Medical Doctor Insurance Fraud

If you are a doctor facing an accusation of medical insurance fraud, then you are likely to face litigation on multiple fronts, which can include criminal, civil, and professional license proceedings. Even the simple accusation of a crime of dishonesty such as medical insurance fraud can have permanent effects on your life, your relationships, and your ability to be a practicing doctor. If you are a doctor who holds a medical license from your state o allowing you to practice, then your license can be at stake if you are charged with medical insurance fraud. If you are a doctor facing a medical insurance fraud charge, then it is imperative that you get in touch with an experienced lawyer as quickly as possible.

What is Medical Insurance Fraud?

Medical or health insurance fraud deals with providing false or misleading information to a health insurance company to try to have them pay benefits that are unauthorized. Both an individual and a health care provider such as a doctor can be charged medical insurance fraud for giving false information to a health insurance company. As a medical professional, you are under both a legal and ethical duty to file truthful and accurate statements relating to your performed medical services, billings, and other doctor-related procedures.

Medical insurance fraud charges are often the result of a lengthy investigation that uncovers a systemic approach to overbilling, performing unnecessary services, or billing for services that weren't actually performed. Some doctors are even accused of falsifying medical diagnoses to justify additional costly testing, medication, and even surgeries. Any sort of medical insurance fraud accusation should be taken very seriously as these charges can have impacts on almost every facet of your life, both personally and professionally.

What Are Some Examples of Medical Insurance Fraud?

There are countless ways that doctors can find themselves facing a charge of medical insurance fraud. The main element involved in medical insurance fraud is a purposeful activity that is meant to defraud in some way. If a medical billing issue was deemed to be a system error or oversight, then the doctor accused of medical insurance fraud could be appropriately acquitted of any charges because he or she did not have the necessary intent to defraud the insurance company. Some common examples of medical insurance fraud include:

  • Example 1: Fraudulent billing – This involves a doctor billing a medical insurance company for medical services, medical supplies, or procedures that were never actually rendered. This up charging of a health insurance company can result in millions of dollars lost.
  • Example 2: Performing unnecessary services – This involves a doctor actually performing unnecessary medical services to bill the health insurance company for those services. This doctor-patient violation of trust can result in significant penalties criminally, civilly, and regarding a doctor's license to practice medicine.
  • Example 3: Paying illegal kickbacks – This involves a doctor illegally paying people a referral fee or kickback to refer accident victims for health care treatment. Doctors may not accept nor give any payment of any kind for referring a patient.

Any of the above scenarios can be the basis for a medical insurance fraud claim. Medical insurance fraud laws and punishments vary by state, so it is important to understand what the law is in the state you practice in. Medical insurance fraud cases typically have multiple components to them which include criminal and civil litigation, as well as medical board license disciplinary proceedings. It is critical that you have a comprehensive defense to deal with all three of these fronts if you are accused of medical insurance fraud.

What Are the Medical Insurance Fraud Laws in Pennsylvania?

In Pennsylvania, the crime of medical insurance fraud can be located within the insurance fraud statute as it does not stand on its own as its own in the criminal laws of the state. The crime of medical insurance fraud can be found within the following section of the Pennsylvania statutes:

In Pennsylvania, criminal charges are categorized depending on the severity of the crime alleged. Both felony and misdemeanor offenses are broken into three different degrees of severity correspondingly, from first-degree to third-degree offenses. Medical insurance fraud can be charged as follows in Pennsylvania:

  • First-degree felony: when $500,000 or more is alleged to have been defrauded from a medical insurance company, this can end in 10-20 years in prison and fines as much as $25,000.
  • Second-degree felony: when $100,000-$499,999 is alleged to have been defrauded, this can end in 5-10 years in prison, and fines up to $25,000.
  • Third-degree felony: when $2,000-$99,999 is alleged to have been defrauded, this can end in 3.5-7 years in prison and fines of up to $15,000.

Misdemeanor medical insurance fraud offenses in Pennsylvania can also result in significant incarceration, fines, and restitution. A first-degree misdemeanor conviction can end in up to 5 years in prison and up to a $10,000 fine under Pennsylvania law.

What Are the Medical Insurance Fraud Laws in New Jersey?

New Jersey does not have a named medical insurance fraud statute, so these crimes are typically charged under the general insurance fraud statute. In New Jersey, the crime of medical insurance fraud can be found within the following section of the New Jersey Revised Statutes:

In New Jersey, criminal charges are categorized based on the severity of the crime alleged. Felony offenses are divided into four different degrees of crimes, while misdemeanors are charged as “disorderly persons” offenses. Medical insurance fraud charges in New Jersey can be charged as follows:

  • Second-degree offense: when a health care provider is accused of knowingly making at least five false, fraudulent, or misleading statements on any records or bills in the course of providing medical services and benefitting at least $1,000, this can result in 5-10 years in prison, fines up to $150,000, and comes with a presumption of incarceration.
  • Third-degree offense: when a health care provider is accused of knowingly making less than five false, fraudulent, or misleading statements on any records or bills in the course of providing medical services and/or benefitting less than $1,000, this can result in 3-5 years in prison and fines up to $15,000.

