New Jersey Health Care Fraud

Health Care Fraud

Healthcare Claims Fraud is a common and diverse crime in New Jersey.

Defendants may include a patient who falsifies or exaggerates an injury or a doctor that is engaging excessive billing, false billing, duplicate billing or a with other New Jersey doctors

Healthcare fraud investigations often start with an entity that is not directly connected to a law enforcement agency such as an insurance company. In fact, some insurance companies employ former police officers that investigate alleged healthcare fraud. This is important for two reasons. First, anything a target or defendant says to these investigators can be used against them. Second, a knowledgeable healthcare fraud attorney may be able to negotiate with the insurance company investigator to reach a civil resolution before it gets to law enforcement. This lag time between investigation and prosecution also allows a healthcare fraud attorney to prepare to defend against a potential prosecution well before any law enforcement agencies are contacted.

New Jersey’s Health Care Fraud Penalties

New Jersey’s Health Care Fraud Statute is found within Title 2C. The New Jersey Code of Criminal Justice; Subtitle 2. Definition of Specific Offenses; Part 2. Offenses Against Property; Chapter 21. Forgery and Fraudulent Practices; 2C:21-4.3. Health care claims fraud; elements; penalties; evidence

As the statute states, Health care fraud may be a second degree crime for practitioners who commit Health care fraud.  This means that a defendant can be sentenced up to 10 years in New Jersey State prison.  Additionally, a practitioner may be fined up to five times the pecuniary benefit obtained or sought to be obtained.

For patients, Health care fraud usually is a third degree crime which has the possible exposure of 5 years in New Jersey State prison.  The crime may a second degree crime if the defendant commits more than 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. In addition to all other criminal penalties allowed by law, a patient convicted under this subsection may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained.

New Jersey’s Health Care Fraud Statute

2C:21-4.3. Health care claims fraud; elements; penalties; evidence

a. A practitioner is guilty of a crime of the second degree if that person knowingly commits health care claims fraud in the course of providing professional services. In addition to all other criminal penalties allowed by law, a person convicted under this subsection may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained.

b. A practitioner is guilty of a crime of the third degree if that person recklessly commits health care claims fraud in the course of providing professional services. In addition to all other criminal penalties allowed by law, a person convicted under this subsection may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained.

c. A person, who is not a practitioner subject to the provisions of subsection a. or b. of this section, is guilty of a crime of the third degree if that person knowingly commits health care claims fraud. A person, who is not a practitioner subject to the provisions of subsection a. or b. of this section, is guilty of a crime of the second degree if that person 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. In addition to all other criminal penalties allowed by law, a person convicted under this subsection may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained.

d. A person, who is not a practitioner subject to the provisions of subsection a. or b. of this section, is guilty of a crime of the fourth degree if that person recklessly commits health care claims fraud. In addition to all other criminal penalties allowed by law, a person convicted under this subsection may be subject to a fine of up to five times the pecuniary benefit obtained or sought to be obtained.

e. Each act of health care claims fraud shall constitute an additional, separate and distinct offense, except that five or more separate acts may be aggregated for the purpose of establishing liability pursuant to subsection c. of this section. Multiple acts of health care claims fraud which are contained in a single record, bill, claim, application, payment, affidavit, certification or other document shall each constitute an additional, separate and distinct offense for purposes of this section.

f. (1) The falsity, fictitiousness, fraudulence or misleading nature of a statement may be inferred by the trier of fact in the case of a practitioner who attempts to submit, submits, causes to be submitted, or attempts to cause to be submitted, any record, bill, claim or other document for treatment or procedure without the practitioner, or an associate of the practitioner, having performed an assessment of the physical or mental condition of the patient or client necessary to determine the appropriate course of treatment.

(2) The falsity, fictitiousness, fraudulence or misleading nature of a statement may be inferred by the trier of fact in the case of a person who attempts to submit, submits, causes to be submitted, or attempts to cause to be submitted any record, bill, claim or other document for more treatments or procedures than can be performed during the time in which the treatments or procedures were represented to have been performed.

