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Insurance Fraud in the Fifth through First Degree

Fraud is stealing, which is a crime, and it is a crime that affects everyone. When people commit health care fraud crimes, those actions contribute to rising costs of health care. Reducing health care fraud and abuse can help contain rising health care costs.

The most common kind of fraud involves a false statement, misrepresentation or deliberate omission that is critical to the determination of benefits payable. The most common examples of health care fraud include, but are not limited to:

1.)Billing for services, procedures and/or supplies that were not provided;

2.) Ordering services that are unnecessary or unwarranted for the purpose of financial gain;

3.) the intentional misrepresentation of any of the following for purposes of manipulating the benefits payable: a.)The nature of services, procedures and/or supplies provided; b.) The dates on which the services and/or treatments were rendered; c.) The medical record of service and/or treatment provided; d.) The condition treated or diagnosis made; e.) The charges or reimbursement for services, procedures, and/or supplies provided; f.) The identity of the provider or the recipient of services, procedures and/or supplies.

By its nature, health care fraud revolves around the exploitation of patients and their health insurance information, and as such, it involves much more than financial loss. Fraud also involved the creation of false medical histories for the persons in whose names those false claims are filed. Depending on the nature of the fraud, some providers put patients at physical risk solely for the purpose of generating falsified claims.

The cost of health insurance fraud and abuse is estimated to be as much as $54 billion dollars each year. Efforts to identify and report fraud can save tens of millions of dollars. That’s why New York’s health insurers, working with the New York Health Plan Association and the National Health Care Anti-Fraud Association, are joining together in a campaign to educate the public about fraud and its costs and to get consumers involved in the effort to reduce fraud.

Definition of terms on Health care fraud under New York Penal Law S 177.00 states that: The following definitions are applicable to this article: 1. “Health plan” means any publicly or privately funded health insurance or managed care plan or contract, under which any health care item or service is provided, and through which payment may be made to the person who provided the health care item or service. The state’s medical assistance program (Medicaid) shall be considered a single health plan. For purposes of this criminal article, a payment made pursuant to the state’s managed care program as defined in paragraph (c) of subdivision one of section three hundred sixty-four-j of the social services law shall be deemed a payment by the state’s medical assistance program (Medicaid).

2. “Person” means any individual or entity, other than a recipient of a health care item or service under a health plan unless such recipient acts as an accessory to such an individual or entity.

New York Criminal Penal Law S 177.05 on Health care fraud in the fifth degree, states that: A person is guilty of health care fraud in the fifth degree when, with intent to defraud a health plan, he or she knowingly and willfully provides materially false information or omits material information for the purpose of requesting payment from a health plan for a health care item or service and, as a result of such information or omission, he or she or another person receives payment in an amount that he, she or such other person is not entitled to under the circumstances. Health care fraud in the fifth degree is a class A misdemeanor.

Health care criminal fraud in the fourth degree under New York Penal Law S 177.10 states that: A person is guilty of health care fraud in the fourth 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 three thousand dollars in the aggregate. Health care fraud in the fourth degree is a class E felony.

Health care fraud in the third degree under New York Penal Law S 177.15 states that: A person is guilty of health care fraud in the third 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 ten thousand dollars in the aggregate. Health care fraud in the third degree is a class D criminal felony.

Health care fraud in the second degree under New York Penal Law S 177.20 states that: A 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. Health care fraud in the second degree is a class C felony.

Health care fraud in the first degree under New York Penal Law S 177.25, states that: 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. Health care fraud in the first degree is a class B felony.

Health care fraud: affirmative defense, under New York Penal Law S 177.30 states that: In any prosecution under this article, it shall be an affirmative defense that the defendant was a clerk, bookkeeper or other employee, other than an employee charged with the active management and control, in an executive capacity, of the affairs of the corporation, who, without personal benefit, merely executed the orders of his or her employer or of a superior employee generally authorized to direct his or her activities.

Having a counsel can assist you with the following issues pertaining to your case; the prosecution in a medical fraud case must prove that the defendant acted with the intent to defraud a private or public insurer (or other health plan). The prosecution must also prove that the defendant knowingly and willfully provided false information for the purpose of requesting payment from a health plan for a healthcare item or service and, as a result, the defendant or another person received payment in an unjustified or excessive amount.

On discovery issues, because most medical fraud claims relate to the false or exaggerated medical conditions, discovery sometimes focuses on the health and diagnosis of an individual or group of individuals.

The key witnesses, Insurance experts and medical doctors are usually the primary expert witnesses relied upon in a medical fraud case.

In defending against charges for medical fraud, the New York Criminal Defense Lawyers at Stephen Bilkis and Associates provides skilled legal guidance to clients facing charges for all types of healthcare fraud. Visit our offices located around New York City for free legal consultation.

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