Medicaid Fraud

2025-2026 Bill 5285: Medicaid Fraud - South Carolina Legislature Online

South Carolina General Assembly
126th Session, 2025-2026
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H. 5285
STATUS INFORMATION
General Bill
Sponsors: Reps. Sessions, Cox, Bradley, Erickson, M.M. Smith, Martin, Brittain, Wooten, Neese, W. Newton, Chapman, Long, C. Mitchell, Gatch, Ford, Brewer, Davis, Landing, B. Newton, Teeple and Crawford
Document Path: LC-0448VR26.docx
Introduced in the House on February 26, 2026
Currently residing in the House
Summary: Medicaid Fraud
HISTORY OF LEGISLATIVE ACTIONS

Date

Body

Action Description with journal page number

2/26/2026

House

Introduced and read first time (
House Journal-page 14
)

2/26/2026

House

Referred to Committee on
Judiciary
(
House Journal-page 14
)

4/29/2026

House

Member(s) request name added as sponsor: Crawford

View the latest
legislative information
at the website
VERSIONS OF THIS BILL
02/26/2026

A bill

TO AMEND THE SOUTH CAROLINA CODE OF LAWS BY AMENDING
SECTIONS
43-7-60
AND
43-7-70
, RELATING TO PROVIDER AND RECIPIENT MEDICAID
FRAUD, SO AS TO CREATE TIERED CRIMINAL PENALTIES CORRELATING TO THE AMOUNT OF
FRAUD, TO REQUIRE RESTITUTION, TO AUTHORIZE THE ATTORNEY GENERAL'S USE OF
CONSENT AGREEMENTS, AND FOR OTHER PURPOSES; AND BY AMENDING SECTION
43-7-90
,
RELATING TO ENFORCEMENT OF SECTIONS
43-7-60
TO
43-7-80
, SO AS TO AUTHORIZE THE
ATTORNEY GENERAL TO ISSUE ADMINISTRATIVE SUBPOENAS AND INSTITUTE PROCEEDINGS.

B
e it enacted by the
General Assembly of the State of South Carolina:

S
ECTION 1.
S
ection
43-7-60
of the S.C. Code is amended to read:

S
ection
43-7-60
.
(
A) For purposes of this
section:

(
1)

"provider" includes
"Provider"
means
a person who provides goods, services, or assistance and who is
entitled or claims to be entitled to receive reimbursement, payment, or
benefits under the state's Medicaid program. "Provider"
also

includes
an owner, a billing agent, and
a
person acting as an employee, representative, or agent of the provider.

(
2)
"
false
False
claim,
statement, or representation" means a claim, statement, or representation made
or presented
, or attempted to be made or presented,

in any form including, but not limited to, a claim, statement, or
representation which is computer generated or transmitted or made, produced, or
transmitted by an electronic means or device.

(
3) "State Medicaid program" means the
state or federal agency which administers or assists in the administration of
the state Medicaid program and a managed care organization or similar entity under
contract with the state Medicaid program to provide goods, services, or
assistance.

(
B) It
is unlawful for a provider of medical assistance, goods, or services to
knowingly and wilfully make or cause to be made a false claim, statement, or
representation of a material fact:

(
1)
in an application or request, including an electronic or computer generated
claim, for a benefit, payment, or reimbursement from
a
state or federal agency which administers or assists in the administration of
the state's medical assistance or
the state
Medicaid
program; or

(
2)
on a report, certificate, or similar document, including an electronic or
computer generated claim, submitted to
a state or federal
agency which administers or assists in the administration of the state's
the state
Medicaid program in order for a provider or
facility to qualify or remain qualified under the
state's
state
Medicaid program to provide assistance, goods, or
services, or receive reimbursement, payment, or benefit for this assistance,
goods, or services.

For purposes of this
subsection, each false claim, representation, or statement constitutes a
separate offense.

