Healthcare Fraud - NYPL § 177
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Healthcare fraud refers to an act committed with the intent to defraud a health plan, such as an insurance company or a government-funded healthcare program. Healthcare fraud encompasses various fraudulent activities related to healthcare services and benefits, typically involving the submission of false or misleading information to obtain unauthorized payments or benefits.
Healthcare fraud is considered a white-collar crime because it shares several characteristics and attributes commonly associated with this category of criminal activity. White-collar crimes typically involve non-violent, financially motivated offenses. Regardless of this definition, healthcare fraud is punished severely in New York and even just being accused of this crime can have long-standing consequences.
Healthcare fraud allegations can disrupt not only your personal life but also your professional career, reputation, and financial stability. In such challenging times, it’s crucial to have a knowledgeable and skilled New York fraud attorney by your side to protect your interests and navigate the complexities of the legal system.
Related Offenses:
Case Example
Dr. Smith, a practicing physician, knowingly bills Medicaid for services not rendered. He submits inflated claims for multiple patient visits, medications, and procedures that never occurred. Dr. Smith’s actions resulted in Medicaid overpaying him by thousands of dollars. This scenario constitutes health care fraud under New York law, as Dr. Smith engaged in a fraudulent scheme, made false representations, and intended to receive unauthorized benefits. In this case, the degree of the charges applied would be dependent on the total amount defrauded from Medicaid.
Elements and Definitions
Understanding the elements and definitions of healthcare fraud is crucial for both defendants and legal professionals.
Elements of Health Care Fraud in New York:
- The defendant knowingly and intentionally engaged in a fraudulent scheme.
- The defendant made false representations, statements, or omissions related to health care benefits or services.
- The fraudulent acts were committed with the intent to receive unauthorized benefits, payments, or services that they are not entitled to under their circumstances.
Definitions:
- Fraudulent Scheme: Any deceitful or dishonest plan or course of action designed to obtain unauthorized benefits from a health care provider or payer.
- False Representations: Statements, claims, or information that are intentionally inaccurate or misleading.
- Health Care Benefits/Services: Encompasses medical treatments, prescriptions, insurance claims, and any other health-related financial transactions.
Defenses
A possible defense that could be used against charges of healthcare fraud is a lack of knowledge. The law does not intend to punish cases of human error and a person who displays a lack of knowledge or intent to defraud a healthcare provider may be able to use this defense. Being coerced into committing fraud can also be a possible defense.
In addition, according to New York Penal Law § 177.30, an employee or bookkeeper may also not be prosecuted for healthcare fraud if they were only following the instructions of their employer.
Related Offenses
Healthcare fraud charges in New York span from Fifth Degree Health Care Fraud to First Degree Health Care Fraud. Each degree represents a varying level of severity in the offense.
NYPL § 177.05: Fifth Degree Health Care Fraud
A person is guilty of healthcare fraud if he or she knowingly and willfully provides false information to defraud a health plan of an amount not exceeding $3000 in a year.
Healthcare fraud in the fifth degree is a class A misdemeanor in New York. A conviction can result in imprisonment for up to a year, probation, and payment of a fine.
NYPL § 177.10: Fourth Degree Health Care Fraud
Healthcare fraud in the fourth degree involves committing the same act as fifth-degree healthcare fraud with the defrauded amount exceeding $3000 but not exceeding $10,000 in a single year.
Healthcare fraud in the fourth degree is a class E non-violent felony in New York. A conviction can result in 16 months up to four years in prison, probation, and payment of a fine
NYPL § 177.15: Third Degree Health Care Fraud
A person is guilty of healthcare fraud in the third degree if he or she knowingly and willfully defrauds a health plan of an amount exceeding $10,000 but not exceeding $50,000 in a single year.
Healthcare fraud in the third degree is a class D non-violent felony in New York. A conviction can result in 28 months up to seven years in prison, probation, and payment of a fine
NYPL § 177.20: Second Degree Health Care Fraud
A person is guilty of healthcare fraud in the second degree if he or she knowingly and willfully provides false information and defrauds a health plan of an amount exceeding $50,000 but not exceeding $1,000,000 in a single year.
Healthcare fraud in the second degree is a class C non-violent felony in New York. A conviction can result in imprisonment with a minimum of 5 to up to 15 years in prison, probation, and payment of a fine.
