2010 saw the implementation of the H.E.A.T. Taskforce by the Department of Health and Human Services. H.E.A.T. stands for Health Care Fraud Prevention and Enforcement Action Team. This team was created to combat growing issues with healthcare fraud involving the recipients of government benefits.
Since the implementation of the team, law enforcement and the government have both made incredible strides regarding the identification and elimination of healthcare fraud. This fraud costs billions of dollars in taxpayer money each year. But with the dedication to the elimination of wasteful spending, wrongful prosecutions have become more and more common. Unrelenting harassment and unlawful searches have also plagued people in the healthcare industry, particularly office managers and doctors.
If you’re facing a possible investigation or charge for fraud, an experienced healthcare fraud attorney is essential. You need someone to help you understand your options and negotiate your case.
Definition of Healthcare Fraud
Healthcare fraud is addressed under Article 177 of New York’s Penal Law. This statute has a large number of healthcare-related activities that have been prohibited. Each crime is categorized based on the degree of severity. First degree crimes are the most severe, with crimes decreasing in severity as their degree grows larger.
First degree healthcare fraud: This is the most severe offense, and as such is classified as a class B felony. To be convicted of this crime, an individual must have intended to defraud a health plan by providing false information to request reimbursement from that healthcare plan. The person must have received payment of more than $1 million in less than one year for the first-degree charge to be applicable.
Second degree healthcare fraud: This is defined as a class C felony. The same circumstances must occur for this offense as for the first degree healthcare, but the stolen amount must be $50,000 or more within less than one year.
Third degree healthcare fraud: A D-class felony, a person meets this definition if they steal funds of up to $10,000.
Fourth degree healthcare fraud: An E-class felony with up to $3,000 stolen within one year.
Fifty degree healthcare fraud: This is a catchall umbrella crime involving the circumstances described above, but no cumulative dollar amount or time limit is imposed. It’s classified as a Class A misdemeanor, which is the most serious misdemeanor class.
Under the New York Statute, “health plans” are defined as any healthcare plan put out by any public or private institution. Included in the definition are all private insurance companies, Tricare, Medicaid, and Medicare.
The penalties a defendant faces will vary widely depending on the circumstances of the fraud. The amount stolen is the main contributing factor, along with the time period during which the funds were stolen. All convictions come with hefty fees on top of needing to pay restitution. There are potential prison sentences as well.
For first degree offenders, there’s a maximum prison sentence of twenty-five years. This sentence is likely to be imposed if the defendant is a repeat offender. For second degree offenders, prison sentences could last up to fifteen years. Third degree convictions come with a potential of seven years in prison, while fourth degree has a maximum penalty of four years in prison. Since the fifth degree is a class A misdemeanor, the maximum penalty is one year in jail.
For a healthcare fraud charge to be applicable, the defrauding must have been intentional on the part of the defendant. It could not be caused accidentally or through negligence. If the defense attorney can prove that the defendant accidentally or negligently caused the circumstances, rather than intentionally and maliciously doing so, the defendant has a viable defense.
If the defendant was working at the behest of a superior employee, they also have a viable criminal defense. In order for the defense to be applicable, the defendant could not have received any benefits resulting from the scheme.