FALSE HEALTH CARE CLAIMS

M.G.L. pt. Part I, tit. Title XXII, ch. c. 175H

in effect

M.G.L. c. 175H, § 1 Definitions

c. 175H, § 1. Definitions Section 1. As used in this chapter the following words shall have the following meanings, unless the context otherwise requires:— ''False'', wholly or partially false, fictitious, fraudulent, untrue or deceptive. ''Health care benefit'', a payment for health care services or the right under a contract or a certificate or policy of insurance to have a payment made by a health care corporation or health care insurer for a specified health care service. ''Health care corporation'', a nonprofit hospital service corporation organized pursuant to chapter one hundred and seventy-six A, a nonprofit medical service corporation organized pursuant to chapter one hundred and seventy-six B, a medical service corporation organized pursuant to chapter one hundred and seventy-six C, a dental service corporation organized pursuant to chapter one hundred and seventy-six E, an optometric service plan organized pursuant to chapter one hundred and seventy-six F, and a health maintenance organization organized pursuant to chapter one hundred and seventy-six G. ''Health care insurer'', any insurance company authorized to provide health insurance in this state or any legal entity which is self-insured and providing health care benefits to its employees. ''Person'', an individual, corporation, partnership, association, or any other legal entity.

M.G.L. c. 175H, § 2 False statements on applications for coverage and claims; failure to disclose

c. 175H, § 2. False statements on applications for coverage and claims; failure to disclose Section 2. Any person who (1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in any application for a payment of a health care benefit; or (2) knowingly and willfully presents or causes to be presented an application for a health care benefit containing any false statement or representation of a material fact; or (3) knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to a health care benefit, including whether goods or services were medically necessary in accordance with professionally accepted standards; or (4) having knowledge of the occurrence of any event affecting his initial or continued right to any health care benefit, conceals or fails to disclose such an event with an intent to fraudulently secure such benefit either in a greater amount than is due or when no such benefit is due; or (5) having knowledge of the occurrence of any event affecting the health care benefit of any other individual in whose behalf he has made or presented an application for such benefit, or in whose behalf he is receiving any health care benefit, conceals or fails to disclose such an event with an intent to fraudulently secure such benefit either in a greater amount than is due or when no such benefit is due, shall be punished by a fine of not more than ten thousand dollars, or by imprisonment in a jail or house of correction for not more than two and one-half years or in the state prison for not more than five years, or by both such fine and imprisonment, and may be held liable in a civil action under section seven. Notwithstanding the foregoing, a person who is not a provider of services for which a health care benefit may be paid shall not be subject to prosecution hereunder for any statement or representation which such person makes without fraudulent intent.

M.G.L. c. 175H, § 3 Solicitation, improper inducement to use goods, facilities, services, or products covered by insurance

