Assembly Bill No. 274-Committee on Health and Human Services
(On Behalf of the Office of the Attorney General)
March 13, 1997
____________
Referred to Committee on Health and Human Services
SUMMARY--Revises provisions concerning fraud related to Medicaid. (BDR 38-622)
FISCAL NOTE: Effect on Local Government: Yes.
Effect on the State or on Industrial Insurance: Yes.
EXPLANATION - Matter in italics is new; matter in brackets [ ] is material to be omitted.
AN ACT relating to state welfare administration; expanding the application of the provisions imposing liability for fraud in the Medicaid program; providing specific criminal penalties; clarifying certain provisions concerning civil penalties and limitations of actions; and providing other matters properly relating thereto.
THE PEOPLE OF THE STATE OF NEVADA, REPRESENTED IN SENATE AND ASSEMBLY, DO ENACT AS FOLLOWS:
Section 1 Chapter 422 of NRS is hereby amended by adding thereto the provisions set forth as sections 2 and 3 of this act.
Sec. 2. "Statement or representation" includes, without limitation, a report, claim, certification, acknowledgment or ratification of:
1. Financial information;
2. An enrollment claim;
3. Demographic statistics;
4. Encounter data;
5. Health services available or rendered;
6. The qualifications of the persons rendering the health care or ancillary services; or
7. Any combination of subsections 1 to 6, inclusive.
Sec. 3. An action brought pursuant to NRS 422.540 to 422.580, inclusive, must be commenced within 4 years, but the cause of action in such a case shall be deemed to accrue upon the discovery by the aggrieved party of the facts constituting a violation of NRS 422.540 to 422.580, inclusive.
Sec. 4. NRS 422.450 is hereby amended to read as follows:
422.450As used in NRS 422.450 to 422.580, inclusive, and sections 2 and 3 of this act, unless the context otherwise requires, the words and terms defined in NRS 422.460 to 422.520, inclusive, and section 2 of this act, have the meanings ascribed to them in those sections.
Sec. 5. NRS 422.490 is hereby amended to read as follows:
422.490"Provider" means a [person] :
1. Person who has applied to participate or who participates in the plan as the provider of goods or services [.] ; or
2. Private insurance carrier, health care cooperative or alliance, health maintenance organization, insurer, organization, entity, association, affiliation or person, who contracts to provide or provides goods or services that are reimbursed by or are a required benefit of the plan.
Sec. 6. NRS 422.530 is hereby amended to read as follows:
422.530For the purposes of NRS 422.540 and 422.550:
1. A person shall be deemed to have known that a claim, statement or representation was false if he knew, or by virtue of his position, authority or responsibility had reason to know, of the falsity of the claim, statement or representation.
2. A person shall be deemed to have made or caused to be made a claim, statement or representation if he:
(a) Had the authority or responsibility to:
(1) Make the claim, statement or representation;
(2) Supervise another who made the claim, statement or representation; or
(3) Authorize the making of the claim, statement or representation,
whether by operation of law, business or professional practice, or office procedure; and
(b) Exercised that authority or responsibility or failed to exercise that authority or responsibility and, as a direct or indirect result, the false claim, statement or representation was made.
Sec. 7. NRS 422.540 is hereby amended to read as follows:
422.5401. A person commits an offense [and shall be punished as provided in NRS 205.380] if with respect to the plan he:
[1.] (a) Makes a claim or causes it to be made, knowing the claim to be false, in whole or in part, by commission or omission;
[2.] (b) Makes or causes to be made a statement or representation for use in obtaining or seeking to obtain authorization to provide specific goods or services, knowing the statement or representation to be false, in whole or in part, by commission or omission;
[3.] (c) Makes or causes to be made a statement or representation for use by another in obtaining goods or services pursuant to the plan, knowing the statement or representation to be false, in whole or in part, by commission or omission; or
[4.] (d) Makes or causes to be made a statement or representation for use in qualifying as a provider, knowing the statement or representation to be false, in whole or in part, by commission or omission.
2. A person who commits an offense described in subsection 1 shall be punished for a:
(a) Category D felony, as provided in NRS 193.130, if the amount of the claim or the value of the goods or services obtained or sought to be obtained was greater than or equal to $250.
(b) Misdemeanor if the amount of the claim or the value of the goods or services obtained or sought to be obtained was less than $250.
Amounts involved in separate violations of this section committed pursuant to a scheme or continuing course of conduct may be aggregated in determining the punishment.
3. In addition to any other penalty for a violation of the commission of an offense described in subsection 1, the court shall order the person to pay restitution.
Sec. 8. NRS 422.550 is hereby amended to read as follows:
422.5501. Each application or report submitted to participate as a provider, each report stating income or expense upon which rates of payment are or may be based, and each invoice for payment for goods or services provided to a recipient must contain a statement that all matters stated therein are true and accurate, signed by a natural person who is the provider or is authorized to act for the provider, under the pains and penalties of perjury.
2. A person is guilty of perjury which is a category D felony and shall be punished as provided in NRS 193.130 if he signs or submits, or causes to be signed or submitted, such a statement, knowing that the application, report or invoice contains information which is false, in whole or in part, by commission or by omission.
3. For the purposes of this section, a person who signs on behalf of a provider is presumed to have the authorization of the provider and to be acting at his direction.
Sec. 9. NRS 422.580 is hereby amended to read as follows:
422.5801. A provider who receives payment to which he is not entitled by reason of a violation of NRS 422.540, 422.550, 422.560 or 422.570 is liable for:
(a) An amount equal to three times the amount unlawfully obtained;
(b) Not less than $5,000 for each [act of deception;] false claim, statement or representation;
(c) An amount equal to three times the total of the reasonable expenses incurred by the state in enforcing this section; and
(d) Payment of interest on the amount of the excess payment at the rate fixed pursuant to NRS 99.040 for the period from the date upon which payment was made to the date upon which repayment is made pursuant to the plan.
2. A criminal action need not be brought against the provider before civil liability attaches under this section.
3. A provider who unknowingly accepts a payment in excess of the amount to which he is entitled is liable for the repayment of the excess amount. It is a defense to any action brought pursuant to this subsection that the provider returned or attempted to return the amount which was in excess of that to which he was entitled within a reasonable time after receiving it.
4. The attorney general shall cause appropriate legal action to be taken on behalf of the state to enforce the provisions of this section.
5. Any penalty or repayment of money collected pursuant to this section is hereby appropriated to provide medical aid to the indigent through programs administered by the welfare division.