Health care fraud in Nevada comprises situations where doctors or medical staff try to bilk patients' insurance companies for more money than they are legally entitled to.1 Examples of health insurance fraud include:
- Falsifying patient records
- Charging for medical procedures that were never performed
Health care fraud also goes by the names “health insurance fraud,” “medical billing fraud,” “HMO fraud” and “Medicare fraud.”
Defenses to Health Care Fraud
Two common defenses to Nevada charges of health care fraud include:
- No intent to defraud
- Police misconduct
Penalties for Health Care Fraud
A sentence for health care fraud in Nevada carries:
The defendant might also lose his/her professional license.
“A Nevada conviction of health care fraud may result in the suspension or revocation of the defendant's professional license.” - North Las Vegas criminal defense attorney Michael Becker
Scroll down for more information on the Nevada crime of health care fraud:
Legal Definition of “Health Care Fraud” in Nevada
Often doctors get paid not by patients but by patients' insurance companies. Health care fraud occurs when doctors or their staff deliberately try to swindle insurance companies out of money the doctors or staff did not earn.3
Example: Oncologist Dr. Smith treats his patient John with a standard form of chemotherapy. But Dr. Smith deliberately bills John's insurance company United Healthcare for a more expensive type of chemotherapy. (This type of fraudulent billing for pricier procedures is called “upcoding.”) Since Dr. Smith is intentionally trying to get United Healthcare to pay him more money that he is owed, Dr. Smith could be convicted of health care fraud in Las Vegas.
Dr. Smith in the above example would still be criminally liable if United Healthcare catches the fraud before they overpay Dr. Smith. A defendant may be convicted of health care fraud whether or not the victim loses any money from the fraud. Nor does it matter whether the insurer is private or government-funded.
Other common examples of Nevada health care fraud include:
- Double-billing for medical procedures that were performed only once.
- Charging for health care procedures that were never performed.
- Exaggerating costs of performing medical procedures.
- Falsifying patient records in order to justify tests and operations that are unnecessary.
Note that any type of health care worker…and not just physicians…may be liable for health care fraud in Nevada.4 Anybody who intentionally tries to defraud a health insurance company faces criminal prosecution. Other potential defendants in health care fraud cases include:
- Physician's assistants
- Medical equipment suppliers
- Hospital management and staff
- Medical laboratory management and staff
- Drug researchers
- Nursing home management and staff
- Group home management and staff
- Other medical staff including secretaries and record clerks
“Possible defendants in Nevada health care fraud cases include medical professionals and their staffs. Health care workers can also be prosecuted for conspiring with one another to carry out health care fraud.” - Nevada criminal defense attorney Mike Becker.
Also note that the Nevada offense of “health care fraud” goes by several names including:
- “Medical insurance billing fraud”
- “Health insurance fraud”
- “HMO fraud”
- “Medicare fraud”
Federal Health Care Fraud:
Health care fraud is a crime under not only Nevada law but also federal law. Depending on the case, defendants may face health care fraud charges in both state court and Nevada federal court. Health care fraud cases involving federal health insurers such as Medicare are prosecuted in federal court.5
“Defrauding a health insurer may invite federal prosecution as well. And the federal penalties are harsher than Nevada state penalties.” - Las Vegas criminal defense attorney Neil Shouse
Defenses to “Health Care Fraud” in Nevada
Defenses to fight Nevada charges of health care fraud usually involve the defendant's intent and/or the police's conduct:
- Lack of fraudulent intent. A key element to the Nevada offense of health care fraud is that the defendant intentionally gave a health insurer false information in an effort to defraud them. It is no crime to accidentally give false information, even if the mistake causes the health insurer to pay out extra money.6 Nevada judges understand that health insurers are confusing bureaucracies with complicated procedures, and that innocent people may make honest errors.
Example: Jack is a neurosurgeon in Henderson who buys a new CT scan machine that is cheaper to operate than his old one. But by mistake he continues to bill his patients' insurers for scans done under the old CT machine. Because Jack had no intention of tricking the insurance companies, his overbilling does not make him liable for health care fraud. (However, the insurers may be able to sue Jack in civil court to recoup the extra money they paid due to Jack's oversight.)
