Healthcare Fraud Lawyers in New York, NY

As healthcare fraud lawyers, we play a crucial role in our clients' defense by evaluating the case, preparing a strategic defense, and negotiating with the prosecution for a favorable plea deal. Each case has unique circumstances, and we strive to obtain the best possible resolution for each of our clients.

We can defend you in allegations and investigations of healthcare fraud to ensure your interests are protected and rights are preserved.

The government considers healthcare fraud as a serious matter, and allegations concerning healthcare fraud can have major repercussions to a person’s business and career. Having an experienced healthcare fraud lawyer to defend your interests ensures that your case is professionally evaluated, that legal issues have been identified, and that strong effective defenses have been crafted in your favor.

What is Considered Healthcare Fraud?

Article 177 of the New York Penal Law defines healthcare fraud as an act where 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 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, which can range from the fifth degree (a class A misdemeanor) to the first degree (a class B felony). 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 other medical professional) can commit healthcare fraud. 

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 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.

Types of Healthcare Fraud

The most common types of healthcare fraud are billing fraud, kickbacks and bribery, upcoding and unbundling, phantom billing, and false diagnosis and treatment. In these types of healthcare fraud, both the healthcare provider and the medical professionals may be investigated. In these cases, it is important to procure a healthcare fraud lawyer independent from the attorneys of the other persons being investigated. This ensures that your lawyer is only representing your separate interests, without any conflict from other clients.

Billing Fraud

Billing fraud occurs when false or inflated claims are submitted to the government, even if these services were never provided or not medically and diagnostically required.

Kickbacks and Bribery

Kickbacks and briberies are prohibited when referring patients to other healthcare providers, facilities and services. In this context, physicians, hospitals, and healthcare facilities are prohibited from receiving referral fees. Pharmaceutical companies and medical device manufacturers, on the other hand, are prohibited from giving referral fees to the physicians and hospitals who refer or recommend their medicines or medical devices.

Upcoding and Unbundling

Upcoding occurs when a healthcare provider bills for a more expensive procedure than what was given. Unbundling happens when a healthcare provider separates services that could have been billed together as a single procedure to maximize reimbursement.

Phantom Billing

Phantom billing is a type of billing fraud where a healthcare provider submits a reimbursement bill for procedures or services that were never performed or not necessary.

False Diagnosis and Treatment

When physicians diagnose patients incorrectly or falsely with the intent to push the patients to obtain services that are not medically required, this action is considered healthcare fraud.

Possible Defenses to Healthcare Fraud

The defenses to healthcare fraud will depend on the healthcare fraud charge one is facing and your participation in the entire healthcare procedure. Generally however, your healthcare fraud lawyer can use any of the following defenses, depending on the unique circumstances of your case:

Compliance with Medical Standards

In cases where the allegation claims that the diagnosis or treatment is not medically necessary or the service was unbundled, showing proof that the billing made was in compliance with standard medical practices and procedures can help refute the claims.

Lack of Intent

Lack of intent is an acceptable defense when billing mistakes are made because healthcare fraud requires a person to knowingly and willfully provide materially false information or omit material information. When there is no willful and knowing commission, there can be no healthcare fraud.

Error or Administrative Oversight

Administrative errors that lead to billing discrepancies may mitigate allegations of healthcare fraud.

Audit and Compliance Programs

Showing that the medical and billing procedures established and observed by the organization are compliant with industry regulations and standards can be a defense against any allegation claiming that there was an intent to defraud the insurers or the government.

Lack of Evidence

Challenging the sufficiency of the evidence can lead to a reasonable doubt that a medical professional or healthcare provider committed healthcare fraud.

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 your defense has a bigger chance of success.

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 representation, we at the Law Offices of Albert Goodwin are here for you. We are located in New York, NY. You can call us at 212-233-1233 or send us an email at [email protected].