Health care fraud is considered a white collar crime, which involves a submission of false medical claims to receive payments from an insurance company or health plan.
Under New York Penal Code § 177.05, a person is guilty of committing health care fraud in the fifth degree when with intent, she or he knowingly and willfully gives false information materially or by omission to receive payment from a health plan for an item or service.
Whether it is for the person submitting the false claim, or for someone else, receiving the benefits of something for which they are not entitled is a crime.
What Constitutes Health Care Fraud in the Fifth Degree in New York?
Before winning a conviction, the prosecution must, beyond a reasonable doubt, prove each one of the following:
• You knowingly and willfully either provided information that was false or you omitted information for the sole purpose of requesting and receiving payment from a health insurance plan for a service or item.
• You did so with the intent to defraud the health insurance plan.
• As a result of the omitted or falsely submitted information, you or someone else received a payment amount that you were not entitled to receive.
For the purpose of this statute, a “person” is not defined as the recipient of the item or service under a health insurance plan. An exception is if the patient was an accessory to the individual o entity who received the payment.
Examples of Violating Penal Code 177.05
One example of committing health care fraud in the fifth degree is a chiropractor who has hit a slow period in his business. To make up for the loss in revenue, the chiropractor inflates the bills he submits to health plans for services rendered. He may do this in a variety of ways such as billing for:
• services he never provided
• services that are not reimbursable
• services fully provided
In an attempt to avoid getting caught, he submits small amounts of fraudulent claims. However, he was caught and can face charges of health care fraud in the fifth degree if the total payments he received payments were less than $3,000.
Defense for Being Charged with Health Care Fraud in the Fifth Degree
If the defendant can prove that their position was as a bookkeeper, clerk or any other position where they received no personal benefit from the fraud, but only executed their superior’s orders, the law recognizes an affirmative defense against the charge.
Employees who have active control and management responsibilities, and serve in an executive capacity within the corporation cannot use the affirmative defense.
Sentencing after Conviction
As a Class A misdemeanor, being convicted of health care fraud in the fifth degree can lead to a sentence of up to one year in jail. You could also receive three years’ probation. A conviction or guilty plea means you will most likely be required to pay restitution along paying up to $1,000 in a fine. The alternative amount required could be twice the amount of the financial gain from committing the crime.
Contact the Spodek Law Group Today!
The fact that health care fraud in the fifth degree is not a felony does not mean it is a charge that you should not take seriously. Not only can you face jail time after being convicted, but you may also put your career and reputation in jeopardy.
The NYC criminal attorneys at Spodek Law Group have successful years of defending clients in New York’s criminal courts who were charged with different white collar crimes, including fraud. Contact our law firm today to schedule a no obligation consultation to discuss your case.