Is Healthcare Fraud a Felony? It Depends!

It may seem that any healthcare fraud accusation would result in a felony conviction with hefty fines and years in prison. However, healthcare fraud isn’t always a felony. It is a serious charge that should be handled with care and expertise by professionals, but it does not always result in a felony conviction. Keep reading to learn more about healthcare fraud and the implications of being accused. 

Healthcare Fraud Defined 

Healthcare fraud can be committed by providers, patients, and others who intentionally set out to deceive the healthcare system to receive unlawful benefits or payments. Under the False Claims Act, every act of healthcare fraud is considered a federal offense. 

Therefore, the Federal Bureau of Investigations (FBI) is involved in investigations along with state and local agencies as well as the Healthcare Fraud Prevention Partnership and insurance groups such as the National Health Care Anti-Fraud Association. There is also an online tip website set up through the FBI that allows citizens to report suspected healthcare fraud. 

There are various types of healthcare fraud, some that are committed by medical providers and some that are carried out by patients or other individuals. 

Types of fraud committed by healthcare providers include:

  • Double Billing: Submitting multiple claims for the same service. 
  • Phantom Billing:Billing for a service visit or supplies that a patient never received. 
  • Unbundling:Submitting multiple bills for the same service. 
  • Upcoding: Billing for a more expensive procedure than the one the patient received. 

Types of fraud committed by patients and other individuals: 

  • Bogus Marketing: Convincing people to provide their healthcare information and using that information to bill for unrendered services. 
  • Identity Theft: Using another person’s healthcare information, or allowing others to use yours. 
  • Impersonating a Healthcare Professional: Providing or billing for healthcare services or equipment without a license. 
  • Forgery: Creating or using fake prescriptions. 

Penalties for Healthcare Fraud in New Jersey

The penalties for healthcare fraud convictions in New Jersey greatly depend on whether the person who committed the crime is a practitioner or non-practitioner. Whether the fraud was committed “recklessly” or “knowingly” is also considered and is reflected in the consequence if convicted. 

It is considered “reckless” behavior if the practitioner consciously disregards a substantial and unjustifiable risk that fraud may be committed. If a healthcare fraud crime is committed “knowingly”, the person committing it is aware of the actions they are taking, is aware that they are against the law, and understands what results may follow. 

A healthcare fraud offense in New Jersey may be labeled as a fourth degree, third degree, or second degree crime based on who committed it and what their intentions were. “Knowingly” committing a fraud offense generally carries a stiffer penalty than “recklessly” carrying out an offense. 

Second Degree Crime: A practitioner who knowingly commits healthcare fraud is charged with a second degree crime. A non-practitioner who can be charged with a second degree crime if they commit 5 or more violations worth $1K or more. 

The penalties for a second degree healthcare fraud conviction fines of up to $150K, and 5-10 years in prison. 

Third Degree Crime: A practitioner or non-practitioner who recklessly commits healthcare fraud is charged with a third degree crime. The non-practitioner in this case must have 5 or more violations with a loss of more than $1K to be charged with this degree of crime. 

The penalties for a third degree healthcare fraud conviction would include fines up to $15K and up to 5 years in prison. 

Fourth Degree Crime: A non-practitioner who recklessly commits a healthcare fraud crime under any circumstance and up to any loss can expect up to 18 months in prison and a fine of up to $15K. 

A misdemeanor charge may be assigned depending on the severity of the fraud, whether it was knowingly committed, and whether there are any previous violations. However, healthcare fraud is taken very seriously by the State of New Jersey, and the consequences can be severe. 

If You’re Accused, Contact an Attorney 

If you are accused of committing any healthcare fraud offense, it is imperative that you contact an experienced criminal defense attorney immediately. There are technicalities to every case, and a lawyer with a background in healthcare fraud can help bring them to the surface and craft a defense for you. Trying to defend yourself against these serious charges is not recommended. 

If you or someone you know is facing healthcare fraud accusations, reach out to the experienced and talented team at the Law Offices of Robert J. DeGroot.