New York Penal Law 177.10 Health Care Fraud in the Fourth Degree Lawyer

What Prosecutors Must Prove

Using the New York statutory framework and the Criminal Jury Instructions approach, prosecutors must be able to prove each required element beyond a reasonable doubt. For New York Penal Law 177.10, the proof usually focuses on the following:

1. that the accused acted with intent to defraud a health plan;
2. that the accused knowingly and willfully provided materially false information or omitted material information;
3. that the information or omission was used to request payment for a health care item or service;
4. that a payment was received that the recipient was not entitled to under the circumstances; and
5. that the wrongfully received payment from a single health plan within the statutory period exceeded $3,000.

The proof is not just whether an insurer, health plan, investigator, or agency thinks something looks suspicious. The government must prove the charged mental state, the material falsehood or omission, the connection to payment or benefits, and the statutory dollar threshold where the degree requires one.

How This Charge Can Come Up

A felony health-care fraud allegation may arise from billing disputes involving Medicaid, Medicare-related plans, private insurers, treatment records, coding, durable medical equipment, therapy services, or provider documentation.

Fraud cases frequently begin before an arrest. A person may first receive a call from an investigator, a subpoena, an insurance SIU inquiry, an audit request, a letter from a government agency, an employer inquiry, or a request for documents. Early defense involvement can help control statements, preserve helpful records, and prevent a civil or administrative issue from becoming worse.

Defense Issues in Health Care Fraud Cases

• The amount does not meet the felony threshold.
• Payments were not wrongfully received.
• The billing records are incomplete or misunderstood.
• The prosecution cannot prove a knowing and willful false submission.
• Compliance problems are being recast as criminal intent.

Depending on the case, the defense may also involve forensic accounting, expert review of billing or claim practices, suppression motions, subpoena challenges, witness investigation, restitution negotiations, licensing strategy, immigration analysis, and careful handling of any parallel federal inquiry.

Sentencing, Restitution, and Collateral Consequences

Health Care Fraud in the Fourth Degree Lawyer is charged as a Class E felony. Beyond the statutory criminal exposure, these cases can involve restitution, civil recovery, asset restraint or forfeiture, exclusion from programs, professional discipline, employment consequences, immigration issues, and long-term reputational harm.

For professionals and business owners, the goal is not only to address the courtroom case. The defense should also consider licenses, credentialing, employment records, public reputation, search results, and whether the case can be narrowed or resolved before it causes wider damage.

Why Contact Lebedin Kofman LLP

Russ Kofman and Lebedin Kofman LLP handle serious criminal matters, fraud investigations, federal cases, asset issues, DWI cases, Title IX matters, and high-stakes allegations where employment, licensing, and reputation are on the line. The firm works to identify proof problems early, challenge overbroad allegations, and position cases for dismissal, reduction, trial, or strategic resolution.

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If you are under investigation, received a subpoena, were contacted by an insurer or health plan, or were arrested for health care fraud, early legal representation can affect the direction of the case.

Source basis: NY Senate Penal Law 177.05 and 177.10; NY Courts CJI Article 177 framework. Prior results do not guarantee a similar outcome. Every case is unique and must be evaluated on its own facts and circumstances.