of treatment, services or goods;
O. "psychological harm" means emotional or psychological damage of such a nature as to cause fear, humiliation or distress or to impair a person's ability to enjoy the normal process of his life;
P. "recipient" means any individual who receives or requests benefits under the program;
Q. "records" means any medical or business documentation, however recorded, relating to the treatment or care of any recipient, to services or goods provided to any recipient or to reimbursement for treatment, services or goods, including any documentation required to be retained by regulations of the program; and
R. "unit" means the medicaid fraud control unit or any other agency with power to investigate or prosecute fraud and abuse of the program.
Laws 1989, ch. 286, § 2; 1997, ch. 98, § 2.
NMSA 1978, § 30-44-3 Power to investigate and enforce civil remedies and prosecute criminal actions
30-44-3. Power to investigate and enforce civil remedies and prosecute criminal actions
A. The attorney general, the district attorneys, the unit and the department have the power and authority to investigate violations of the Medicaid Fraud Act and bring actions to enforce the civil remedies established in the Medicaid Fraud Act.
B. The attorney general, the district attorneys and those attorneys who are employees of the unit to whom the attorney general or a district attorney has, by appointment made through a joint powers agreement or other agreement for that purpose, delegated criminal prosecutorial responsibility, shall have the power and authority to prosecute persons for the violation of criminal provisions of the Medicaid Fraud Act and for criminal offenses that are not defined in the Medicaid Fraud Act, but that involve or are directly related to the use of medicaid program funds or services provided through medicaid programs.
Laws 1989, ch. 286, § 3; 1991, ch. 79, § 1.
NMSA 1978, § 30-44-4 Falsification of documents; defined; penalties
30-44-4. Falsification of documents; defined; penalties
A. Falsification of documents consists of:
(1) knowingly making or causing to be made a misrepresentation of a material fact required to be furnished under the program or knowingly failing or causing the failure to include a material fact required to be furnished under the program in any record required to be retained in connection with the program pursuant to the Medicaid Fraud Act or regulations issued by the department for the administration of the program, or both; or
(2) knowingly submitting or causing to be submitted false or incomplete information for the purpose of receiving benefits or qualifying as a provider.
B. Whoever commits the crime of falsification of documents is guilty of a fourth degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
Laws 1989, ch. 286, § 4.
NMSA 1978, § 30-44-5 Failure to retain records; defined; penalties
30-44-5. Failure to retain records; defined; penalties
A. Whoever receives payment for treatment, services or goods under the program shall retain all medical and business records relating to:
(1) the treatment or care of any recipient;
(2) services or goods provided to any recipient;
(3) rates paid by the department under the program on behalf of any recipient; and
(4) any records required to be maintained by regulation of the department for administration of the program.
B. Failure to retain records consists of intentionally failing to retain the records specified in Subsection A of this section for a period of at least five years from the date payment was received or knowingly destroying or causing those records to be destroyed within five years from the date payment was received.
C. Whoever commits the crime of failure to retain records:
(1) is guilty of a misdemeanor if the treatment, services or goods for which records were not retained amounts to not more than one thousand dollars ($1,000) and shall be sentenced pursuant to Section 31-19-1 NMSA 1978;
(2) is guilty of a fourth degree felony if the value of the treatment, services or goods for which records were not retained is more than one thousand dollars ($1,000) and shall be sentenced pursuant to the provisions of Section 13-18-15 [31-18-15] NMSA 1978; and
(3) is guilty of a misdemeanor if the records not retained were used in whole or in part to determine a rate of payment under the program and shall be sentenced pursuant to Section 31-19-1 NMSA 1978.
Laws 1989, ch. 286, § 5.
NMSA 1978, § 30-44-6 Obstruction of investigation; defined; penalty
30-44-6. Obstruction of investigation; defined; penalty
A. Obstruction of investigation consists of:
(1) knowingly providing false information to, or knowingly withholding information from, any person authorized under the Medicaid Fraud Act to investigate violations of that act or to enforce the criminal or civil remedies of that act where that information is material to the investigation or enforcement; or
(2) knowingly altering any document or record required to be retained pursuant to the Medicaid Fraud Act or any regulation issued by the department, or both, when the alteration is intended to mislead an investigation and concerns information material to that investigation.
B. Whoever commits obstruction of investigation is guilty of a fourth degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
Laws 1989, ch. 286, § 6.
NMSA 1978, § 30-44-7 Medicaid fraud; defined; investigation; penalties
30-44-7. Medicaid fraud; defined; investigation; penalties
A. Medicaid fraud consists of:
(1) paying, soliciting, offering or receiving:
(a) a kickback or bribe in connection with the furnishing of treatment, services or goods for which payment is or may be made in whole or in part under the program, including an offer or promise to, or a solicitation or acceptance by, a health care official of anything of value with intent to influence a decision or commit a fraud affecting a state or federally funded or mandated managed health care plan;
(b) a rebate of a fee or charge made to a provider for referring a recipient to a provider;
(c) anything of value, intending to retain it and knowing it to be in excess of amounts authorized under the program, as a precondition of providing treatment, care, services or goods or as a requirement for continued provision of treatment, care, services or goods; or
(d) anything of value, intending to retain it and knowing it to be in excess of the rates established under the program for the provision of treatment, services or goods;
(2) providing with intent that a claim be relied upon for the expenditure of public money:
(a) treatment, services or goods that have not been ordered by a treating physician;
(b) treatment that is substantially inadequate when compared to generally recognized standards within the discipline or industry; or
(c) merchandise that has been adulterated, debased or mislabeled or is outdated;
(3) presenting or causing to be presented for allowance or payment with intent that a claim be relied upon for the expenditure of public money any false, fraudulent, excessive, multiple or incomplete claim for furnishing treatment, services or goods; or
(4) executing or conspiring to execute a plan or action to:
(a) defraud a state or federally funded or mandated managed health care plan in connection with the delivery of or payment for health care benefits, including engaging in any intentionally deceptive marketing practice in connection with proposing, offering, selling, soliciting or providing any health care service in a state or federally funded or mandated managed health care plan; or
(b) obtain by means of false or fraudulent representation or promise anything of value in connection with the delivery of or payment for health care benefits that are in whole or in part paid for or reimbursed or subsidized by a state or federally funded or mandated managed health care plan. This includes representations or statements of financial information, enrollment claims, demographic statistics, encounter data, health services available or rendered and the qualifications of persons rendering health care or ancillary services.
