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H 5285

Medicaid Fraud

2025-2026 Regular Session Introduced by Jeff Bradley and 19 co-sponsors

The bill imposes tiered criminal penalties for Medicaid fraud by providers and recipients, with restitution, triple damages, civil penalties, and new AG powers to subpoena and sue.

Member(s) request name added as sponsor: Crawford
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WeVote Research Nonpartisan
Bill Summary · H 5285

Summary of Bill H 5285 (South Carolina, 2025-2026 Session) – Medicaid Fraud

Purpose and Intent

  • The bill strengthens South Carolina’s laws governing Medicaid fraud by creating tiered criminal penalties based on the amount of economic advantage obtained through fraudulent acts.
  • It expands tools for enforcement by authorizing the Attorney General to use consent agreements and, in addition, authorizes administrative subpoenas and court proceedings to pursue fraud cases.
  • Overall goal: deter and punish provider and recipient fraud in the state Medicaid program and recover overpayments or damages.

Key Provisions and Changes

1) Provider Fraud (Section 43-7-60)

  • Defines “provider,” “false claim/statement/representation,” and “state Medicaid program.”
  • Unlawful acts:
    • Knowingly and willfully making or causing false claims or statements for benefits, payments, or to qualify/retain qualification under Medicaid (including electronic claims).
    • Concealing or failing to disclose material facts affecting entitlement or payment amount.
  • Offense structure:
    • Each false claim or concealment is a separate offense.
  • Penalties (tiered by amount of economic advantage):
    • False claims/intentional misrepresentations with small economic gain: Class A misdemeanor; up to 3 years’ imprisonment and up to $1,000 fine per offense.
    • Economic advantage less than $5,000: misdemeanor; up to 3 years and up to $1,000 fine.
    • $5,000 to $50,000: felony; fines $5,000 to $20,000 or up to 5 years in prison (or both).
    • $50,000 or more: felony; fines $20,000 to $50,000 or up to 10 years in prison (or both).
  • Restitution: Court must order full restitution to victims for any economic advantage gained.
  • Civil/administrative remedies: Attorney General may seek triple damages (three times the amount of overstatement/overpayment) and a civil penalty of $2,000 per false claim. State Medicaid agency may impose administrative sanctions.
  • Venue: Civil or criminal actions may be filed in the county where the false claim originated or where it was received by the Medicaid agency.
  • Consent agreements: Allows resolution without admission/deny charges, with civil penalties or restitution; cannot be used in subsequent proceedings.

2) Recipient Fraud (Section 43-7-70)

  • Unlawful acts:
    • False statements on Medicaid applications for entitlements.
    • Concealment or nondisclosure affecting initial or continued entitlement.
    • Recipient selling or transferring benefits.
  • Penalties (tiered by amount):
    • General recipient fraud: Class A misdemeanor; up to 3 years’ imprisonment or $1,000 fine (or both).
    • Less than $5,000: misdemeanor; up to 3 years or $1,000.
    • $5,000 to $50,000: felony; fines $5,000 to $20,000 or up to 5 years (or both).
    • $50,000 or more: felony; fines $20,000 to $50,000 or up to 10 years (or both).
  • Restitution: Court must order restitution to victims for economic advantage gained.
  • Civil remedies: Attorney General may pursue damages equal to three times the overpayment; civil or criminal actions may be filed in the same venues as provider fraud.
  • Civil penalties: Additional penalties per offense:
    • First offense: up to $5,000.
    • Second offense: $5,000 to $20,000.
    • Third or subsequent offenses: $20,000 to $50,000.
  • Consent agreements: Permitted under similar terms as provider fraud.

3) Attorney General Authority and Investigative Tools (Section 43-7-90)

  • Grants the Attorney General explicit authority to:
    • Issue administrative subpoenas to gather information and documents related to Medicaid fraud investigations.
    • Institute court proceedings to obtain relief and enforce provisions of the article.

4) Effective Date

  • The act takes effect upon approval by the Governor.

Who Is Affected

  • Medicaid providers (hospitals, clinics, physicians, suppliers, etc.) who submit claims or documents.
  • Medicaid recipients and beneficiaries who may be implicated in fraud or improper disposal of benefits.
  • South Carolina Department of Health and Human Services/Medicaid program administrators.
  • The Attorney General’s Office, which gains enhanced enforcement tools.

Procedural and Timeline Aspects

  • Establishes a tiered offense structure tied to monetary thresholds, with corresponding penalties.
  • Creates restitution obligations and tripled-damages civil actions in favor of the state.
  • Introduces administrative subpoenas and court-ordered relief as standard enforcement mechanisms.
  • Consent agreements provide an optional settlement path without admission of guilt, applicable to both provider and recipient fraud cases.
  • No specific date-based phase-in is listed; the bill becomes effective upon gubernatorial approval.

If you’d like, I can provide a quick comparison to existing SC Medicaid fraud penalties or outline anticipated budgetary or enforcement implications.

Compiled from official sources — confirm details with the bill’s official record.

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