What Is First-Degree Health Care Fraud?
This is a crime that is often considered to be white collar. It typically involves doctors and those who work in the field of healthcare. However, it crimes could also involve those who receive healthcare benefits and offer information that is not true in order to receive those benefits. In most situations, heath care fraud involves a turning in medical claims that have been falsified in order to get more money for the services that are provided in a hospital or an office. The health plan that the claims are submitted to could be a government office or an insurance company, such as medicaid.
Anyone in the health care field can commit health care fraud. Doctors, dentists, pharmacists and those who provide emergency services all fall into the category of people who can be charged with the crime. A manager of a healthcare facility could also be held responsible for committing the fraud in question.
A common example of health care fraud is when a doctor submits a claim for more services or procedures that are performed for a patient who is on Medicaid in order to get more money. From testing for illnesses to lab work that is unnecessary, doctors will often file for more money to be received from Medicaid than they would with a private insurance company.
A billing manager could work with a doctor to send in claims so that the business could make more money. When that money is received, then the doctor and the manager would split the amount. Others who are involved would get a portion of the money as well as long as they wouldn’t say anything about the false claims. This is sometimes how doctors and managers keep employees working for the office or hospital. They are paid off with money received from the false claims in exchange for their silence.
Another example would be of a surgeon who bills claims for surgeries that were never even performed on patients. The office manager might be suspicious of the claims but goes along with the billing in order to keep her job. Over the course of a few years and several thousands of dollars, the fraud continues until both the doctor and the manager are arrested. They are both charged with fraud because they both knew about the claims and filed for the money to be received from insurance companies or government services. In this situation, the prosecution will need to determine that the manager benefited from the claims that the doctor filed. A first-degree charge would be difficult if the claims were filed for less than a year and if the claims were for less than $1 million. Charges for first-degree fraud are typically seen if the claims are filed for longer than one year, even if it’s to multiple plans or companies.
A NYC criminal attorney could use the defense that the billing manager didn’t know about the false claims and only went along with filing for the money because it was part of the job. The attorney would also be able to use the defense that there wasn’t as much money received over the course of time declared by the prosecution, as the $1 million threshold must be met in order to achieve first-degree status.
Health care fraud involves submitting false claims in medical partitioning to a health plan to receive a payment. A health plan is defined as a managed care plan, any health insurance, or any contract under the health care service or item provided. This definition is also included in Medicaid. Healthcare fraud can be committed when a doctor submits false claims to an insurance company for service that patients did not receive. In the end, the patients receive that money from the insurance firm as compensation. Another example can be from a pharmacist submitting false claims in an insurance company for medication provided to someone other than the listed in the claim or services not provided to the person.
Healthcare fraud has more than five related offenses. They include the healthcare fraud in the second, first, third, and fourth degrees. The specific amount of money received from the insurance firm will determine the degree of a crime. You will be charged as a result of committing the crime. Under the New York Penal Code 177:20, you could face prosecution for the second-degree health care fraud if you submit false information to an insurance firm knowingly. As a result of that action, you receive a payment that you are not entitled to receive. The amount of money you receive must be more than $50,000. However, it must not exceed $1,000,000.
Dr. Mark Kelly is one of the most prominent orthopedic surgeons. When he wanted to find ways to increase his income, he started billing insurance companies after performing unnecessary surgeries on the patients. For botched surgeries, he started receiving numerous complaints against his service. Investigators began searching his practice to find more evidence of what he was doing. If the amount of money he charged the insurance officers was not exceeding $1,000,00 and not less than $50,000, he could face prosecution for the third-degree health care assault.
1. First-degree health care fraud: New York penal law 177:25
2. Third-degree health care fraud: New York Penal Law 177:15
3. Fourth-degree health care fraud: New York Penal Law 177:10
4. Fifth-degree health care fraud: New York Penal Law 177:05
For you to face conviction for second-degree health care fraud, the prosecutor must prove that you received fraudulent claims from a healthcare medical facility that does not total less than $50,000. In this case, the money must also not exceed $1,000,000. You might have a defense against these charges if the prosecutor fails to provide enough evidence against this case. For instance, he might provide evidence that suggests you received $2,000,000. That is a big difference that eliminates this crime.
Second-degree health care fraud is a class C felony. You could face a 15-year prison term if you are convicted of the second-degree health care offense. A five-year jail probation term is also applicable to this sentence. Moreover, you can also pay a substantial amount of fine or restitution under this charge.
The nyc criminal attorneys Law Firm
You must consider contacting an experienced lawyer if you are under investigation for the second-degree health care fraud charge. While this conviction will ruin your career, it will also lay great financial stress on your family. You can also face a prison term as a result of these charges. The staff at NYC Criminal Attorneys Law Firm has many years of professional experience in defending clients in New York Criminal Courts. For a free consultation session, please contact us to speak with an experienced attorney.
