Finance

When we mention crime, even white-collar crime, insurance fraud is not what immediately comes to mind. Yet, insurance fraud has lately become one of the front-runners among the most often prosecuted white-collar crimes in New Jersey.

In fact, New Jersey has the toughest criminal insurance fraud statutes in the country. The Health Care Claims Fraud statute, N.J.S.A. 21-4.3 and the Insurance Fraud statute, N.J.S.A. 2C:21-4.6, make many acts of insurance fraud second-degree crimes. For starters, a second-degree crime in New Jersey carries with it a prison term of up to ten years and fines of up to $150,000.

The vast majority of insurance fraud cases in New Jersey are investigated and prosecuted by the Office of Insurance Fraud Prosecutor (OIFP) and these cases involve all thinkable areas of insurance fraud, including health, life, disability, auto, homeowners’ or commercial insurance coverages.

According the 2007 OIFP report, there was “a 10% increase in criminal sentences over last year’s figure and sent defendants to prison for a combined total of 147 years”. The report exemplifies the wide array of individuals who found themselves in trouble for insurance fraud: ” In 2007, OIFP recorded OIFP won convictions of four former police officers, two of whom will serve a total of 12 years in State prison. Four licensed health care providers received State prison sentences totaling 12 years. A licensed insurance agent was sentenced to a five-year State prison term. An auto body shop owner and his accomplice were sent to State prison for a total of nine years. The sentences imposed on several members of vehicle theft rings totaled 77 years in State prison, over $1.8 million in restitution, and $9,500 in civil insurance fraud fines”. The list goes on.

So, what is “insurance fraud” made of? One large area of Insurance fraud in New Jersey is Automobile Insurance Fraud. The most popular crime here is auto theft and “give up schemes”, where the owner or lessee of a car abandons the car or gives it up to a someone who agrees to dispose of the car. Next come staged accidents and fraudulent Personal Injury Protection Claims and criminal use of “runners”. These types of cases normally involve organized rings of “runners”, medical providers, and lawyers. Vehicle Insurance policies in New Jersey provide medical benefits for persons injured in car accidents as part of Personal Injury Protection (PIP) coverage. PIP insurance typically covers diagnostic testing and treatment for persons injured in automobile accidents. In many cases, uninjured passengers involved in accidents are contacted by “runners” who convince them to file claims for “soft tissue” injuries, such as “whiplash”. Such injuries are not easily verifiable by x-rays and MRI. In the end, “runners” receive their illegal commissions, medical and chiropractic mills provide unnecessary medical services, including fake diagnostic and treatment, for which they bill, and lawyers file unwarranted lawsuits.

Other case involving New Jersey Automobile Insurance Fraud are selling and buying fake insurance ID cards and insurance agent fraud where licensed agents steal insurance premiums or are engaged in fraudulent premium financing schemes.

Another large area that pays bills for New Jersey insurance fraud criminal defense attorneys is Health Care insurance fraud. Most such cases involve submitting fraudulent claims for payment for health care services that were never provided and received. The most often targeted individuals here are New Jersey doctors, dentists, chiropractors, nurses, physical therapists, pharmacists, and social workers.

The most widely used tool in New Jersey heal care insurance fraud prosecutions is the Health Care Claims Fraud status, N.J.S.A. 2C:21-4.3 that makes it a crime for any health care provider just to submit a false claim to insurance companies, no matter what the amount is. A non-provider only needs to submit a false claim for $1,000 to have committed a second-degree crime. Other criminal charges used in prosecutions of New Jersey health care insurance fraud cases are usually charges of theft, conspiracy, and falsifying records.

Another area of New Jersey insurance fraud is life and disability insurance fraud, both governed by the Insurance Fraud Statute, N.J.S.A. 2C:21-4.6. Life insurance fraud offense is submitting a claim that falsely represents death of a claimant or otherwise misrepresenting important facts concerning the claim. Disability fraud involves faking a non-existing condition in order to receive benefits or knowingly failing to disclose new income.

Probably the largest single area of New Jersey Insurance Fraud is Medicaid fraud, which is investigated and prosecuted by the OIFP’s Medicaid Fraud Section. New Jersey Medicaid Fraud can be committed by any health care provider that participates in the Medicaid program. New Jersey physicians, dentists, clinics, chiropractors, pharmacists, laboratories, nursing homes, etc. are routinely prosecuted for New Jersey Medicaid fraud.

The basic New Jersey Medicaid fraud crime involves billing the Medicaid program for services that were never provided or might not be provided by the billing provider, or when the amount billed exceeds the costs of services performed (over billing). Other Medicaid fraud charges in New Jersey may be associated with charges of patient abuse and criminal neglect.

Another related New Jersey Medicaid fraud area is Medicaid prescription and drug diversion fraud. This involves pharmacies billing Medicaid for drugs that were not actually dispensed. Doctors, who sometimes form “partnerships” with pharmacies to engage in this fraud, are understandably find themselves in deep trouble as well.

Home health care fraud is the last largely prosecuted New Jersey Medicaid fraud crime. Medicaid pays for personal care provided for eligible beneficiaries by certified home care assistants, aides, and nurses, all of whom must be certified and licensed by the State to participate in the program. Criminal activities in this are involve billing for services that were not provided, employing non-certified providers, and lying in the certification process.

New Jersey insurance fraud is a wide area and persons facing any of the insurance fraud charges should seek legal counsel as soon as they discover that they are under investigation. A consultation with a competent New Jersey fraud defense attorney is absolutely indispensable.