Nevada "Health Care Fraud" Laws (NRS 686A.2815)
Explained by Las Vegas Criminal Defense Attorneys


Definition

Health care fraud in Nevada is when medical providers try to cheat insurance companies out of money they are not lawfully entitled to. Examples include:

  • Double-billing / duplicate claims
  • Falsifying patient records
  • Charging for medical procedures that were unnecessary, excessive, or never performed
  • Upcoding or unbundling of services or items
  • Accepting kickbacks in exchange for using unnecessary equipment or prescription drugs

Violating NRS 686A.2815 also goes by the names “health insurance fraud,” “medical billing fraud,” “HMO fraud” and “Medicare fraud.”

Defenses

Two common defense strategies to Nevada charges of health insurance fraud include:

  • The defendant had no intent to defraud (the incident was an accident), and
  • The police committed misconduct

Penalties

Health care fraud in a category D felony in Nevada, carrying:

The defendant's professional license may also be suspended or revoked.

In this article, our Las Vegas criminal defense attorneys discuss:

health insurance fraud
Health insurance fraud is both a Nevada state and a federal crime.

1. What is health care fraud in Nevada?

An NRS 686A.2815 violation occurs when doctors or their staff deliberately try to swindle health insurance companies out of money they did not earn or are not entitled to.1

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 insurance fraud in Las Vegas.

Note that 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.

Eight common examples of Nevada health insurance fraud include:

  1. Double-billing for medical procedures that were performed only once ("making duplicate claims");
  2. Charging for health care procedures that were never rendered;
  3. Charging for health care procedures or equipment that were unnecessary or excessive;
  4. Exaggerating / inflating costs of performing medical procedures;
  5. Falsifying patient records in order to justify tests and operations that are unnecessary;
  6. Using unnecessary equipment or meds in exchange for kickbacks from pharmaceutical companies (such as cash or other gifts);
  7. Unbundling services (submitting bills in piecemeal, which usually increases the costs); and
  8. Conspiring with anyone to do any of the above (learn more about the Nevada crime of conspiracy)

Note that any type of health care worker -- and not just physicians -- may be liable for health insurance fraud in Nevada. Anybody who intentionally tries to defraud a health insurance company faces criminal prosecution.2 Other potential defendants in health care fraud cases include:

  • Physician's assistants
  • Dentists
  • Chiropractors
  • Therapists
  • Nurses
  • 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

1.1. Federal Health Care Fraud

gavel

Health insurance 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.

The federal crime of health care fraud often involves federal health insurers such as Medicare.3

2. What are the defenses to Nevada charges of health care fraud?

Two defenses to health insurance fraud charges in Nevada are:

  1. The defendant had no intention to defraud, or
  2. Law enforcement committed misconduct

2.1. Lack of fraudulent intent

A key element of the Nevada offense of health insurance 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.4

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 criminally liable for health insurance 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.)

Even if Jack in the above example was prosecuted in federal instead of state court, the criminal charges should still be dismissed. This is because Jack's actions were a pure oversight, not part a "scheme" or "artifice."5

2.2. Police misconduct

Sometimes Nevada courts dismiss criminal charges solely due to police error, such as:

For instance, if law enforcement performs an illegal search while investigating a health insurance fraud case, then the defendant's attorney can file a motion to suppress evidence. A suppression 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.

3. What are the Nevada penalties for health care fraud?

Health insurance fraud is a category D penalty in Nevada. The punishment for committing health care fraud carries a sentence of:

  • 1 - 4 years in prison,
  • restitution to the insurance company,
  • up to $5,000 (at the judge's discretion),
  • court costs, and
  • reimbursement costs to the state for investigating and prosecuting the insurance fraud case7

Depending on the case, the health insurance worker may also face suspension or revocation of his/her professional license. So in addition to criminal penalties, the defendant faces the loss of his/her livelihood.8

jail

3.1. Federal Penalties for Health Care Fraud:

Federal law carries harsher penalties than Nevada law for health insurance fraud. And the extent of the sentence depends on whether the patient sustains serious harm or death:9

Federal health care fraud offense Penalties

If no bodily injury results

Up to 10 years in prison

If serious bodily injury results

Up to 20 years in prison

If death results

Up to life in prison

4. Can I get a Nevada conviction of health care fraud sealed?

A health insurance fraud conviction can usually be sealed five (5) years after the case ends. But there is no waiting period for a record seal if the charge gets dismissed (meaning there is no conviction).10

Learn more about getting criminal records sealed in Nevada.

