Health Care Fraud

In 2006, the New York legislature enacted Penal Law Article 177 to address health care fraud cases because the laws against larceny and insurance fraud proved inadequate.

Many of these prosecutions were aimed at health care providers who were defrauding the system. The legislation made it easier for the prosecutor to punish the aggregate impact of the crimes instead of prosecuting each individual instance of fraud against a single health plan. The legislation provide for five different degrees in the statutory scheme.

Queens Health Care Fraud Lawyer

If you are under investigation for any allegation of health care fraud in Queens County, NY, or the surrounding areas of New York City, then contact an experienced criminal defense attorney at the Law Office of Rochelle S. Berliner. We represent individuals, including health care providers, accused of criminal wrongdoing, throughout Queens, Brooklyn, Manhattan, and The Bronx.

Call 718-261-5600 today to discuss your case.

Health Care Fraud Information

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Examples of Health Care Fraud Cases in New York City

Health care fraud involves an allegation of filing a dishonest or deceptive health care claim in order to make a profit. Both the individuals seeking treatment or the health care provider can be implicated in these fraud cases.

Health care fraud charges can be filed against an individual entitled to private or pubic health care benefits for engaging in the following types of fraudulent activities:

  • loaning an insurance card to someone else or pretending to be someone else by using their insurance card;
  • forging prescriptions for medications or drugs and/or selling the drugs illegally obtained on the black market;
  • providing untrue information when submitting an application for services;
  • obtaining subsidized prescription pills and medications and then selling them on the black market for a profit; and
  • using transportation services for purposes not related to any medical service allowed by the program.

When health care fraud cases are filed against practitioners, the alleged schemes can include:

  • maximizing payments by intentional reporting the wrong diagnosis;
  • writing a prescription for unnecessary medical treatments to maximize payments;
  • falsifying billing information or medical records such as the description of services renders;
  • giving or receiving illegal kickbacks in exchange for member referrals;
  • filing numerous claims (double billing) for services rendered only one time;
  • billing the public or private insurance company or program for services that were never actually rendered;
  • submitting a bill for a service that is uncovered and presenting it as a covered service; and
  • employing staff that are not licensed to perform the services they are providing.

The federal version of health care fraud is 18 U.S.C. 1347 or conspiracy to commit health care fraud.

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Health Care Fraud in the Fifth Degree under Penal Law § 177.05

The charge of health care fraud in the fifth degree is a class A misdemeanor under the State of New York's Penal Law § 177.05. The charge alleges that a person did the following:

  • Provided materially false information or omitted material information for the purpose of requesting payment from a health plan for a health care item or service;
  • Did so knowingly, willfully and with intent to defraud a health plan; and
  • As a result of such information or omission, he or she or another person received payment in an amount that he, she or such other person was not entitled to under the circumstances.

The statute defines the term "health plan" to mean "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 term is defined to include a payment to New York's managed care program or medical assistance program, Medicaid.

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Felony Heath Care Fraud Charges in New York

The felony version of health care fraud allows for the aggregation of the amount of money wrongfully received during a one year period from a single health plan. The degree classification depends on the amount wrongfully received:

  • $3,000 for fourth degree charges;
  • $10,000 for third degree charges;
  • $50,000 for second degree charges; and
  • $1 million for first degree charges.

The amount "wrongfully" received can include the total amount paid, but only if the total amount was wrongfully received. In many of these cases, a portion of that amount received was proper, and a portion of the amount was wrongfully received. In those cases, the person accused is entailed to have the total amount reduced to include only that portion that was wrongfully received.

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Affirmative Defense for Employees Merely Following Orders

New York Penal Law § 25.00(2) provides for an affirmative defense for certain lower level employees who "merely executed the orders" of their employers "without personal benefit." The phrase without personal unfit should normally exclude the normal benefits of employment. The affirmative defense applies only to health care fraud but does not apply to other types of related offenses such as falsifying business records.

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Resources for Fraudulent Health Care Schemes

NY Attorney General's Heath Care Bureau - The HCB investigates cases against insurers, heath care providers, and drug companies that act in deceptive, fraudulent, misleading or illegal ways in the health care industry. The Health Care Bureau of the State of New York's Attorney General's Office also provides assistance to consumers and patients to help them resolve disputes with their health care providers.

FBI on Health Care Fraud - Information from the Federal Bureau of Investigations on health care fraud. Recent FBI statistics and studies estimate that health care fraud costs an estimated $80 billion per year. Also find information on those most wanted by the FBI for healthcare fraud and news on recent indictments for Medicare fraud.

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Attorney in Queens for Health Care Fraud Cases

If you are under investigation for any health care fraud case in Queens or throughout New York City, contact Law Office of Rochelle S. Berliner. Queens criminal defense attorney Rochelle S. Berliner has the experience and skill to handle this particular type of charge and work to achieve the most favorable possible outcome.

Law Office of Rochelle S. Berliner represents clients on a variety of white collar crime charges throughout Queens, Brooklyn, The Bronx and Manhattan. Call 718-261-5600 or complete an online form today to set up a free initial consultation to discuss your case.

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Rochelle Berliner
Rochelle Berliner

Rochelle Berliner grew up in Queens, NY. She started New York Law School in January 1989 and graduated in June 1991. Immediately after law school, she started working at the New York County District Attorney’s Office, where she stayed for approximately 14 years...

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