Healthcare fraud is a kind of white collar crime that entails putting in false medical claims in order to get payments from a health plan or health insurance company. If a physician sends in a claim to an insurance company for a procedure that he or she never carried out in order to receive payment for that procedure and they do receive a payment from the insurance company, that physician would have committed health care fraud. Health care fraud can also be committed by dentists, pharmacists, chiropractors, ambulance business operators, as well as other employees or owners of companies who send insurance claims to health plans for payment. Five offenses related to health care fraud exist in the New York criminal code. They are health care fraud in the first, second, third, fourth and fifth degrees. The specific charge that you could be looking at depends on the amount of money you received as a result of the fraud in a single year. You could be charged with health care fraud in the fourth degree under New York Penal Code § 177.10 if you knowingly submitted falsified health insurance claims and, as a result, you received payments to which you were not entitled. For this charge to be valid, the amount of the payments you received fraudulently must be more than $3000 but less than $10,000 in a single year.
Dr. Marcus, an internal medicine physician, sent some bills to a particular insurance company. The bills indicated that he visited with, on average, about 50 patients a day. This number raised an immediate red flag at the insurance company. Under normal circumstances, it would be nearly impossible for a single doctor to see that many patients in a single day. After disbursing the payments on a few of the bills, the insurance company stopped sending payments and started an investigation into the matter. The firm’s accounting department discovered that many of the claims Dr. Marcus submitted were duplicated. In this scenario, Dr. Marcus could be convicted of health care fraud in the fourth degree. To get the conviction, the prosecutor would need to show that Dr. Marcus knowingly submitted duplicate bills and that the total amount of fraudulent claims for which he was sent payments was greater than $3,000.
Offenses that are Related
Health care fraud in the fifth degree: New York Penal Law § 177.05
Health care fraud in the third degree: New York Penal Law § 177.15
Health care fraud in the second degree: New York Penal Law § 177.20
Health care fraud in the first degree: New York Penal Law § 177.25
If you were not aware that you were submitting fraudulent claims, then you could not be convicted for health care fraud in the fourth degree. For example, if a technical issue resulted in your computer sending out the same claims multiple times, then there would not have been an intent to defraud and the charge would not hold.
You cannot be prosecuted under New York Penal Law § 177.30 for health care fraud if your position in a hospital, medical clinic or private practice office is bookkeeper, clerk or other employee besides a manager or physician, and you simply executed the orders of your superiours without gaining any personal benefit from the fraud.
The crime of health care fraud in the fourth degree is categorized as a class E felony offense. Should you are convicted of this offense, you could get sent to jail for up to 4 years. You could also get sentenced to up to 5 years of probation. The pecuniary consequences of a conviction may be that you will be obligated to pay restitution to the victim as well as a substantial fine to the court.
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