5. Can I get deported for health care fraud?

Yes. Health care fraud is an aggravated felony, which is a class of deportable offenses.11

However, a skilled criminal defense attorney may be able to persuade the prosecutor to reduce the charge to a non-deportable offense. Therefore, aliens charged with a crime should retain an attorney as soon as possible in an effort to safeguard their resident status. Learn more about the criminal defense of immigrants in Nevada.

6. Related offenses

6.1. Nevada forgery laws (NRS 205.090)

The Nevada crime of forgery is when someone intentionally tries to defraud another person or company by using falsified documents. A common example is signing someone else's name to a contract.

As a category D felony, a forgery conviction carries:

  • 1 - 4 years in prison;
  • up to $5,000 in fines (at the judge's discretion); and
  • restitution

6.2. Nevada commercial bribery laws (NRS 207.295)

The Nevada crime of commercial bribery is when a company employee is offered gifts, cash, or benefits in return for making a business decision without the employer's permission. As a misdemeanor, violating NRS 207.295 carries

  • up to 6 months in jail, and/or
  • up to $1,000 in fines

6.3. Nevada crime of obtaining money by false pretenses (NRS 205.380)

The Nevada crime of obtaining money by false pretenses is when people knowingly misrepresent themselves in order to obtain money from someone else relying on their misrepresentation. A common example is getting paid for a job the person never performed.

Fraudulently obtaining less than $650 is a misdemeanor, carrying:

  • up to 6 months in jail, and/or
  • up to $1,000 in fines, and
  • restitution

Fraudulently obtaining $650 or more is a category B felony, carrying:

  • 1 - 6 years in prison, and/or
  • up to $10,000 in fines, and
  • restitution

Call a Nevada criminal defense attorney...

702-DEFENSE (702-333-3673)
Call our Las Vegas criminal defense attorneys at 702-DEFENSE for a FREE consultation.

If you have been charged with fraudulent health care acts 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.

Arrested in California? Refer to our informational article on Penal Code 550 PC | California health care fraud law.


Legal References:

  1. NRS 686A.2815 “Insurance fraud” defined.

          1. “Insurance fraud” means knowingly and willfully:

          (a) 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.

          (b) 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, 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.

          (c) 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 or a claim for payment or other benefits under such a policy.

          (d) 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 or any proceeds or other benefits under such a policy.

          (e) 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.

          (f) Accepting any proceeds or other benefits under a policy of insurance, 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.

          (g) Employing a person to procure clients, patients or other persons who obtain services or benefits under a policy of insurance 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.

          (h) 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.

          2. As used in this section, “policy of insurance” means:

          (a) Any policy issued in this State by an authorized insurer; and

          (b) Any policy issued outside this State by an authorized insurer which relates to property that:

                 (1) Is located in this State when any act or omission specified in this section occurs; or

                 (2) Was located in this State when the incident that gave rise to the act or omission specified in this section occurred.

  2. Id.
  3. 18 USC § 1347. (a) Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice -
    1. to defraud any health care benefit program; or
    2. 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.
    (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.Also, see Nevada's Medicaid Fraud Control Unit.
  4. See Perelman v. State, 981 P.2d 1199, 115 Nev. 190. (1999)("Although NRS 686A.291 makes the filing of a false statement a crime, the overall intent of the statute is to address the filing of a false claim through the use of fraud, misrepresentations, or false statements. Thus, when multiple false statements are made in support of one claim, only one crime has been committed.").
  5. 18 USC § 1347.
  6. Illinois v. Gates, 462 U.S. 213, 103 S. Ct. 2317 (1983)("The exclusionary rule is 'a judicially created remedy designed to safeguard Fourth Amendment rights generally'").
  7. NRS 686A.291.
  8. NRS 630.160.
  9. 18 USC § 1347(a)(2); see Steve Ganigher, Las Vegas woman pleads guilty to health care fraud, 8NewsNow.com (May 7, 2013); see also federal Anti Kickback statute 42 U.S.C. § 1320a-7b.
  10. NRS 179.245; NRS 179.255.
  11. See, e.g., United States v. Popov, 742 F.3d 911 (9th Cir. Feb. 11, 2014).
  12. NRS 205.090.
  13. NRS 207.295.
  14. NRS 205.380.

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