(
C) It
is unlawful for a provider of medical assistance, goods, or services knowingly
and wilfully to conceal or fail to disclose any material fact, event, or
transaction which affects the:

(
1)
provider's initial or continued entitlement to payment, reimbursement, or
benefits under the
state's
state

Medicaid
plan
program
;
or

(
2)
amount of payment, reimbursement, or benefit to which the provider may be
entitled for services, goods, or assistance rendered.

For purposes of this
subsection, each fact, event, or transaction concealed or not disclosed
constitutes a separate offense.

(
D) A person who violates the
provisions of this section is guilty of medical assistance provider fraud, a
Class A misdemeanor and, upon conviction, must be imprisoned not more than
three years and fined not more than one thousand dollars for each offense.

(
D)
(
1)
A person who, in violation of the provisions of this section, knowingly makes a
false claim, statement, or misrepresentation, or who knowingly assists, abets,
solicits, or conspires with a person to make a false claim, statement, or
misrepresentation is guilty of a misdemeanor if the amount of economic
advantage or benefit sought or received is less than five thousand dollars and,
upon conviction, must be fined not more than one thousand dollars or imprisoned
not more than three years, or both.

(
2) A person who, in violation of the
provisions of this section, knowingly makes a false claim, statement, or
misrepresentation, or who knowingly assists, abets, solicits, or conspires with
a person to make a false claim, statement, or misrepresentation is guilty of a felony
if the amount of economic advantage or benefit sought or received is at least five
thousand dollars but less than fifty thousand dollars and, upon conviction,
must be fined not less than five thousand dollars nor more than twenty thousand
dollars or imprisoned not more than five years, or both.

(
3) A person who, in violation of the
provisions of this section, knowingly makes a false claim, statement, or
misrepresentation, or who knowingly assists, abets, solicits, or conspires with
a person to make a false claim, statement, or misrepresentation is guilty of a
felony if the amount of economic advantage or benefit sought or received is
fifty thousand dollars or more and, upon conviction, must be fined not less
than twenty thousand nor more than fifty thousand dollars or imprisoned not
more than ten years, or both.

(
E) In addition to the criminal
penalties set forth in subsection (D), a person convicted pursuant to the
provisions of this section must be ordered by the court to make full
restitution to a victim for any economic advantage or benefit that has been
obtained by the person as a result of that violation.

(E)
(
F)
In addition to all other remedies provided by law, the
Attorney General may bring an action to recover damages equal to three times
the amount of an overstatement or overpayment and the court may impose a civil
penalty of two thousand dollars for each false claim, representation, or
overstatement made to a state or federal agency which administers funds under
the
state's
state

Medicaid program. Upon a finding that the provider has violated a provision of
this section, the state agency which administers the Medicaid program may
impose other administrative sanctions against the provider authorized by law. A
civil or criminal action brought under this section may be filed or brought in
either the county where the false claim, statement, or representation
originated or in the county in which the false claim, statement, or
representation was received by the
South Carolina
Department of
Health and Human Services
Finance
Commission
or other agency of the State responsible for administering
the
state's
state
Medicaid

Program
program
.

(
G) Nothing in this section shall be
construed to prohibit the Attorney General and the person alleged to be guilty
of a violation of this section from entering into a written agreement in which
the person does not admit or deny the charges but consents to payment of the
civil penalty or appropriate voluntary restitution amount, or both. A consent
agreement may not be used in a subsequent civil or criminal proceeding relating
to any violation of this article.

S
ECTION 2.
S
ection
43-7-70
of the S.C. Code is amended to read:

S
ection
43-7-70
.
(
A)(1) It is unlawful for a
person to knowingly and wilfully to make or cause to be made a false statement
or representation of material fact on an application for assistance, goods, or
services under the
state's
state

Medicaid program when the false statement or representation is made for the
purpose of determining the person's entitlement to assistance, goods, or
services.

(
2)
It is unlawful for any applicant, recipient, or other person acting on behalf
of the applicant or recipient knowingly and wilfully to conceal or fail to
disclose any material fact affecting the applicant's or recipient's initial or
continued entitlement to receive assistance, goods, or services under the
state's
state
Medicaid
program.

