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Health Care Claims Fraud

Under the New Jersey Criminal Code, both licensed medical practitioners and private citizens alike may be charged with health care claims fraud. Clients are often unsure of what constitutes health care claims fraud. Simply explained, health care claims fraud involves making, or causing to be made, a false or misleading statement of material fact in any claim or other document, in an attempt to obtain payment or reimbursement for health care services. An example of health care claims fraud would be when someone intentionally stages a slip and fall accident, and suffers actual injuries, and they then make a claim for injuries suffered in an accidental fall. Health care claims fraud is a second, third or fourth degree offense, all of which are indictable in Essex County. This means that a conviction may carry up to ten years in prison. If you or a loved one have been indicted for health care claims fraud, then contact the Law Offices of Jonathan F. Marshall and receive your free consultation today.

Health Care Claims Fraud Committed By A Doctor/Physician

For practitioners there are two types of health care claims fraud under N.J.S.A. 2C:21-4.3: (1) knowingly committing health care claims fraud and (2) recklessly committing health care claims fraud. “Practitioner” refers to any a person licensed in New Jersey or any other jurisdiction to practice medicine, surgery, chiropractic, podiatry, dentistry, optometry, psychology, pharmacy, nursing, physical therapy, or law; and any other person licensed, registered or certified by any State agency to practice a profession or occupation in the State of New Jersey.

Knowingly Commit Health Care Claims Fraud. Under this portion of the New Jersey Criminal Code, a practitioner who knowingly commits health care claims fraud is guilty of a second degree offense. In order to obtain a conviction for this second degree crime, the State must demonstrate the following four (4) things. First, that the defendant was a practitioner. Second, that the defendant made, or caused to be made, a false, fictitious, fraudulent, or misleading statement of material fact in, or omitted a material fact from, or caused a material fact to be omitted from, any record, bill, claim or other document, in writing, electronically or in any other from. Third, that the defendant attempted to submit, submitted, caused to be submitted, or attempted to cause to be submitted the record, bill or claim for payment or reimbursement for health care services. Fourth, that the defendant acted knowingly. You will note that the amount of the claim is not an element of this offense. As a result, no matter what the amount of the claim or benefit received, this is a second degree crime, that carries up to ten (10) years in prison and a $150,000 fine.

Recklessly Commit Health Care Claims Fraud. Where the doctors actions were done recklessly, rather than knowingly, health care claims fraud is a third degree offense. In New Jersey, a practitioner acts recklessly when he or she consciously disregards a substantial and unjustifiable risk that a circumstance exists or will result from his or her conduct. This risk must be such a nature and degree that, considering the nature and purpose of the defendant’s conduct and the circumstances known to him or her, its disregard involves a gross deviation from the standard of conduct that a reasonable person would observe in the defendant’s situation. Once again, the amount of the claim is not relevant.

Health Care Claims Fraud By Non-Doctor Including Patient

As is the case with health care claims fraud for doctors, there are two distinct types of health care fraud for non-doctors: (1) knowingly committing health care claims fraud and (2) recklessly committing health care claims fraud.

Knowing Fraud. A defendant who is not a practitioner providing the services for which the claim is made, is guilty of a crime of the third degree, if that defendant knowingly commits health care claims fraud. However, this crime is elevated to a second degree if the defendant knowingly commits five or more acts of health care claims fraud and the aggregate pecuniary benefit obtained or sought to be obtained is at least $1,000.00. The elements of this offense are the same as those for practitioners, except the State does not need to demonstrate the defendant is a practitioner.

Reckless Fraud. Where the non-practitioner defendant’s conduct reaches the reckless standard, then it is a crime of the fourth degree. The elements are the same as for the third degree crime except that for this offense the state need only prove that the defendant acted recklessly.

Can A Physician Lose His License If Convicted of Health Care Claims Fraud?

Beyond the stigma that this conviction carries, a defendant found guilty of health care claims fraud may be subject to mandatory medical license forfeiture. Where the practitioner is convicted of second degree health care claims fraud for a second time, they must forfeit their license and be forever barred from the practice of medicine or psychiatry. In the case of a third degree health care claims fraud conviction, even for a first-time offender, the practitioner must have his or her license suspended and be barred from the practice of the profession for a period of at least one year. Upon a second conviction of third degree health care claims fraud, a practitioner must forfeit his license and be forever barred from the practice of the profession. In addition to the medical license suspension, the defendant will be subject to the penalties and fines commonly associated with second, third and fourth degree offenses.

If you have been charged with health claims fraud, our Newark criminal attorneys are prepared to assist you. A lawyer is available immediately at 973-710-1520.