B. Except as otherwise provided for in this section regarding the payment of fines by an entity, whoever commits medicaid fraud as described in Paragraph (1) or (3) of Subsection A of this section is guilty of a fourth degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
C. Except as otherwise provided for in this section regarding the payment of fines by an entity, whoever commits medicaid fraud as described in Paragraph (2) or (4) of Subsection A of this section when the value of the benefit, treatment, services or goods improperly provided is:
(1) not more than one hundred dollars ($100) is guilty of a petty misdemeanor and shall be sentenced pursuant to the provisions of Section 31-19-1 NMSA 1978;
(2) more than one hundred dollars ($100) but not more than two hundred fifty dollars ($250) is guilty of a misdemeanor and shall be sentenced pursuant to the provisions of Section 31-19-1 NMSA 1978;
(3) more than two hundred fifty dollars ($250) but not more than two thousand five hundred dollars ($2,500) is guilty of a fourth degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978;
(4) more than two thousand five hundred dollars ($2,500) but not more than twenty thousand dollars ($20,000) shall be guilty of a third degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978; and
(5) more than twenty thousand dollars ($20,000) shall be guilty of a second degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
D. Except as otherwise provided for in this section regarding the payment of fines by an entity, whoever commits medicaid fraud when the fraud results in physical harm or psychological harm to a recipient is guilty of a fourth degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
E. Except as otherwise provided for in this section regarding the payment of fines by an entity, whoever commits medicaid fraud when the fraud results in great physical harm or great psychological harm to a recipient is guilty of a third degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
F. Except as otherwise provided for in this section regarding the payment of fines by an entity, whoever commits medicaid fraud when the fraud results in death to a recipient is guilty of a second degree felony and shall be sentenced pursuant to the provisions of Section 31-18-15 NMSA 1978.
G. If the person who commits medicaid fraud is an entity rather than an individual, the entity shall be subject to a fine of not more than fifty thousand dollars ($50,000) for each misdemeanor and not more than two hundred fifty thousand dollars ($250,000) for each felony.
H. The unit shall coordinate with the human services department [health care authority department], department of health and children, youth and families department to develop a joint protocol establishing responsibilities and procedures, including prompt and appropriate referrals and necessary action regarding allegations of program fraud, to ensure prompt investigation of suspected fraud upon the medicaid program by any provider. These departments shall participate in the joint protocol and enter into a memorandum of understanding defining procedures for coordination of investigations of fraud by medicaid providers to eliminate duplication and fragmentation of resources. The memorandum of understanding shall further provide procedures for reporting to the legislative finance committee the results of all investigations every calendar quarter. The unit shall report to the legislative finance committee a detailed disposition of recoveries and distribution of proceeds every calendar quarter.
Laws 1989, ch. 286, § 7; 1997, ch. 98, § 3; 2003, ch. 291, § 1.
NMSA 1978, § 30-44-8 Civil penalties; created; enumerated; presumption; limitation of action
30-44-8. Civil penalties; created; enumerated; presumption; limitation of action
A. Any person who receives payment for furnishing treatment, services or goods under the program, which payment the person is not entitled to receive by reason of a violation of the Medicaid Fraud Act, shall, in addition to any other penalties or amounts provided by law, be liable for:
(1) payment of interest on the amount of the excess payments at the maximum legal rate in effect on the date the payment was made, for the period from the date payment was made to the date of repayment to the state;
(2) a civil penalty in an amount of up to three times the amount of excess payments;
(3) payment of a civil penalty of up to ten thousand dollars ($10,000) for each false or fraudulent claim submitted or representation made for providing treatment, services or goods; and
(4) payment of legal fees and costs of investigation and enforcement of civil remedies.
B. Interest amounts, legal fees and costs of enforcement of civil remedies assessed under this section shall be remitted to the state treasurer for deposit in the general fund.
C. Any penalties and costs of investigation recovered on behalf of the state shall be remitted to the state treasurer for deposit in the general fund except an amount not to exceed two hundred fifty thousand dollars ($250,000) in fiscal year 2004, one hundred twenty-five thousand dollars ($125,000) in fiscal year 2005 and seventy-five thousand dollars ($75,000) in fiscal year 2006 may be retained by the unit and expended, consistent with federal regulations and state law, for the purpose of carrying out the unit's duties.
D. A criminal action need not be brought against a person as a condition precedent to enforcement of civil liability under the Medicaid Fraud Act.
E. The remedies under this section are separate from and cumulative to any other administrative and civil remedies available under federal or state law or regulation.
F. The department may adopt regulations for the administration of the civil penalties contained in this section.
G. No action under this section shall be brought after the expiration of five years from the date the action accrues.
1989, ch. 286, § 8; 1997, ch. 98, § 4; 2004, ch. 54, § 1.
Source: New Mexico Compilation Commission (nmonesource.com)URL: https://nmonesource.com/nmos/nmsa-unanno/en/item/18530/index.doFetched: 10/20/2026