Health Care Claims Fraud
Typically, health care claims fraud involves submitting a claim form to an insurance company that contains false information. The fraud allows an individual to obtain money from an insurer for services they did not provide or receive. Health care claims fraud can involve monetary compensation for treatment that was unnecessary, exaggerated, or never occurred.
A practitioner or their staff may be guilty of health care claims fraud if they attempt to obtain money for services they did not provide. A patient or person claiming to be a patient may be guilty of health care claims fraud if they attempt to obtain money for services they did not receive. People often attempt to receive “compensation” for treatments involving cash payments. Health care claims fraud can involve persons who are practitioners and non-practitioners. New Jersey statutes address the two groups of individuals differently.
Practitioners may be charged with a crime of the second degree for knowingly committing health care claims fraud in the course of providing professional services. The maximum penalty for a crime of the second degree is 5-10 years in prison and a fine up to $150,000. A person who has been convicted of this offense may be fined up to five times as much as the monetary benefit they obtained or sought to obtain.
A practitioner may be charged with a crime of the third degree if they recklessly commit health care claims fraud in the course of providing professional services. A crime of the third degree has a maximum penalty of between 3 and 5 years in prison and a fine up to $15,000. People who are convicted of recklessly committing health care claims fraud may be fined as much as five times the amount they obtained or sought to obtain.
A person who is not a practitioner may be charged with a crime of the third degree if they knowingly commit health care claims fraud. They may be charged with a crime of the second degree for knowingly committing five or more acts of health care fraud, and the monetary benefit obtained or sought to be obtained from the fraud is at least $1,000. A person who is not a practitioner may be fined up to five times the amount they obtained or sought to obtain.
A person who is not a practitioner may be charged with a crime of the fourth degree if they recklessly commit health care claims fraud. The maximum penalty for a crime of the fourth degree is up to 18 months in prison and a fine up to $10,000. If convicted, they may be fined up to five times the amount they obtained or sought to obtain. New Jersey considers each act of fraud a separate offense. Five or more separate acts may be grouped so that a higher degree of crime can be charged. If there are multiple acts of health care claims fraud in a single document, such as a bill or claim, each act is considered a distinct offense.
