36-2993. Prohibited acts; penalties

A. A person shall not present or cause to be presented to this state or to a contractor:

1. A claim for a medical service or any other item that the person knows or has reason to know was not provided as claimed.

2. A claim for a medical service or any other item that the person knows or has reason to know is false or fraudulent.

3. A claim for payment that the person knows or has reason to know may not be made by the administration because:

(a) The person was terminated or suspended from participation in the program on the date for which the claim is being made.

(b) The item or service claimed is substantially in excess of the needs of the individual or of a quality that fails to meet professionally recognized standards of health care.

(c) The person was not a member on the date for which the claim is being made.

4. A claim for a service or an item by a person who knows or has reason to know that the individual who furnished or supervised the furnishing of the service:

(a) Was not licensed as a physician or another health care professional requiring state licensure.

(b) Obtained the individual's license through a misrepresentation of material fact.

(c) Represented to the member at the time the service was furnished that the physician was certified in a medical specialty by a medical specialty board if the individual was not certified.

5. A request for payment that the person knows or has reason to know is in violation of an agreement between the person and this state or the administration.

B. A person who violates this section is subject, in addition to any other penalties that may be prescribed by law, to a civil penalty of not more than two thousand dollars for each item or service claimed and is subject to an assessment of not more than twice the amount claimed for each item or service.

C. The director or the director's designee shall make the determination to assess civil penalties and is responsible for the collection of penalty and assessment amounts. The director shall adopt rules that prescribe procedures for the determination and collection of civil penalties and assessments. Civil penalties and assessments imposed under this section may be compromised by the director or the designee in accordance with criteria established in rules. The director or the director's designee may make this determination in the same proceeding to exclude the person from participation in the program.

D. A person adversely affected by a determination of the director or the director's designee under this section may appeal that decision in accordance with provider grievance provisions prescribed by rule. The final decision is subject to judicial review pursuant to title 12, chapter 7, article 6.

E. The administration shall deposit, pursuant to sections 35-146 and 35-147, monies collected pursuant to this section in the state general fund. The amount of the penalty or assessment may be deducted from any amount then or later owing by the administration or this state to the person against whom the penalty or assessment has been imposed.

F. If a civil penalty or assessment imposed pursuant to this section is not paid, this state or the administration shall file an action to collect the civil penalty or assessment in the superior court in Maricopa county. Matters that were raised or could have been raised in a hearing before the director or in an appeal pursuant to title 12, chapter 7, article 6 may not be raised as a defense to the civil action. An action brought pursuant to this subsection shall be initiated within six years after the date the claim was presented.