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and more conservative or less costly treatment is available; statewide" Fla. Admin. Code 590-

1.010(1 66)(a)(4); see also, FL Prescribed Drug Services Coverage, Limitations and

Reimbursement Handbook 9-2 and D-9. 2

  • E.

    THE ILLiNOIS INSURANCE FRAUD CLAIMS PREVENTION ACT (ICFPA)

    • 51.

      The Illinois Insurance Claims Fraud Prevention Act (ICFPA), 740 ILCS 9211 et

seq., provides that "[a] person who violates any provision of this Act or Article 46 of the

Criminal Code of 1961 [720 ILCS 5/46] shall be subject, in addition to any other penalties that

may be prescribed by law, to a civil penalty of not less than $5,000 nor more than $10,000, plus

an assessment of not more than 3 times the amount of each claim for compensation under a

contract of insurance." 740 ILCS 92/5(b).

52.

Article 46 of the Criminal Code of 1961 delineates insurance fraud as follows:

A person commits the offense of insurance fraud when he or she knowingly obtains, attempts to obtain, or causes to be obtained, by deception, control over the property of an insurance company or self-insured entity by the making of a false claim or by causing a false claim to be made on any policy of insurance issued by an insurance company or by the making of a false claim to a self insured entity permanently of the use and benefit of that property.

720 ILCS 5/46-1 (d)(5).

53.

Article 46 of the Criminal Code of 1961, 720 ILCS 5/46, also defines "false

claim" broadly as:

[A]ny statement made to any insurer purported insurer, servlcmg corporation, insurance broker, or insurance agent, or any agent or employee of the entities, and made as part of, or in support of, a claim for payment or other benefit under a policy of insurance ... when the statement contains any false, incomplete, or misleading information concerning any fact or thing material to the claim...

2 See also. e.g., Ohio, Ohio Admin. Code §5101:3-1-01(A) (5) (For a service to be medically necessary, as required for payment under Medicaid, it must be the lowest cost alternative that effectively addresses and treats the medical problem); Massachusetts, Mass. Regs. Code tit. 130, §450.204(A)(2) (A service is medically necessary if "there is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to the Division,")

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