What Constitutes Healthcare Fraud in New York?

Healthcare fraud involves intentionally deceiving or misrepresenting information to obtain reimbursement or payments from government healthcare programs like Medicare and Medicaid. There are several degrees of healthcare fraud charges in New York:

• 1st Degree – Defrauding over $1 million in one year – Felony with 1 to 25 years in prison
• 2nd Degree – Defrauding up to $50,000 in one year – Felony with up to 15 years in prison
• 3rd Degree – Defrauding over $10,000 in one year – Felony with up to 7 years in prison
• 4th Degree – Defrauding over $3,000 in one year – Felony with up to 4 years in prison
• 5th Degree – Any amount defrauded – Misdemeanor with up to 1 year in jail

Common Healthcare Fraud Allegations

Some of the most common allegations of healthcare fraud include:

• Billing for services not performed – This involves billing for medical services, tests, or procedures that were never actually done.
• Upcoding – Billing for more expensive services than were actually performed to obtain higher reimbursements.
• Billing for unnecessary services – Performing and billing tests, services or procedures that are not medically needed.
• Identity theft – Using a patient or provider’s insurance information to submit fraudulent claims.
• Prescription fraud – Writing unnecessary prescriptions, altering prescriptions, or self-prescribing controlled substances.

Gathering Evidence and Building a Defense

The key to defending healthcare fraud charges is gathering evidence to show you did not intentionally commit fraud. An experienced attorney can help collect:

• Medical records – These show what services were actually provided and if they were medically necessary.
• Billing records – Review records for errors that led to incorrect billing.
• Witness statements – Interview staff to show billing was done properly per protocol.
• Expert opinions – Have other doctors review records to assess medical necessity.
• Compliance program – Demonstrate you had a program to prevent fraud and errors.

Common Defenses in Healthcare Fraud Cases

Some potential defenses your attorney may use include:

• Lack of intent – If errors were unintentional, it was not fraud.
• Billing mistakes – Show the wrong code was used or other clerical errors caused overbilling.
• Medical necessity – Have doctors testify services were necessary for proper care.
• Lack of knowledge – You were unaware of improper billing by staff members.
• Compliance program – Demonstrate efforts were made to comply with regulations.

Tips for Finding the Right New York Healthcare Fraud Lawyer

Finding an attorney experienced in healthcare law is crucial for building a strong defense. Consider these tips:

• Specialization – Find lawyers focused specifically on healthcare fraud, not general fraud.
• Experience – Look for extensive experience defending healthcare fraud cases.
• Resources – Choose a law firm with the resources to do a full investigation.
• Reputation – Select an attorney with a solid reputation and proven results.
• Communication – Find a lawyer who is responsive and explains things clearly.
• Strategy – Pick a lawyer who develops creative defense strategies tailored to your case.
• Fees – Discuss fee structures to find one that fits your budget.

What to Do If You Are Under Investigation

If you receive a subpoena or learn you are under investigation for healthcare fraud, be sure to:

• Consult an attorney – Do not speak to investigators without an attorney present.
• Preserve records – Do not destroy any records requested in the subpoena.
• Remain silent – Do not try to explain anything or make statements about the case.
• Review billing – Work with your lawyer to proactively review billing for errors.
• Cooperate – While asserting your rights, cooperate respectfully with the investigation.

Take Your Defense Seriously

Healthcare fraud convictions can result in enormous fines and years in prison, as well as loss of licensure and exclusion from government programs. Building an strong defense requires working diligently with an experienced attorney. Thoroughly investigate the facts of your case and understand the relevant healthcare regulations. With the right legal strategy and advocacy, many healthcare providers can resolve these cases favorably. Do not leave the fate of your practice and reputation to chance – consult a dedicated New York healthcare fraud lawyer.