287.128. Unlawful acts, penalties--fraud or noncompliance, complaint may be filed, effect--fraud and noncompliance unit established, purpose, confidentiality of records--annual report, contents. - Missouri Statutes

Unlawful acts, penalties--fraud or noncompliance, complaint may befiled, effect--fraud and noncompliance unit established, purpose,confidentiality of records--annual report, contents.

287.128. 1. It shall be unlawful for any person to knowingly present orcause to be presented any false or fraudulent claim for the payment ofbenefits pursuant to a workers' compensation claim.

2. It shall be unlawful for any insurance company or self-insurer inthis state to knowingly and intentionally refuse to comply with known andlegally indisputable compensation obligations with intent to defraud.

3. It shall be unlawful for any person to:

(1) Knowingly present multiple claims for the same occurrence withintent to defraud;

(2) Knowingly assist, abet, solicit or conspire with:

(a) Any person who knowingly presents any false or fraudulent claim forthe payment of benefits;

(b) Any person who knowingly presents multiple claims for the sameoccurrence with an intent to defraud; or

(c) Any person who purposefully prepares, makes or subscribes to anywriting with the intent to present or use the same, or to allow it to bepresented in support of any such claim;

(3) Knowingly make or cause to be made any false or fraudulent claim forpayment of a health care benefit;

(4) Knowingly submit a claim for a health care benefit which was notused by, or on behalf of, the claimant;

(5) Knowingly present multiple claims for payment of the same healthcare benefit with an intent to defraud;

(6) Knowingly make or cause to be made any false or fraudulent materialstatement or material representation for the purpose of obtaining or denyingany benefit;

(7) Knowingly make or cause to be made any false or fraudulentstatements with regard to entitlement to benefits with the intent todiscourage an injured worker from making a legitimate claim;

(8) Knowingly make or cause to be made a false or fraudulent materialstatement to an investigator of the division in the course of theinvestigation of fraud or noncompliance.

For the purposes of subdivisions (6), (7), and (8) of this subsection, theterm "statement" includes any notice, proof of injury, bill for services,payment for services, hospital or doctor records, X-ray or test results.

4. Any person violating any of the provisions of subsection 1 or 2 ofthis section shall be guilty of a class D felony. In addition, the personshall be liable to the state of Missouri for a fine up to ten thousand dollarsor double the value of the fraud whichever is greater. Any person violatingany of the provisions of subsection 3 of this section shall be guilty of aclass A misdemeanor and the person shall be liable to the state of Missourifor a fine up to ten thousand dollars. Any person who has previously pledguilty to or has been found guilty of violating any of the provisions ofsubsection 1, 2 or 3 of this section and who subsequently violates any of theprovisions of subsection 1, 2 or 3 of this section shall be guilty of a classC felony.

5. It shall be unlawful for any person, company, or other entity toprepare or provide an invalid certificate of insurance as proof of workers'compensation insurance. Any person violating any of the provisions of thissubsection shall be guilty of a class D felony and, in addition, shall beliable to the state of Missouri for a fine up to ten thousand dollars ordouble the value of the fraud, whichever is greater.

6. Any person who knowingly misrepresents any fact in order to obtainworkers' compensation insurance at less than the proper rate for thatinsurance shall be guilty of a class A misdemeanor. Any person who haspreviously pled guilty to or has been found guilty of violating any of theprovisions of this section and who subsequently violates any of the provisionsof this section shall be guilty of a class D felony.

7. Any employer who knowingly fails to insure his liability pursuant tothis chapter shall be guilty of a class A misdemeanor and, in addition, shallbe liable to the state of Missouri for a penalty in an amount up to threetimes the annual premium the employer would have paid had such employer beeninsured or up to fifty thousand dollars, whichever amount is greater. Anyperson who has previously pled guilty to or has been found guilty of violatingany of the provisions of this section and who subsequently violates any of theprovisions of this section shall be guilty of a class D felony.

8. Any person may file a complaint alleging fraud or noncompliance withthis chapter with a legal advisor in the division of workers' compensation.The legal advisor shall refer the complaint to the fraud and noncomplianceunit within the division. The unit shall investigate all complaints andpresent any finding of fraud or noncompliance to the director, who may referthe file to the attorney general. The attorney general may prosecute anyfraud or noncompliance associated with this chapter. All costs incurred bythe attorney general associated with any investigation and prosecutionpursuant to this subsection shall be paid out of the workers' compensationfund. Any fines or penalties levied and received as a result of anyprosecution under this section shall be paid to the workers' compensationfund. Any restitution ordered as a part of the judgment shall be paid to theperson or persons who were defrauded.

9. Any and all reports, records, tapes, photographs, and similarmaterials or documentation submitted by any person, including the departmentof insurance, financial institutions and professional registration, to thefraud and noncompliance unit or otherwise obtained by the unit pursuant tothis section, used to conduct an investigation for any violation under thischapter, shall be considered confidential and not subject to the requirementsof chapter 610, RSMo. Nothing in this subsection prohibits the fraud andnoncompliance unit from releasing records used to conduct an investigation tothe local, state, or federal law enforcement authority or federal or stateagency conducting an investigation, upon written request.

10. There is hereby established in the division of workers' compensationa fraud and noncompliance administrative unit responsible for investigatingincidences of fraud and failure to comply with the provisions of this chapter.

11. Any prosecution for a violation of the provisions of this section orsection 287.129 shall be commenced within three years after discovery of theoffense by an aggrieved party or by a person who has a legal duty to representan aggrieved party and who is not a party to the offense. As used in thissubsection, the term "person who has a legal duty to represent an aggrievedparty" shall mean the attorney general or the prosecuting attorney havingjurisdiction to prosecute the action.

12. By January 1, 2006, the attorney general shall forward to thedivision and the members of the general assembly the first edition of anannual report of the costs of prosecuting fraud and noncompliance under thischapter. The report shall include the number of cases filed with the attorneygeneral by county by the fraud and noncompliance unit, the number of casesprosecuted by county by the attorney general, fines and penalties levied andreceived, and all incidental costs.

(L. 1992 H.B. 975, A.L. 1993 S.B. 251, A.L. 1998 H.B. 1237, et al., A.L. 2005 S.B. 1 & 130)

(2003) Statutory penalty is premised upon the guilt of employer for failure to insure workers' compensation liability and not upon the sentencing of the employer. State ex rel. v. Jamison, 103 S.W.3d 836 (Mo.App.E.D.).