Medical insurance fraud charges can only be charged as second- or third-degree offenses. A conviction for any one of these offenses can result in the loss of your medical license.

What Are the Medical Insurance Fraud Laws in New York?

In New York, medical insurance fraud is included within the state statute against insurance fraud. The crime of medical insurance fraud can be found within the New York Penal Laws starting at:

The New York Penal Laws divide insurance fraud into five different degrees under the insurance fraud statute as follows:

  • First-degree insurance fraud: if more than $1,000,000 is alleged to have been defrauded, a conviction can end in up to 25 years in prison.
  • Second-degree insurance fraud: if $50,000-$999,999 is alleged to have been defrauded, a conviction can result in up to 15 years in prison.
  • Third-degree insurance fraud: if $3,000-$49,999 is alleged to have been defrauded, a conviction can end in up to 7 years in prison.
  • Fourth-degree insurance fraud: if more than $1,000 but less than $3,000 is alleged to have been defrauded, a conviction can end in up to 4 years in prison.

An individual can also be charged with aggravated insurance fraud in the fourth degree if he or she commits insurance fraud and has been previously convicted of insurance fraud within the past five years.

Collateral Consequences of a Medical Insurance Fraud Conviction

If you are a doctor who holds a state medical license to practice, then the consequences of a medical insurance fraud conviction can be perilous. Medical licensing boards expect their licensed doctors to be honest and of good moral character. A conviction for a crime of dishonesty and broken trust such as medical insurance fraud can result in the loss of most any professional license.

A medical insurance fraud conviction can also result in severe trouble getting a job, housing, and the ability to do business with others. You can lose your constitutional right to own a gun, right to vote, and the ability to be accepted into a branch of the United States Military. If you are not a United States citizen, then a conviction for medical insurance fraud can have significant immigration consequences and can even result in your deportation.

How Can a Medical Insurance Fraud Conviction Hurt Your License to Practice Medicine?

If you hold a professional license of any kind, then you must follow all rules of ethics, or else your license can be suspended or revoked. Most professional organizations that oversee professional licenses have written ethics rules and regulations. One major requirement of medical licensure is good moral character. A crime of deceit such as medical insurance fraud can not only result in the suspension of your license, it can also result in you never being licensed again.

The Importance of Proper Professional License Defense

If you hold any type of professional license, then you likely realize its importance in your ability to earn a living and work in your desired profession. As a doctor, any claims made against you of medical insurance fraud or other forms of misconduct, even if untrue, can have a serious impact on your license to practice. Any accusation can start the process of an investigation that can affect your medical license, professional reputation, and ability make income. A claim of medical insurance fraud can also lead to substantial costs if the insurance company is claiming it suffered significant economic damages. If you are facing a medical insurance fraud accusation, then it is essential to speak to an attorney experienced in criminal defense as well as professional license defense as soon as possible.

How an Attorney Help You if You Are a Professional Who Is Facing a Medical insurance Fraud Charge

If you are a doctor who is facing a medical fraud charge, then it is important to a multi-faceted plan of attack for your defense. An attorney can help you investigate your case, negotiate on your behalf, and represent you in any matter or proceeding with your state licensing board. Medical licensing boards operate through a set of administrative rules that outline the boards' powers and how to conduct license proceedings dealing with their licensees. It is important that you understand that those on the licensing board are not your friends and are not there to cut you any breaks. Medical licensing boards exist to protect the public and promote the wellbeing of citizens by only awarding licenses to those they deem appropriate and fit to practice medicine. It is your responsibility to demonstrate to your licensing board that you are deserving of a medical license. Having the right attorney can be the difference between you having your license or being left without a way to earn your expected living as a medical professional.

Contact the Lento Law Firm Today

If you are a doctor who is facing a criminal charge related to an alleged act of medical insurance fraud, then it is important to speak to an attorney experienced in both criminal defense and professional license defense. Understanding how the criminal court system and your state licensing board intermingle is critical to deciding on your best legal approach. Attorney Joseph D. Lento and his team at the Lento Law Firm have the necessary knowledge and experience that you need to help you find success in defending both your criminal charge and your professional license. To learn why the Lento Law Firm is the right choice to help you fight for your freedom and your professional license, call us toll-free at 888-535-3686 or contact us online.

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