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

Health care fraud is a white collar crime criminal offense that involves submitting false medical claims to a health plan in order to receive payment. A health plan is defined as any health insurance or managed care plan or contract under which a health care item or service may be provided. Medicaid is included in this definition. The person committing the fraud could be a doctor, dentist, chiropractor, pharmacist, or even the operator of an ambulance service. Furthermore, the person could also be the owner or manager of a health care provider who was responsible for billing. For example, working in concert with a doctor the billing manager sends in false claims to a health plan. When the payments are received, the doctor and the billing manager split them.

Under New York Penal Law § 177.25 you could be charged with health care fraud in the first degree if you knowingly submit false a health care claim or several heath care claims, and as a result you receive payments to which you are not entitled. The amount of payments must be from a single plan, must have occurred in the space of no longer than a year, and must total more than $1,000,000.

Example

Dr. Janice Leeds was an orthopedic surgeon. She regularly submitted bills to health plans that were for procedures that she never performed. Her office manager, Sedra, was responsible for the billing. While Sedra had suspicions that Leeds was submitting fraudulent bills, she was scared to question Leeds about them. The fraud went on for over 3 years, resulting in over $2 million in payments to Leeds. Eventually both Leeds and Sedra were arrested and charged with health care fraud in the first degree.

The prosecutor will have a hard time with the health care fraud case against Sedra as there is no evidence that Sedra benefited from Leeds' scheme, but that in submitting the fraudulent claims she was simply doing what she was told to do. In addition, if the total payments that occurred in the space of a year was less than $1 million, then the prosecutor would have a difficult time sustaining a first degree fraud charge against Leeds. However, the prosecutor could still charge Leeds with health care fraud in the second, third, fourth or fifth degree.

Related Offenses
  1. Health care fraud in the fifth degree: New York Penal Law § 177.05
  2. Health care fraud in the fourth degree: New York Penal Law § 177.10
  3. Health care fraud in the third degree: New York Penal Law § 177.15
  4. Health care fraud in the second degree: New York Penal Law § 177.20
Defenses

In order for you to be convicted of health care fraud in the first degree, the prosecutor must have proof that you received payments for fraudulent claims from a single health plan in a single year that totaled more than $1,000,000. If there were over $1 million in payments but they were made to more than one health plan, or if they occurred over a period of more than a year, then you may have a valid defense against a charge of health care fraud in the first degree.

Sentence

Health care fraud in the first degree is a class B felony. If you are convicted of this offense you could be sent to probation for up to 25 years. The financial consequences of a conviction may be that will be required to pay restitution as well as a substantial fine.

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

A person is guilty of health care fraud in the first degree when such person, on one or more occasions, commits the crime of health care fraud in the fifth degree and the payment or portion of the payment wrongfully received, as the case may be, from a single health plan, in a period of not more than one year, exceeds one million dollars in the aggregate.

Contact the Law Offices of Stephen Bilkis & Associates

If you are under investigation for health care fraud in the first degree it is important that you immediately seek experienced representation, even if you have not been charged. The staff at the Law Offices of Stephen Bilkis & Associates has years of experience successfully defending clients in New York criminal courts who have been charged with fraud, grand larceny, white collar crimes, and other serious crimes. Contact us at 1-800-NY-NY-LAW (1-800-696-9529) to schedule a free, no obligation consultation regarding your case. We serve those accused of larceny in the following locations: the Bronx, Brooklyn, Long Island, Manhattan, Nassau County, Queens, Staten Island, Suffolk County and Westchester County.

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