Related Nevada Regulations: Workers’ Compensation, Insurance, and Business Practice Rules
Workers’ compensation and insurance
This domain tests payor rules that surround clinical care. Nevada workers’ compensation and insurance requirements can determine whether treatment is authorized, paid, and documented.
- For injured workers, verify claim acceptance and authorization before non-emergency treatment. Follow the Nevada workers’ compensation treatment guidelines, fee schedule, and reporting requirements; document mechanism of injury, objective findings, diagnosis, and work status.
- Do not misrepresent services or diagnoses to obtain payment. Claims must be accurate, and records must support the billed codes.
- Insurance: submit accurate claims, respond to requests, and follow prompt-payment and appeal rules. Balance billing and patient responsibility depend on the plan and contract.
- Business practice: use a proper professional entity, register any fictitious name, maintain required licenses, and keep business and clinical records consistent.
Worked example
An injured worker’s claim is denied, but the patient wants treatment today and asks you to bill it as a “routine office visit.” That is insurance fraud and misrepresentation. The correct path is to treat only under an accepted self-pay arrangement with clear disclosure, or wait for authorization, and document the status accurately.
Traps
Treating without authorization and hoping for retroactive payment; upcoding; failing to document work restrictions; ignoring the fee schedule; using a business name not registered with the Board. Payment rules do not change clinical scope, but they do create independent violations.