NYPL § 177.25: First Degree Health Care Fraud
A person is guilty of healthcare fraud in the first degree if he or she knowingly and willfully provides false information to defraud a health plan of an amount exceeding $1,000,000 in a single year.
Healthcare fraud in the first degree is a class B non-violent felony in New York. A conviction can result in imprisonment for up to 25 years, probation, and payment of a fine.
Working with a Skilled New York City Healthcare Fraud Attorney from Lebedin Kofman LLP
Healthcare fraud charges can be particularly complex, carrying severe penalties and long-lasting consequences for those accused. When facing such allegations in Manhattan, having a skilled healthcare fraud attorney from Lebedin Kofman LLP by your side can be a game-changer.
Our experienced legal team understands the nuances of healthcare fraud laws and the intricacies of the healthcare industry. We are committed to safeguarding the rights and interests of individuals facing these charges. From meticulous case analysis to strategic defense planning, our attorneys are dedicated to providing the highest level of representation.
At Lebedin Kofman LLP, we recognize that every case is unique, and we tailor our approach to meet the specific needs of our clients. We work tirelessly to build strong defenses, negotiate with prosecutors, and, when necessary, vigorously advocate in court.
Your future and reputation are at stake, and we are here to help you navigate the legal challenges ahead. With a skilled Manhattan healthcare fraud attorney from Lebedin Kofman LLP on your side, you can trust that your rights will be protected, and every avenue for a favorable resolution will be explored.
Experienced Medicaid Fraud Attorney NYC | Lebedin Kofman LLP | New York City Health Care Fraud Attorneys
Under 18 USC §1347, anyone who knowingly and willfully executes a scheme to defraud any healthcare benefit program or to obtain by means of any false or fraudulent pretenses or promises any money of a healthcare benefit program in connection with the delivery of or payment for healthcare benefits is guilty of healthcare fraud.
In other words, if an individual lies to get paid by Medicare, Medicaid, or any other health insurance company, then he or she is guilty of healthcare fraud.
The government may prosecute an individual for healthcare fraud in many different ways. It may allege that an individual did not provide the services claimed or that the services rendered were not medically necessary. Additionally, it may allege that the individual charged more for the services rendered or that the services were based upon an illegal kickback arrangement.
Lebedin Kofman LLP has a team of experienced Medicaid fraud lawyers and legal professionals who may be able to provide you with a solid defense strategy. Medicaid fraud attorney Arthur Lebedin and criminal defense attorney Russ Kofman are skilled at dealing with criminal offenses. If you want to learn more about your case and how our healthcare fraud attorneys in Manhattan and throughout New York City can assist you, contact us today at 646-663-4430 or contact us online.
Medicaid Fraud Lawyer Explains the Types of New York Medicaid Fraud Offenses
To be convicted of healthcare fraud, the prosecution must be able to prove two elements:
- That there was a scheme to defraud or obtain money from a healthcare benefit program in connection with the delivery of or payment for healthcare benefit items or services; and
- That the defendant knowingly and willfully executed or attempted to execute the scheme.
- Fraudulent healthcare schemes come in many forms.
Some of the common forms include:
- Medical identity theft
- Billing for unnecessary services or items
- Billing for services or items not furnished
- Up-coding
- Unbundling and
- Kickbacks
At the law firm of Lebedin Kofman LLP, health care fraud attorney Russ Kofman and his team of lawyers may be able to provide you with the skilled legal representation you need. To learn more about how we can help with Medicaid fraud cases, contact us today. We may be able to provide you with more information about your NYC Medicaid fraud case.
Medical Identity Theft
Medical identity theft involves the misuse of a person’s medical identity to wrongfully obtain healthcare goods, services, or funds.
It is defined as “the appropriation or misuse of a patient’s or provider’s unique medical identifying information to obtain or bill public or private payers for fraudulent medical goods or services.” Stolen physician identifiers can be used to fill fraudulent prescriptions, refer patients for unnecessary additional services or supplies, or bill for services that were never provided.
The Social Security Act
The Social Security Act allows states to place limits on services based on criteria such as medical necessity.
Providers must ensure that the authorized services rendered meet the definition of medical necessity according to the law of the state in which they practice. Intentional billing of unnecessary services or items can lead to a conviction of healthcare fraud. Similarly, providers may not bill Medicaid for a covered service or item if they did not deliver the service or item. If a provider bills for something that is not medically necessary, not authorized, or an item not actually furnished, it may lead to a conviction of healthcare fraud.
