False Billing & Claims

Defense Against Fraudulent Medical Billing and Insurance Claims

False medical billing allegations typically include upcoding, submitting duplicate insurance claims, and/or billing insurance companies for medical services that were not performed. If these allegations are proven true, they may result in severe criminal penalties under both Nevada and federal law.

At LV Criminal Defense, Las Vegas criminal defense attorney Nick Wooldridge represents individuals facing federal and state fraud investigations, including allegations involving medical billing and insurance claims.

What Is Considered False Medical Billing in Nevada?

False medical billing occurs when someone submits an insurance claim that has been intentionally inflated, misleading, or made up in order to get paid by the insurance company. If you submit a bill for services you did not provide; use incorrect billing codes to increase your payment; or hide important information, you could be charged with a crime.

False billing is a type of insurance fraud and can also be considered healthcare fraud.

Examples of potentially fraudulent billing practices include:

• Upcoding: Knowingly billing for a more expensive medical service than the one actually provided.

• Duplicate billing: Deliberately submitting multiple claims to obtain improper payment for the same procedure.

• Unbundling: Knowingly billing separately for services that applicable reimbursement rules require to be billed together.

• False medical records: Falsifying patient documentation to justify unnecessary or more expensive treatments and testing.

• Phantom billing: Charging for office visits, tests, surgeries, or other medical services that were never provided.

Conspiring with others to submit fraudulent claims or knowingly assisting in false billing activity may also lead to prosecution under Nevada law.

A billing error does not always indicate fraud. Criminal intent cannot be proven simply because there were coding errors, administrative issues, incomplete documentation, or a dispute over what should have been reimbursed. To prove that someone committed a crime, prosecutors will need to show that they met all of the criteria for that specific offense; this includes meeting the knowledge and intent requirements.

Who Is Liable For False Billing In Las Vegas?

Medical practitioners (physicians), medical practice owners, billing clerks/specialists, administrators and others involved in the operation of a medical facility can be held liable for false billing as long as there is evidence that they knowingly participated in an illegal act.

However, merely being employed at a medical facility that has submitted false claims is not sufficient to create criminal liability. It depends on the individual’s role, knowledge and participation in the scheme.

The penalties for submitting a fraudulent bill are based on Nevada Revised Statutes (NRS) 686A.2815 and NRS 686A.291.

If an individual knowingly and willfully submits a materially false claim to an insurance company, they could be charged with a Category D felony. A felony conviction can result in a sentence of one to four years in a Nevada state prison and/or a fine of up to $5,000.

In addition to prison time and/or fines, there are other possible penalties that may include restitution, court costs, investigation and prosecution costs, and/or professional licensing proceedings. A conviction may also affect a medical professional’s right to practice medicine.

Federal False Billing Charges Under 18 U.S.C. § 1347

False medical billing could result in federal prosecution based on 18 U.S.C. § 1347. This statute is applicable to those who knowingly and willfully execute or attempt to execute a scheme to defraud a healthcare benefit program. The statute can be applied to Medicare, Medicaid, and qualifying private health insurance plans.

Sentences for federal healthcare fraud depend in part on whether the violation results in serious bodily injury or death:

• Standard violation: Up to 10 years in federal prison, a fine, or both.

• Violation resulting in serious bodily injury: Up to 20 years in federal prison, a fine, or both.

• Violation resulting in death: Any term of years or life imprisonment, a fine, or both.

Federal healthcare fraud is not a strict-liability offense. Prosecutors must establish knowing and willful participation in a fraudulent scheme. Although the government does not need to prove that the defendant knew the precise federal statute being violated, it must establish the required fraudulent conduct and intent. Billing mistakes, inaccurate records, or administrative failures alone do not automatically prove a criminal scheme.

Separately, 18 U.S.C. § 1035 provides penalties of up to five years’ imprisonment for certain knowing and willful material false statements relating to healthcare benefits or payments.

Can False Medical Billing Lead to a False Claims Act Case?

Yes. If false billing is related to claims for federal government money, then the Federal False Claims Act (31 U.S.C. § 3729) can be used. This act allows for civil liability when someone knowingly submits or causes to be submitted a false claim, which can result in treble damages and other financial penalties. The civil False Claims Act has a different standard of knowledge than criminal prosecution.

The standard for knowledge in the Civil False Claims Act is defined as actual knowledge, deliberate ignorance, and/or reckless disregard. Depending on the evidence and law, a billing investigation can lead to either civil claims, criminal charges, or both.