Healthcare fraud is a 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. Health care fraud usually takes the form of a doctor submitting claims to an insurance company for services that were never provided to patients, and then receiving payment form the insurance company. Another example is a pharmacist submitting claims to an insurance company for medications never provided or for medications provided to someone other than the person listed in the claim.
There are 5 offenses related to health care fraud: health care fraud in the first, second, third, fourth and fifth degrees. The specific crime that you will face depends on the amount of money received from a health plan as a result of the fraud. Under New York Penal Law § 177.20 you could be prosecuted for health care fraud in the second degree if you knowingly submit false a health care claim or heath care claims, and as a result you received payments to which you were not entitled from a single plan that total more than $50,000, but not more than $1,000,000.
ExampleDr. Mark Kelly was an orthopedic surgeon. Seeking ways to boost his income he started to perform unnecessary surgeries on patients and billing insurance companies. After a number of complaints were filed against Kelly for botched surgeries, investigators began to look into Kelly's practice and discovered that he was performing unnecessary procedures. If the amount of money that he received from insurance companies for unnecessary procedures totaled more than $50,000, but not more than $1,000,000, then Kelly could be prosecuted for health care fraud in the second degree.
Related OffensesIn order for you to be convicted of health care fraud in the second degree, the prosecutor must have proof that you received payments for fraudulent claims from a single health plan that totaled more than $50,000, but not more than $1,000,000. If the prosecutor is unable to produce solid evidence of the amount of payments involved, then you may have a valid defense against the charge. For example, if the prosecutor submits that you received payments of between $300,000 and $500,000, the range may be too vague to sustain a charge of health care fraud in the second degree.
Furthermore, under New York Penal Law § 177.30 you cannot be prosecuted for health care fraud in the second degree if you were a bookkeeper, clerk or other employee who is merely following orders without receiving any personal benefit.
SentenceHealth care fraud in the second degree is a class C felony. If you are convicted of this offense you could be sent to prison for up to 15 years. You could also receive a probation sentence of up to 5 years. In addition, the financial consequences of a conviction may be that you will be required to pay restitution as well as a substantial fine.
New York Penal Law § 177.20: Health care fraud in the second degreeA person is guilty of health care fraud in the second 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 fifty thousand dollars in the aggregate.
Contact the Law Offices of Stephen Bilkis & AssociatesIf you are under investigation for health care fraud in the second degree it is imperative that you immediately seek experienced representation. A health care fraud conviction will not only jeopardize your career and cause you and your family great financial stress, it may also result in you going to prison. 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 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.