In 2010, the Department of Health and Human Services implemented the H.E.A.T. Taskforce, which stands for Health Care Fraud Prevention and Enforcement Action Team, in order to combat the growing problems with health care fraud involving government benefit recipients. Since then, the government and law enforcement has made great strides in identifying and eliminating health care fraud, which costs taxpayers billions of dollars annually. However, with this newfound dedication to eliminating wasteful spending and unnecessary payouts comes the increasing instance of wrongful prosecutions, unlawful searches and unrelenting harassment of those in the health care industry, particularly doctors, office managers and hospital management corporations. If you are one of the thousands of members in the health care industry facing a possible fraud investigation, indictment or charge, a New York Health Care Fraud Attorney can help you combat the state’s charges and protect your business.
What Is Health Care Fraud?
Article 177 of New York Penal Law addresses the crime of health care fraud. The statute contains a number of prohibited activities involving health care, and crimes are categorized according to degree. The following list describes the health care fraud laws in New York, beginning with the most severe.
Health care fraud in the first degree: This is a “B felony” crime and is described as any person with an intent to defraud a health plan, who knowingly and willfully provides false information (or omits relevant information) in order to request payment or reimbursement from a health care plan and, as a result of the falsity, the person receives payment to which he or she is not entitled. In order to face first-degree charges, the aggregate amount stolen must exceed $1 million and occur in a span of time not exceeding one year.
Health care fraud in the second degree: This is a “C felony” crime requiring the same mental state as first-degree health care fraud; however, the defendant must have stolen up to $50,000 in the aggregate within one year or less.
Health care fraud in the third degree: This “D felony” involves theft of health care funds within one year’s time exceeding $10,000.
Health care fraud in the fourth degree: This “E felony” involves theft of health care funds within one year’s time exceeding $3,000.
Health care fraud in the fifth degree: This catchall crime involves the type of fraud described above, but does not include an aggregate dollar amount threshold or a time limit. Health care fraud in the fifth degree is a Class A misdemeanor (the most serious).
The New York statute defines a “health plan” to include any public or private health care plan, including Medicare, Medicaid, TRICARE and all private insurers.
Penalties for Health Care Fraud in New York
As with most crimes, the penalties awaiting a health care fraud defendant depend upon the severity and extent of the alleged fraud. In addition to restitution and financial penalties, the following potential jail sentences may be imposed upon a convicted health care fraud defendant:
First-degree health care fraud: One to three years’ incarceration, with a 25-year maximum sentence for repeat offenders
Second-degree health care fraud: Generally, probation for first-time offenders; defendants with an extensive criminal history may face a minimum of 1 year up to 15 years
Third-degree health care fraud: A first-time offender will likely receive probation, whereas a repeat offender may face 1-7 years’ incarceration
Fourth-degree health care fraud: A first-time offender will likely receive probation, whereas a repeat offender may face up to 4 years in jail
Fifth-degree health care fraud: Most misdemeanor crimes carry a maximum sentence not to exceed one year
Federal Laws to Consider
Federal health care programs like Medicare and Medicaid are extremely cash-strapped, giving the government extra incentives to pursue and prosecute health care fraud offenders. As your New York fraud attorney will explain, U.S.C. § 1347 addresses health care fraud involving the federal system and prohibits anyone from knowingly and intentionally defrauding any health care benefit program or intentionally obtaining money or property from a health care benefit program using false statements or misrepresentations. Under federal law, health care fraud carries a general sentence of 10 years, unless the fraud resulted in bodily injury. In that case, the penalty increases to 20 years. If a person is killed as a result of health care fraud, which is possible in cases of neglect or abuse, the defendant may be sentenced to any term of years or for life.
Defenses to Health Care Fraud Charges
As your New York health care fraud attorney will explain, health care fraud cannot occur by accident or due to a negligent oversight. By contrast, the defendant must have acted willfully, intentionally, and purposefully to defraud health care benefit systems, and the prosecution must put forth enough evidence to show this mental state; otherwise, a charge of health care fraud cannot sustain. In the context of a bustling health care practice, it is common for untrained or unfocused staff members to make billing or coding mistakes, an act which is not considered intentional health care fraud.
Under Section 177.30 of the New York health care fraud penal code, it is also considered an affirmative defense to prosecution that the defendant was merely an employee, bookkeeper or clerk acting under the management and control of a supervisory employee or employer. This affirmative defense also requires that the defendant did not receive any personal gain or benefit as a result of the fraudulent scheme.
Contact a Renowned New York Health Care Fraud Attorney Today
If you are facing possible health care fraud charges under federal or New York laws, we encourage you to contact our office right away to get started on your representation. The time to retain an attorney is prior to or during the investigation stage – not later. Once the investigation has concluded, your New York Health Care Fraud Attorney will need to work to exclude evidence that should not have been recovered by the government in the first place, which is a daunting task.
