375.991. Fraudulent insurance act, committed, when--powers and duties of department--penalties.

MISSOURI STATUTES AND CODES

375.991. Fraudulent insurance act, committed, when--powers and duties of department--penalties.

Fraudulent insurance act, committed, when--powers and duties ofdepartment--penalties.

375.991. 1. As used in sections 375.991 to 375.994, the term"statement" means any communication, notice statement, proof of loss, bill oflading, receipt for payment, invoice, account, estimate of damages, bills forservices, diagnosis, prescription, hospital or doctor records, x-rays, testresults or other evidence of loss, injury or expense.

2. For the purposes of sections 375.991 to 375.994, a person commits a"fraudulent insurance act" if such person knowingly presents, causes to bepresented, or prepares with knowledge or belief that it will be presented, toor by an insurer, purported insurer, broker, or any agent thereof, any oral orwritten statement including computer generated documents as part of, or insupport of, an application for the issuance of, or the rating of, an insurancepolicy for commercial or personal insurance, or a claim for payment or otherbenefit pursuant to an insurance policy for commercial or personal insurance,which such person knows to contain materially false information concerning anyfact material thereto or if such person conceals, for the purpose ofmisleading another, information concerning any fact material thereto.

3. A "fraudulent insurance act" shall also include but not be limited toknowingly filing false insurance claims with an insurer, health servicescorporation, or health maintenance organization by engaging in any one or moreof 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", an insurance claim by claiming that a more serious orextensive procedure was performed than was actually performed;

(3) "Exploding", an insurance claim by claiming a series of tests wasperformed on a single sample of blood, urine, or other bodily fluid, whenactually the series of tests was part of one battery 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 sections 375.991 to 375.994 shall prohibitproviders from making good faith efforts to ensure that claims forreimbursement are coded to reflect the proper diagnosis and treatment.

4. 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 fraudulentinsurance act or has violated any provision of chapters 375 to 385, RSMo, itmay administer oaths and affirmations, serve subpoenas ordering the attendanceof witnesses or proffering of matter, and collect evidence. The director mayrefer such evidence as is available concerning violations of this chapter tothe proper prosecuting attorney or circuit attorney who may, with or withoutsuch reference, initiate the appropriate criminal proceedings.

5. 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 department or its representative to examine the matter at the place whereit is located. The department may designate representatives, includingofficials of the state in which the matter is located, to inspect the matteron its behalf, and it may respond to similar requests from officials of otherstates.

6. A fraudulent insurance act for a first offense is a class D felony.Any person who pleads guilty to or is found guilty of a fraudulent insuranceact who has previously pled guilty to or has been found guilty of a fraudulentinsurance act shall be guilty of a class C felony.

7. Any person who pleads guilty or is found guilty of a fraudulentinsurance act shall be ordered by the court to make restitution to any personor insurer for any financial loss sustained as a result of such violation.The court shall determine the extent and method of restitution.

8. Nothing in this section shall limit the power of the state to punishany person for any conduct that constitutes a crime by any other statestatute.