- Police misconduct. Sometimes Nevada courts dismiss criminal charges solely due to police error. If cops perform an unlawful search while investigating a health care fraud case, then the defendant's attorney can file a “motion to suppress evidence in Nevada.” This motion asks the judge to throw out any evidence found from the illegal police search. If the court grants the motion, then the D.A. may be left with too little evidence to sustain a conviction for health care fraud.
“A defendant should not be found guilty of health care fraud in Nevada if the prosecution cannot prove beyond a reasonable doubt that the defendant deliberately tried to defraud the health insurer.” - Reno criminal defense attorney Michael Becker
Penalties for “Health Care Fraud” in Nevada
Health care fraud is a category D penalty in Nevada. The punishment for committing health care fraud carries a sentence of:
- 1 - 4 years in Nevada State Prison, and
- Nevada restitution to the insurance company, and
- possibly a fine of up to $5,000, and
- possibly court costs,
- possibly reimbursement costs to the state for investigating and prosecuting the insurance fraud case7
Depending on the case, the health care worker may also face suspension or revocation of his/her professional license.8
“A conviction of health care fraud not only carries incarceration and fines…it may cost the defendant his/her medical license.” - Henderson criminal defense attorney Neil Shouse
Federal Penalties for Health Care Fraud:
Federal law carries harsher penalties than Nevada law for health care fraud. And the extent of the sentence depends on whether the patient sustains serious harm or death:
- If the health care fraud does not result in serious bodily injury, the defendant faces up to 10 years in Federal Prison and/or fines.
- If the health care fraud does result in serious bodily injury, the defendant faces up to 20 years in Federal Prison and/or fines.
- If the health care fraud results in death, the defendant faces up to life in Federal Prison and/or fines.9
Accused of “health care fraud” in Nevada? Call an attorney for help…
If you have been charged with “health care fraud” in Nevada, call our Las Vegas Criminal Defense Attorneys at 702-DEFENSE (702-333-3673) for a free consultation. We may be able to get the charges reduced or dismissed. And we are ready to take your case to trial in pursuit of a “not guilty” verdict.
We represent clients throughout Nevada, including Las Vegas, Henderson, Washoe County, Reno, Clark County, Carson City, Laughlin, Mesquite, Bunkerville, Moapa, Elko, Pahrump, Searchlight and Tonopah.
Go back to our main page on Nevada fraud crimes.
To learn about Penal Code 550 PC | California health care fraud law, refer to our informational article on Penal Code 550 PC | California health care fraud law.
- Presenting or causing to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance pursuant to this title.
- Presenting or causing to be presented any statement as a part of, or in support of, a claim for payment or other benefits under a policy of insurance issued pursuant to this title, if the person who presents or causes the presentation of the statement knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to that claim.
- Assisting, abetting, soliciting or conspiring with another person to present or cause to be presented any statement to an insurer, a reinsurer, a producer, a broker or any agent thereof, if the person who assists, abets, solicits or conspires knows that the statement conceals or omits facts, or contains false or misleading information concerning any fact material to an application for the issuance of a policy of insurance pursuant to this title or a claim for payment or other benefits under such a policy.
- Acting or failing to act with the intent of defrauding or deceiving an insurer, a reinsurer, a producer, a broker or any agent thereof, to obtain a policy of insurance pursuant to this title or any proceeds or other benefits under such a policy.
- As a practitioner, an insurer or any agent thereof, acting to assist, conspire with or urge another person to commit any act or omission specified in this section through deceit, misrepresentation or other fraudulent means.
- Accepting any proceeds or other benefits under a policy of insurance issued pursuant to this title, if the person who accepts the proceeds or other benefits knows that the proceeds or other benefits are derived from any act or omission specified in this section.
- Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance issued pursuant to this title for the purpose of engaging in any act or omission specified in this section, except that such insurance fraud does not include contact or communication by an insurer or an agent or representative of the insurer with a client, patient or other person if the contact or communication is made for a lawful purpose, including, without limitation, communication by an insurer with a holder of a policy of insurance issued by the insurer or with a claimant concerning the settlement of any claims against the policy.
- Participating in, aiding, abetting, conspiring to commit, soliciting another person to commit, or permitting an employee or agent to commit any act or omission specified in this section.
(a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice -
(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.
- to defraud any health care benefit program; or
- to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.
9 18 USC § 1347(a)(2); see Steve Ganigher, Las Vegas woman pleads guilty to health care fraud, 8NewsNow.com (May 7, 2013).