Understanding Healthcare Fraud as a White Collar Crime

Healthcare fraud is a kind of white collar crime that entails putting in false medical claims in order to get payments from a health plan or health insurance company. Health care fraud commonly takes the form of a doctor, dentist, pharmacist, chiropractor or other medical specialist sending claims to insurance companies for services, items or medications that were not actually given to any patients.

Five Degrees of Healthcare Fraud Under New York Law

Five offenses related to health care fraud exist in the New York criminal code. They are health care fraud in the:

• First degree
• Second degree
• Third degree
• Fourth degree
• Fifth degree

The specific charge that you could be looking at depends on the amount of money you received as a result of the fraud in a single year.

Healthcare Fraud Third Degree Requirements and Thresholds

You could be charged with health care fraud in the third degree under New York Penal Code § 177.15 if you knowingly submitted falsified health insurance claims and, as a result, you received payments to which you were not entitled. For this charge to be valid, the amount of the payments you received fraudulently must be:

• More than $10,000
• Less than $50,000
• In a single year

Real Case Example: Pharmacy Fraud Scheme

For Example Malcolm Ogbeche owned a neighborhood pharmacy. Rumor had it that he sold prescription drugs to people who did not have prescriptions. Based on information they received, police commenced an investigation. On 3 different occasions, undercover police officers went to Ogbeche's Pharmacy posing as customers. They asked to purchase codeine, Ritalin, and Valium without presenting any prescriptions and had their requests filled. On the basis of these transactions, the police procured and executed a search warrant on Ogbeche' pharmacy. Investigators discovered that Mr. Ogbeche had submitted bills to a health plan in the names of other people so that he could receive payments for the prescription drugs he dispensed illegally. Mr. Ogbeche was charged with the crime of health care fraud in the third degree. Investigators discovered that he had received a total of $45,000 in payments from a single health plan from the fraudulent submissions.

Related Healthcare Fraud Offenses in New York

Offenses‌ ‌that‌ ‌are‌ ‌Related‌

• Health care fraud in the fifth degree: New York Penal Law § 177.05
• Health care fraud in the fourth degree: New York Penal Law § 177.10
• Health care fraud in the second degree: New York Penal Law § 177.20
• Health care fraud in the first degree: New York Penal Law § 177.25

Legal Defenses Against Healthcare Fraud Third Degree

Possible Defenses

Payment Requirement Defense

In order for you to be convicted of health care fraud in the third degree, the prosecutor needs to demonstrate that you got payments for fraudulent claims from one individual health plan in a single year that totaled more than $10,000, but less than $50,000. If, for instance, you put in claims that were not legitimate, but the insurance company never made payment on those claims, you cannot be convicted of health care fraud.

Lack of Knowledge Defense

In addition, if you were not aware that you were submitting fraudulent claims, then you could not be convicted for health care fraud in the fourth degree. For example, if a technical issue resulted in your computer sending out the same claims multiple times, then there would not have been an intent to defraud and the charge would not hold.

Sentencing Guidelines for Healthcare Fraud Third Degree

The Sentence The crime of health care fraud in the third degree is categorized as a class D felony offense. Should you are convicted of this offense, you could:

• Get sent to jail for up to 7 years
• Get sentenced to up to 5 years of probation

Financial Penalties and Restitution Requirements

The pecuniary consequences of a conviction may be that you will be obligated to:

• Pay restitution to the victim
• Pay a substantial fine to the court