Louisiana Revised Statutes 22:1924 – Prohibited activities and sanctions
Terms Used In Louisiana Revised Statutes 22:1924
- Claim: shall mean any request or demand for payment or benefit, whether paid or not, made by a person either in writing or filed electronically. See Louisiana Revised Statutes 22:1923
- Defendant: In a civil suit, the person complained against; in a criminal case, the person accused of the crime.
- Department: means the Department of Insurance. See Louisiana Revised Statutes 22:1931.1
- Fraud: Intentional deception resulting in injury to another.
- Fraudulent insurance act: shall include but not be limited to acts or omissions committed by any person who, knowingly and with intent to defraud:
(a) Presents, causes to be presented, or prepares with knowledge or belief that it will be presented to or by an insurer, reinsurer, purported insurer or reinsurer, producer, or any agent thereof, any oral or written statement which he knows to contain materially false information as part of, or in support of, or denial of, or concerning any fact material to or conceals any information concerning any fact material to the following:
(i) An application for the issuance of any insurance policy. See Louisiana Revised Statutes 22:1923
- knowingly: means that the person has actual knowledge of the falsity of the information or that the person acts in deliberate ignorance or reckless disregard of the truth or falsity of the information. See Louisiana Revised Statutes 22:1931.1
- Person: means any natural or juridical entity or agent thereof as defined in federal or state law furnishing or claiming to furnish a good, service, or supply who is compensated with insurance proceeds. See Louisiana Revised Statutes 22:1931.1
- Property: means any and all property, movable and immovable, corporeal and incorporeal. See Louisiana Revised Statutes 22:1931.1
- Restitution: The court-ordered payment of money by the defendant to the victim for damages caused by the criminal action.
- Statement: includes but is not limited to any notice, statement, proof of loss, bill of lading, receipt for payment, invoice, account, estimate of property damages, bill for services, diagnosis, prescription, hospital or doctor records, test results, x-rays, or other evidence of loss, injury, or expense. See Louisiana Revised Statutes 22:1923
A.(1)(a) Any person who, with the intent to injure, defraud, or deceive any insurance company, or the Department of Insurance, or any insured or other party in interest, or any third-party claimant commits any of the acts specified in Paragraph (2) or (3) of this Subsection is guilty of a felony and shall be subjected to a term of imprisonment, with or without hard labor, not to exceed five years, or a fine not to exceed five thousand dollars, or both, on each count.
(b) In addition to the criminal penalties provided in Subparagraph (a) of this Paragraph, the defendant shall make payment of restitution to the victim or victim company of any insurance payments to the defendant that the court determines were not owed and the costs incurred by the victim or victim company associated with the evaluation and defense of the fraudulent claim, including but not limited to the investigative costs, attorney fees, and court costs. However, if the amount of the benefit that is the subject of the criminal act does not exceed one thousand dollars, the term of imprisonment shall not exceed six months, and any fine shall not exceed one thousand dollars on each count.
(2) The following acts shall be punishable as provided in Paragraph (1) of this Subsection:
(a) Committing any fraudulent insurance act as defined in La. Rev. Stat. 22:1923.
(b) Presenting or causing to be presented any written or oral statement including computer-generated documents as part of or in support of or denial of a claim for payment or other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete, or fraudulent information concerning any fact or thing material to such claim or insurance policy.
(c) Assisting, abetting, soliciting, or conspiring with another to prepare or make any written or oral statement that is intended to be presented to any insurance company, insured, the Department of Insurance, or other party in interest or third-party claimant in connection with, or in support of or denial, or any claim for payment of other benefit pursuant to an insurance policy, knowing that such statement contains any false, incomplete, or fraudulent information concerning any fact or thing material to such claim or insurance policy.
(3)(a) Knowingly and willfully committing health care fraud shall be punishable as provided in Paragraph (1) of this Subsection.
(b) “Health care fraud” shall mean, in conjunction with the delivery of or payment for health care benefits, items, or services:
(i) To execute a scheme or artifice to defraud any health care benefit program.
(ii) To obtain, by means of fraudulent claims, or false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.
(c) For the purposes of this Paragraph, “knowingly and willfully” shall mean to continue with a practice, after written notice to cease such practice from a health care benefit program by certified mail, return receipt requested, except when the health care provider reasonably believes that such practice materially complies with coding or billing standards as issued by the American Medical Association, the United States Department of Health and Human Services, the Centers for Medicare and Medicaid Services, or the Louisiana Medicaid Program.
B. The criminal provisions of this Section shall be investigated, enforced, or prosecuted only by the proper law enforcement and prosecutorial agencies.
Acts 1992, No. 707, §2; Acts 2001, No. 1158, §1; Acts 2008, No. 15, §1; Redesignated from La. Rev. Stat. 22:1243 by Acts 2008, No. 415, §1, eff. Jan. 1, 2009; Acts 2010, No. 632, §1; Acts 2019, No. 83, §1, eff. July 1, 2019.