(3) Proof that a practitioner has signed or initialed a record, bill, claim or other document gives rise to an inference that the practitioner has read and reviewed that record, bill, claim or other document.

g. In order to promote the uniform enforcement of this act, the Attorney General shall develop health care claims fraud prosecution guidelines and disseminate them to the county prosecutors within 120 days of the effective date of this act.

h. For the purposes of this section, a person acts recklessly with respect to a material element of an offense when he consciously disregards a substantial and unjustifiable risk that the material element exists or will result from his conduct. The risk must be of such a nature and degree that, considering the nature and purpose of the actor’s conduct and the circumstances known to him, its disregard involves a gross deviation from the standard of conduct that a reasonable person would observe in the actor’s situation.

i. (1) Nothing in this act shall preclude an indictment and conviction for any other offense defined by the laws of this State.

(2) Nothing in this act shall preclude an assignment judge from dismissing a prosecution of health care claims fraud if the assignment judge determines, pursuant to N.J.S.2C:2-11, the conduct charged to be a de minimis infraction.

CREDIT(S)

L.1997, c. 353, § 3, eff. Jan. 15, 1998. Amended by L.2003, c. 89, § 75, eff. June 9, 2003.

De Minimis Infractions

New Jersey Lawyers may also bring De Minimis Infraction motions before the Superior Court Assignment Judge in County where the charges are lodged. Here, the New Jersey Health Care Fraud statute specifically states that “Nothing in this act shall preclude an assignment judge from dismissing a prosecution of health care claims fraud if the assignment judge determines, pursuant to N.J.S.2C:2-11, the conduct charged to be a de minimis infraction.” It is very interesting and important to know that this is specifically included by the New Jersey legislatures.

2C:2-11. De minimis infractions

The assignment judge may dismiss a prosecution if, having regard to the nature of the conduct charged to constitute an offense and the nature of the attendant circumstances, it finds that the defendant’s conduct:

a. Was within a customary license or tolerance, neither expressly negated by the person whose interest was infringed nor inconsistent with the purpose of the law defining the offense;

b. Did not actually cause or threaten the harm or evil sought to be prevented by the law defining the offense or did so only to an extent too trivial to warrant the condemnation of conviction; or

c. Presents such other extenuations that it cannot reasonably be regarded as envisaged by the Legislature in forbidding the offense. The assignment judge shall not dismiss a prosecution under this section without giving the prosecutor notice and an opportunity to be heard. The prosecutor shall have a right to appeal any such dismissal.

CREDIT(S)

L.1978, c. 95, § 2C:2-11, eff. Sept. 1, 1979.

Other New Jersey Fraud Statutes

2C:21-4.1. Purposeful destruction, alteration or falsification of record relating to care of medical or surgical or podiatric patient in order to deceive or mislead

A person is guilty of a crime of the fourth degree if he purposefully destroys, alters or falsifies any record relating to the care of a medical or surgical or podiatric patient in order to deceive or mislead any person as to information, including, but not limited to, a diagnosis, test, medication, treatment or medical or psychological history, concerning the patient.

CREDIT(S)

L.1989, c. 300, § 15, eff. Jan. 12, 1990.

2C:21-4.2. Definitions relating to health care claims fraud

As used in this act:

“Health care claims fraud” means making, or causing to be made, a false, fictitious, fraudulent, or misleading statement of material fact in, or omitting a material fact from, or causing a material fact to be omitted from, any record, bill, claim or other document, in writing, electronically or in any other form, that a person attempts to submit, submits, causes to be submitted, or attempts to cause to be submitted for payment or reimbursement for health care services.

“Practitioner” means a person licensed in this State to practice medicine and surgery, chiropractic, podiatric medicine, dentistry, optometry, psychology, pharmacy, nursing, physical therapy, or law; any other person licensed, registered or certified by any State agency to practice a profession or occupation in the State of New Jersey or any person similarly licensed, registered, or certified in another jurisdiction.

CREDIT(S)

L.1997, c. 353, § 2, eff. Jan. 15, 1998. Amended by L.2005, c. 259, § 20, eff. Jan. 4, 2006.

Types of Fraud Crimes in New Jersey

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