c. 175H, § 3. Solicitation, improper inducement to use goods, facilities, services, or products covered by insurance Section 3. (a) Any person who solicits or receives any remuneration, directly or indirectly, overtly or covertly, in cash or in kind in return for purchasing, leasing, ordering or arranging for or recommending purchasing, leasing, or ordering of any good, facility, service, or item for which payment is or may be made in whole or in part by a health care insurer, or any person who offers or pays any remuneration, including any bribe or rebate, except as provided in subsection (b), directly or indirectly, overtly or covertly, in cash or in kind to induce any person to purchase, lease, order or arrange for or recommend purchasing, leasing or ordering of any good, facility, service, or item for which payment is or may be made in whole or in part by a health care insurer, shall be punished by a fine of not more than ten thousand dollars, or by imprisonment in a jail or house of correction for not more than two and one-half years or in the state prison for not more than five years, or by both such fine and imprisonment, and may be held liable in a civil action under section seven. [Subsections (b) to (d) effective until January 1, 2026. Repealed by 2012, 139, Sec. 131. See 2012, 139, Sec. 226 as amended by 2014, 441, Sec. 2; 2016, 133, Sec. 129; 2018, 363, Sec. 1; 2019, 142, Sec. 15; 2020, 227, Sec. 59; and 2022, 126, Sec. 111.] (b)(1) This section shall not apply to any discount or free product vouchers that a retail pharmacy provides to a consumer in connection with a pharmacy service, item or prescription transfer offer or to any discount, rebate, product voucher or other reduction in an individual's out-of-pocket expenses, including co-payments and deductibles, on: (i) any biological product as defined in section 351 of the Public Health Service Act, 42 USC 262, or (ii) any prescription drug provided by a pharmaceutical manufacturing company, as defined in section 1 of chapter 111N, that is made available to an individual if the discount, rebate, product voucher or other reduction is provided directly or electronically to the individual or through a point of sale or mail-in rebate, or through similar means; provided, however, that a pharmaceutical manufacturing company shall not exclude or favor any pharmacy in the redemption of such discount, rebate, product voucher or other expense reduction offer to a consumer. (2) Pharmaceutical manufacturing companies shall be prohibited from offering any discount, rebate, product voucher or other reduction in an individual's out-of-pocket expenses, including co-payments and deductibles, for any prescription drug that has an AB rated generic equivalent as determined by the United States Food and Drug Administration or for any prescription drug that is an opioid placed by the commissioner of public health on schedule II pursuant to subsection (a) of section 2 of said chapter 94C. (3) This section shall not apply to a discount, rebate or other payment by a pharmaceutical manufacturing company to a patient or another person on the patient's behalf, other than the prescriber of the drug or biologic, for health care items or services related to the patient's use of a drug or biologic of the manufacturer where such items or services are required under a Food and Drug Administration Risk Evaluation and Mitigation Strategy or are for the purpose of monitoring or facilitating the use of the drug or biologic in a manner consistent with the drug or biologic's approved labeling (c) Subsection (b) shall not: (i) restrict a pharmaceutical manufacturing company with regard to how it distributes a prescription drug, biologic or vaccine; (ii) restrict a carrier or a health maintenance organization, as defined in section 1 of chapter 118G, with regard to how its plan design will treat such discounts, rebates, product voucher or other reduction in out-of-pocket expenses; or (iii) affect the obligations of practitioners and pharmacists pursuant to the generic substitution statute as defined in section 12D of chapter 112. (d) For purposes of the federal Health Insurance Portability and Accountability Act of 1996, hereinafter referred to as HIPAA, and regulations promulgated under HIPAA, nothing in this section shall be deemed to require or allow the use or disclosure of health information in any manner that does not otherwise comply with HIPAA or regulations promulgated under HIPAA.

M.G.L. c. 175H, § 4 Criminal proceedings

c. 175H, § 4. Criminal proceedings Section 4. Any criminal proceeding brought under this chapter may be filed in the district, municipal or superior courts of Suffolk county.

M.G.L. c. 175H, § 5 Investigation and proceedings by attorney general

c. 175H, § 5. Investigation and proceedings by attorney general Section 5. The attorney general may conduct an investigation of an alleged violation of this chapter and may commence a proceeding pursuant to section four.

M.G.L. c. 175H, § 6 Liability for false claims; civil proceedings

c. 175H, § 6. Liability for false claims; civil proceedings Section 6. A person who receives a health care benefit or payment from a health care corporation or health care insurer which such person knows that he or she is not entitled to receive or be paid, or a person who knowingly presents or causes to be presented with fraudulent intent a claim which contains a false statement, shall be liable to the health care corporation or health care insurer for the full amount of the benefit or payment made, and for reasonable attorneys fees and costs, inclusive of costs of investigation. A health care corporation or health care insurer may bring a civil action under this chapter in the superior court department of the trial court.

M.G.L. c. 175H, § 7 Restitution; attorneys fees, costs

c. 175H, § 7. Restitution; attorneys fees, costs Section 7. Any person convicted of a violation of sections two or three, in addition to any fines or sentences imposed, including any order of probation, shall be ordered to make restitution to a health care corporation or health care insurer for the full amount of the benefit or payment made, and for reasonable attorneys fees and costs, inclusive of costs of investigation.

M.G.L. c. 175H, § 8 Remedies

c. 175H, § 8. Remedies Section 8. The remedies provided for in this chapter are in addition to any other remedies provided by law.

Source: Massachusetts General Court (malegislature.gov)URL: https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXXII/Chapter175HFetched: 10/20/2026