(
3)
It is unlawful for a person eligible to receive benefits, services, or goods
under the
state
Medicaid program to sell, lease,
lend, or otherwise exchange rights, privileges, or benefits to another person.

(
B) A person who violates the
provisions of this section is guilty of medical assistance recipient fraud, a
Class A misdemeanor and, upon conviction, must be imprisoned not more than
three years or fined not more than one thousand dollars, or both.

(
B)
(
1)
A person who knowingly violates subsection (A), and any other person who
knowingly assists, abets, solicits, or conspires with a person to make a false
statement or representation as described in subsection (A), is guilty of a
misdemeanor if the amount of economic advantage or benefit sought or received
is less than five thousand dollars and, upon conviction, must be fined not more
than one thousand dollars or imprisoned not more than three years, or both.

(
2) A person who knowingly violates
subsection (A), and any other person who knowingly assists, abets, solicits, or
conspires with a person to make a false statement or representation as
described in subsection (A), is guilty of a felony if the amount of economic
advantage or benefit sought or received is at least five thousand dollars but
less than fifty thousand dollars and, upon conviction, must be fined not less
than five thousand dollars nor more than twenty thousand dollars or imprisoned
not more than five years, or both.

(
3) A person who violates subsection
(A), and any other person who knowingly assists, abets, solicits, or conspires
with a person to make a false statement or representation as described in
subsection (A), is guilty of a felony if the amount of economic advantage or
benefit sought or received is fifty thousand dollars or more and, upon
conviction, must be fined not less than twenty thousand nor more than fifty
thousand dollars or imprisoned not more than ten years, or both.

(
C) In addition to the criminal
penalties set forth in subsection (B), a person convicted pursuant to the
provisions of this section must be ordered by the court to make full
restitution to a victim for any economic advantage or benefit that has been
obtained by the person as a result of that violation.

(
D) In addition to all other remedies
under this section, the Attorney General may bring a civil action to recover
damages equal to three times the amount of the overpayment by the state agency
that administers funds under the state Medicaid program. A civil or criminal
action brought pursuant to this section may be filed or brought in either the
county where the false statement or representation originated or in the county
in which the false statement or representation was received by the South
Carolina Department of Health and Human Services or other agency of the State
responsible for administering the state Medicaid program.

(
E) In addition to any criminal
liability, any person who is found by a court of competent jurisdiction to have
violated any provision of this section is subject to a civil penalty for each
violation as follows:

(
1) for a first offense, a fine not to
exceed five thousand dollars;

(
2) for a second offense, a fine of not
less than five thousand dollars but not to exceed twenty thousand dollars; or

(
3) for a third and subsequent offense,
a fine of not less than twenty thousand dollars but not to exceed fifty
thousand dollars.

(
F) Nothing in this section shall be
construed to prohibit the Attorney General and the person alleged to be guilty
of a violation of this section from entering into a written agreement in which
the person does not admit or deny the charges but consents to payment of the
civil penalty or appropriate voluntary restitution amount, or both. A consent
agreement may not be used in a subsequent civil or criminal proceeding relating
to any violation of this article.

S
ECTION 3.
S
ection
43-7-90
of the S.C. Code is amended to read:

S
ection
43-7-90
.
T
he Attorney General has the authority and
responsibility to investigate and initiate appropriate action for alleged or
suspected violations of Sections
43-7-60
through
43-7-80
.
This
includes, but is not limited to, the authority and responsibility to:

(
1) issue administrative subpoenas for
the purpose of gathering information and documents relevant to investigating
fraud involving the state Medicaid program; and

(
2) institute proceedings in a court of
competent jurisdiction to seek relief necessary to carry out the provisions of
this article.

S
ECTION 4. This act takes effect upon approval
by the Governor.

----XX----

This web page was last updated on February 26, 2026 at 11:20 AM