Up-Coding
Up-coding is understood as billing for services at a level of complexity that is higher than the service actually provided or documented in the file.
Providers must only bill for the level of services or items actually furnished. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code. In a case where unbundling has occurred, the reimbursement for the individual codes billed separately is higher than the reimbursement for the single comprehensive code that should be used.
Kickbacks
Kickbacks are defined as offering, soliciting, paying, or receiving compensation to induce, or in return for a referral of patients or the generation of business involving any item or services for which payment may be under federal healthcare programs. Kickbacks are illegal when it comes to federal healthcare programs because they can lead to overutilization, increased program costs, corruption of medical decision-making, patient steering, and unfair competition.
Legislations on Fraud and Abuse
There are many federal laws applicable to doctors and other medical professionals. The best way to fully comprehend these laws, a Medicaid fraud attorney in New York City may be the best option. The following laws are:
- Federal False Claims Act, (FCA).
- Anti-Kickback Statute
- Criminal Health Care Fraud Statute
- Stark Law: The Physician Self Referral Law
- The Exclusive Statute
- Civil Monetary Penalties Law
Abuse and Fraud in the Provider Industry
All medical providers are considered providers. This includes hospitals, doctors, nurses, labs, imaging centers, and any other health care professional. All providers are subject to federal law, which can result in denials of claims and fines as well as criminal prosecutions. Insurance is another category of individuals and businesses that could be harmed by Medicare or Medicaid fraud. The following are common examples of Medicaid or insurer Medicare fraud:
- Over-priced services
- Misrepresented health benefits
- Inadequate valuation of the amounts owed to the insurance company by a provider of health care
- Refusing to accept valid claims
NYC Criminal Defense Attorneys Explain: Making a Mistake Vs. Fraud
It is important to differentiate between health care fraud and mistakes, omissions, or improper payments. A person can commit fraud if they are aware that they have engaged in a scheme, plan, or activity to fabricate falsehoods with the intention of gaining money. Fraud does not include, for instance, making a mistake and resulting in a patient being charged for treatment that he or she didn’t receive. Health care fraud is when a provider of health care knowingly offers unnecessary procedures or treatments and then bills the insurer for them.
What Are the Penalties for Health Care Fraud?
A conviction under 18 USC §1347 can have serious consequences. Healthcare fraud is punishable by a prison sentence of up to 10 years. A criminal penalty can result in fines, imprisonment, and an order for restitution. This is to compensate the victim for any loss of money due to the fraud. Civil penalties usually result in an order to pay restitution but no jail time or fines.
Anyone convicted of criminal health care or Medicaid fraud can face serious consequences, at both the federal and state levels.
- Prison. Long sentences can be handed out for health care or Medicaid fraud. False statements regarding a Medicare or Medicaid claim can lead to a five-year sentence, while a federal conviction for health care or Medicaid fraud could result in a 10-year sentence. A sentence of up to 20 years imprisonment is possible for health care or Medicaid fraud that causes serious bodily injury. An act of health care theft that causes death could result in a life sentence.
- Fines. A person convicted of healthcare fraud is also subject to severe penalties. False claims in Medicare or Medicaid can result in a $250,000 fine, and organizations that make false claims could face a $500,000 penalty. Organizations involved in schemes that involve multiple counts of fraud in the health care system could face fines of millions or even billions of dollars.
- Restitution. A judge can order defendants who have committed criminal fraud to repay the money they wrongfully obtained. A doctor who incorrectly charged an insurance company for tests that were not performed can be ordered by the judge to repay this money to the company. In addition to a fine, restitution can also be paid to the government.
- Probation. A person convicted of health care fraud can also be subject to probation. Instead of sending someone to prison, probation allows them to limit their freedoms. Although probation lasts for 12 months, sentences up to three years are possible. Probation officers must be present at all times, maintain employment, and not associate with felons.
Getting the Help of Skilled NYC Medicaid Fraud Attorneys Against Medicaid Fraud Charges
Being charged with health care fraud can be daunting. It can have a huge impact on your life and risk the possibility of losing your job and professional license. A conviction of health care fraud can also be sentenced to jail time and huge fines. This is why it is important to seek the help of experienced criminal defense attorneys who may be able to help you protect your freedom and receive a more favorable outcome for your case.
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