S 177.00 Health care fraud; definition of terms.
The following definitions are applicable to this article:
1. “Health plan” means any publicly or privately funded health
insurance or managed care plan or contract, under which any health care
item or service is provided, and through which payment may be made to
the person who provided the health care item or service. The state’s
medical assistance program (Medicaid) shall be considered a single
health plan. For purposes of this article, a payment made pursuant to
the state’s managed care program as defined in paragraph (c) of
subdivision one of section three hundred sixty-four-j of the social
services law shall be deemed a payment by the state’s medical assistance
program (Medicaid).
2. “Person” means any individual or entity, other than a recipient of
a health care item or service under a health plan unless such recipient
acts as an accessory to such an individual or entity.
S 177.05 Health care fraud in the fifth degree.
A person is guilty of health care fraud in the fifth degree when, with
intent to defraud a health plan, he or she knowingly and willfully
provides materially false information or omits material information for
the purpose of requesting payment from a health plan for a health care
item or service and, as a result of such information or omission, he or
she or another person receives payment in an amount that he, she or such
other person is not entitled to under the circumstances.
Health care fraud in the fifth degree is a class A misdemeanor.
S 177.10 Health care fraud in the fourth degree.
A person is guilty of health care fraud in the fourth degree when such
person, on one or more occasions, commits the crime of health care fraud
in the fifth degree and the payment or portion of the payment wrongfully
received, as the case may be, from a single health plan, in a period of
not more than one year, exceeds three thousand dollars in the aggregate.
Health care fraud in the fourth degree is a class E felony.
S 177.15 Health care fraud in the third degree.
A person is guilty of health care fraud in the third degree when such
person, on one or more occasions, commits the crime of health care fraud
in the fifth degree and the payment or portion of the payment wrongfully
received, as the case may be, from a single health plan, in a period of
not more than one year, exceeds ten thousand dollars in the aggregate.
Health care fraud in the third degree is a class D felony.
S 177.20 Health care fraud in the second degree.
A person is guilty of health care fraud in the second degree when such
person, on one or more occasions, commits the crime of health care fraud
in the fifth degree and the payment or portion of the payment wrongfully
received, as the case may be, from a single health plan, in a period of
not more than one year, exceeds fifty thousand dollars in the aggregate.
Health care fraud in the second degree is a class C felony.
S 177.25 Health care fraud in the first degree.
A person is guilty of health care fraud in the first degree when such
person, on one or more occasions, commits the crime of health care fraud
in the fifth degree and the payment or portion of the payment wrongfully
received, as the case may be, from a single health plan, in a period of
not more than one year, exceeds one million dollars in the aggregate.
Health care fraud in the first degree is a class B felony.
S 177.30 Health care fraud: affirmative defense.
In any prosecution under this article, it shall be an affirmative
defense that the defendant was a clerk, bookkeeper or other employee,
other than an employee charged with the active management and control,
in an executive capacity, of the affairs of the corporation, who,
without personal benefit, merely executed the orders of his or her
employer or of a superior employee generally authorized to direct his or
her activities.