New York Penal Law 177.25: Health care fraud in the first degree

New York Penal Law 177.25: Health care fraud in the first degree

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.

Examples
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.

Defenses
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.

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