False claim for payment: Withholding by insurer of payment to provider of health care; procedure for withholding; appeal.
1. An insurer may withhold any payment due a provider of health care pursuant to the provisions of chapters 616A to 616D, inclusive, or chapter 617 of NRS, in whole or in part, upon receipt of reliable evidence that the provider of health care knowingly made a false statement or representation or knowingly concealed a material fact to obtain the payment. The insurer may withhold such a payment without first notifying the provider of health care of its intention to do so.
2. The insurer shall, within 5 days after withholding such a payment, send notice of the withholding to the provider of health care by certified mail or electronic transmission. The notice must:
(a) Set forth the factual basis for the withholding, but need not disclose specific information regarding the insurer’s investigation;
(b) Indicate that the payment is being withheld pursuant to the provisions of this section;
(c) Indicate that the payment is being withheld temporarily, as set forth in subsection 4, and describe the circumstances under which the withholding will be terminated;
(d) Specify the charge submitted by the provider of health care for which the payment is being withheld; and
(e) Notify the provider of health care of his right to appeal the withholding.
3. A provider of health care may appeal the decision of the insurer to withhold payment to an appeals officer pursuant to NRS 616C.360.
4. Any payment withheld pursuant to the provisions of this section must be made to the provider of health care if:
(a) The insurer or the Attorney General determines that there is insufficient evidence to prove that the provider of health care knowingly made a false statement or representation or knowingly concealed a material fact to obtain the payment; or
(b) A final judgment or decree was rendered in favor of the provider of health care in a criminal proceeding arising out of the alleged misconduct.
Last modified: February 25, 2006