Health care fraud is considered as a white collar fraud that has the inclusion of submitting false medical claims that will land you in the reception of payment from a health insurance company or a health care plan. This type of crime is charged to a doctor, a chiropractor, a dentist, or a pharmacist for submitting false claims to an insurance company for products, services, or medication that was never administered to the patient. Health care fraud has five offenses concerning this crime. They include the health care fraud in the first, fourth, second, fifth, and third degree. According to the New York penal code, the crime you will face depends on the amount of money you receive from the medical or insurance firm.
Under the New York Penal Code 177:15, you are likely to commit a third-degree health care fraud if you submit false information to the insurance firm intentionally. For this reason, you will receive this amount as entitled to the false claims. For you to be charged with the third-degree health care fraud, you must have received an amount between $10,000 and $50,000. This money must not exceed the one stated above.
Andrew is a prominent pharmacist in the city. It was rumored to the police that he sold prescribed drugs to people who were not entitled to receive that medication. For this reason, an investigation was launched by the police. The undercover police officers, on three different occasions, went to his pharmacy and asked to purchase Valium, Ritalin, codeine without any prescriptions. For this reason, he transacted with them. Based on this action, the police issued a search warrant on his pharmacy. According to the stated investigations, Andrew dispensed drugs using false drug prescriptions. This was an illegal act according to the law. He was charged with a third-degree health care fraud because he had received more than $45,000 in payments from the fraudulent missions in a single health plan.
1. First degree health care charge: New York State Code 177.25
2. Second degree health care charge: New York State Code 177.20
3. Fourth degree health care charge: New York State Code 177.10
4. Fifth degree health care charge: New York State Code 177.05
For you to face conviction in the third-degree health care fraud, the prosecutor must provide evidence that you received fraudulent claims and payments from a health plan that totaled between $10,000 and $50,000. You could not be convicted of that crime if you never received the money from the insurance firm even if they were not legitimate.
Moreover, you cannot also be convicted of the third-degree health care charge if you submitted the fraudulent claims unknowingly. For instance, there will be no fraud if the mistake made in calculation resulted in a computer error.
Third-degree health care charge is a class D felony. You might face a seven-year prison term if you are convicted of this offense. You can also face a five-year probation term in jail. You would pay a fine if you received that money from the health care plan.
The NYC Criminal Attorneys Law Firm
If you are facing investigation for the third-degree health care fraud, it is always important that you seek advice from an experienced legal practitioner. If you are convicted of the third-degree health care plan, your career will be in jeopardy. Moreover, you will spend quality time in prison away from friends and family. The staff at nyc criminal attorneys Law Firm has numerous years of legal experience in representing their clients in the New York Criminal Courts. For a free representation session, please contact us to talk to an experienced legal representative.
Insurance fraud is a serious crime that has been on the rise in recent years. This is a type of white collar crime that involves submitting false claims to an insurance company in an effort to collect money by fraudulent means. There are five different levels to health care fraud. Which penal code you are charged with depends on the amount of money involved. The potential consequences of each sentence depends on which level of crime you are charged with. The more money that is involved, the more serious the crime and the greater the consequences. New York Penal Code 177.10 addresses health care fraud in the fourth degree and is considered a class E felony. It is important to understand the different terms used, the law itself, and any potential defenses if you are charged with a violation of code 177.10.
Penal Code 177.10: Health Care Fraud in the Fourth Degree Broken Down
New York Penal Code 177.10 states a person is guilty of fourth degree health care fraud when they knowingly and willfully provide false information or omit material information to a health care plan with the intention of receiving a payment that they are not otherwise entitled to. Over a period of one year the amount fraudulently received must be over $3,000 but less than $10,000. It can be one claim or a combination of claims over a 12 month period.
The term “person” can mean either an individual or an entity and anyone who acts as an accessory to the individual or entity filing a false claim.
The term “health care plan” means any publicly or privately funded health insurance that makes payment for claims filed by the person supplying the medical service. New York State’s medical assistance program, medicaid is considered a health care plan under this law.
This code can be violated by doctors, dentists, chiropractors, physical therapists, ambulance companies, or any other health care provider who submits claims for insurance reimbursement.
Doctor A submits double claims to an insurance company to receive double payment for the same service. If he received more than $3,000 but less than $10,000 he could be convicted of a violation of penal code 177.10.
There has to be knowing and willful intent to commit fraud for this charge to hold up in a court of law. If, for example, the computer system or insurance claims clerk sent double billings in error, this would be a defense. As soon as the error was detected, the doctor would need to notify the insurance company and pay back the double payment.
In addition, if a claims clerk or bookkeeper was just following orders and didn’t realize that they were filing double or fraudulent claims and didn’t receive any personal benefit, they wouldn’t be held responsible because the “knowing” clause wouldn’t be there.
A violation of Penal Code 177.10 is considered a class E felony. Conviction could result in a prison sentence of up to 4 years, probation of up to 5 years, restitution, and a fine. Even more serious could be the damage to your professional reputation. Your medical business could suffer with a loss of patients and patient trust. The most important thing to do if you are ever facing a charge of health care fraud in the fourth degree is to contact a New York defense attorney experienced in cases such as these. A good attorney will look at the detail of your case and mount the best defense possible to get the charges either dropped or reduced.
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.
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