Louisiana Employee Medicaid Fraud Form

Medicaid fraud occurs when a Medicaid provider knowingly makes, or causes to be
made, a false or misleading statement or representation for use in obtaining
reimbursement from the medical assistance program. This would include, but is not
limited to, billing for services not provided, charging Medicaid more than the
reasonable value of the services and providing services that were medically unnecessary, in order to obtain an improper payment. Medicaid fraud can be a misdemeanor or a felony. If you violate this statute and perform Medicaid fraud you will be prosecuted to the fullest extent of the law. Additionally, if you are convicted of Medicaid fraud, after you complete restitution, which will include penalties which may include a prison sentence and or fine(s), you will be excluded from any employment with a program or facility receiving Medicaid funding. Examples of Medicaid fraud are below.

Signing/submitting a timesheet for services that were not actually provided is Medicaid fraud.*

Signing/submitting a timesheet for services provided by a different person is Medicaid fraud.*

Signing/submitting a timesheet for services that were reimbursed by another source is Medicaid fraud.*

Signing/submitting a duplicate timesheet for reimbursement from the same source is Medicaid fraud.*

In order to be employed in this Medicaid program you will be appropriately trained to properly record your time of services, which will require among other measures for you to record your time of arrival to care for your client and your time of departure. You will be trained to record your signature on the employment time sheet, which will also be signed by the client for whom you work.*

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	Employee Initials
Signing/submitting a timesheet for services that were not actually provided is Medicaid fraud.
Signing/submitting a timesheet for services provided by a different person is Medicaid fraud.
Signing/submitting a timesheet for services that were reimbursed by another source is Medicaid fraud.
Signing/submitting a duplicate timesheet for reimbursement from the same source is Medicaid fraud.
In order to be employed in this Medicaid program you will be appropriately trained to properly record your time of services, which will require among other measures for you to record your time of arrival to care for your client and your time of departure. You will be trained to record your signature on the employment time sheet, which will also be signed by the client for whom you work.

All suspected cases of Medicaid fraud will be referred to the applicable enforcement office for further investigation and prosecution.

I acknowledge that I have read and understand this document.

Employee Legal Name*

Legal First NameLegal Last Name

Employee Email*

example@example.com

Employee Signature*

Time of Employee Signature

Hour Minutes

Date of Signature*

Date

Employer Legal Name*

Legal First NameLegal Last Name

Employer Email*

example@example.com

Employer Signature*

Date of Signature*

Date

Please verify that you are human*

Louisiana Employee Medicaid Fraud Form

Louisiana Employee Medicaid Fraud Form

Signatures