287.129. False billing practices of health care provider, defined, effect--department of insurance, financial institutions and professional registration, powers--penalty.

MISSOURI STATUTES AND CODES

287.129. False billing practices of health care provider, defined, effect--department of insurance, financial institutions and professional registration, powers--penalty.

False billing practices of health care provider, defined,effect--department of insurance, financial institutions andprofessional registration, powers--penalty.

287.129. 1. A health care provider commits a fraudulent workers'compensation insurance act if he knowingly and with intent to defraudpresents, causes to be presented, or prepares with knowledge or belief that itwill be presented, to or by an insurer, purported insurer, broker, or anyagent thereof, any claim for payment or other benefit which involves any oneor more of the following false billing practices:

(1) "Unbundling" an insurance claim by claiming a number of medicalprocedures were performed instead of a single comprehensive procedure;

(2) "Upcoding" a medical, hospital or rehabilitative insurance claim byclaiming that a more serious or extensive procedure was performed than wasactually performed;

(3) "Exploding" a medical, hospital or rehabilitative insurance claim byclaiming a series of tests were performed on a single sample of blood, urine,or other bodily fluid, when actually the series of tests were part of onebattery of tests; or

(4) "Duplicating" a medical, hospital or rehabilitative insurance claimmade by a health care provider by resubmitting the claim through anotherhealth care provider in which the original health care provider has anownership interest.

Nothing in this section shall prohibit providers from making good faithefforts to ensure that claims for reimbursement are coded to reflect theproper diagnosis and treatment.

2. If, by its own inquiries or as a result of complaints, the departmentof insurance, financial institutions and professional registration has reasonto believe that a person has engaged in, or is engaging in, any fraudulentworkers' compensation insurance act contained in this section, it mayadminister oaths and affirmations, serve subpoenas ordering the attendance ofwitnesses or proffering of matter, and collect evidence.

3. If the matter that the department of insurance, financialinstitutions and professional registration seeks to obtain by request islocated outside the state, the person so requested may make it available tothe division or its representative to examine the matter at the place where itis located. The department may designate representatives, including officialsof the state in which the matter is located, to inspect the matter on itsbehalf, and it may respond to similar requests from officials of other states.

4. Any person violating any of the provisions of subsection 1 of thissection is guilty of a class A misdemeanor and the person shall be liable tothe state of Missouri for a fine up to twenty thousand dollars. Any personwho has previously pled guilty to or has been found guilty of violating any ofthe provisions of subsection 1 of this section and who subsequently violatesany of the provisions of subsection 1 of this section is guilty of a class Dfelony.