When you are the subject of an investigation for healthcare fraud, it is imperative to consult with a healthcare fraud lawyer immediately. The government considers healthcare fraud a serious matter, and when it investigates healthcare fraud, it usually finds ways to charge an accused with other crimes such as wire fraud, mail fraud, and bank fraud, especially when mail, telephones, internet or other services were used in the commission of healthcare fraud. The government can also bring the following additional charges: conspiracy to defraud the government with respect to claims; making false, fictitious or fraudulent claims; theft or embezzlement in connection with healthcare; and making false statements relating to healthcare matters.
For this reason, before making any statements with an investigator, you need to make sure that you consult with your healthcare fraud lawyer to ensure your story can support a strong, good legal defense. When your employer is being investigated for healthcare fraud and you are part of the investigation, your interests may be or may not be aligned. If your interests are aligned with your employer, you may share a lawyer. However, it is always recommended to have your own lawyer so you can always protect your interests because your employer might decide to say damaging information against you (whether true or untrue) and at this point, your interests will not be aligned.
What is healthcare fraud?
Article 177 of the New York Penal Law defines healthcare fraud, from the fifth degree (a class A misdemeanor) to the first degree (a class B felony). Under this provision, healthcare fraud occurs when a person 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, the person receives a payment that he is not entitled to under the circumstances. The degree of healthcare fraud committed depends on the amount wrongfully received during a particular period. Based on this definition, both an entity (such as a hospital, laboratory, or nursing home) or a natural person (such as a patient, physician, nurse, or another medical professional) can commit healthcare fraud.
Some examples of provider-committed healthcare fraud are: billing for unperformed services; duplicate billing, falsifying a diagnosis, illegal kickbacks, ordering unnecessary tests, and over-prescribing medications. Common examples of natural person-committed healthcare fraud are: forging or altering receipts, giving false information to be eligible for government healthcare benefits, using another person’s insurance to receive medical care, or filing a claim for a service that was not received.
For example, A was a doctor who wanted to find ways to increase his income. He started performing unnecessary surgeries on his patients and billing insurance companies for these services. After a number of complaints, investigators confirmed that he was performing unnecessary surgeries in order to bill insurers more for his services. In this case, A can be convicted for healthcare fraud, the degree depending on the amount he received.
Elements of Healthcare Fraud
Prosecutors prove healthcare fraud by proving two elements: (a) there was a scheme to defraud a healthcare benefit program or obtain money from the program by false pretenses; and (b) a person knowingly and willfully executed the scheme. Another element that the prosecutor has to prove is the amount received by the person. The amount proven to be received would determine the degree of the offense. If the prosecution is able to prove that the person received only between three to ten thousand dollars in a period of one year, then the crime committed is only health care fraud in the third degree, which is a class D felony. If the amount cannot even be proven, the offense is only a misdemeanor.
If you are an employee of a company that is being investigated for healthcare fraud and you do not actively manage or control the affairs of the business, then you have a strong defense. For example, if you were forced by your employer to forge receipts for billing under threat that you would lose your job, you have a valid defense.
Being investigated for healthcare fraud is a serious matter. It is important to seek counsel from a healthcare fraud lawyer before making any statements to investigators. Should you need assistance, we at the Law Offices of Albert Goodwin are here for you. We have offices in New York, NY, Brooklyn, NY and Queens, NY. You can call us at 718-509-9774 or send us an email at email@example.com.