Insurance fraud encompasses any intentional act designed to obtain an insurance benefit to which the claimant is not entitled. It can be committed by policyholders inflating claims, by healthcare providers billing for services not rendered, or by individuals staging accidents or losses. Under New York Insurance Law §403 and related Penal Law provisions, insurance fraud is charged in five degrees, from misdemeanor to Class B felony, based on the value of the fraudulent claim.

Healthcare fraud is a particularly active area of enforcement, pursued by both state and federal authorities. Physicians, billing companies, and clinical staff have all faced prosecution in recent years for submitting false claims to Medicare, Medicaid, and private insurers. Federal healthcare fraud charges under 18 U.S.C. §1347 carry up to ten years in prison per count, and the government has substantial investigative resources dedicated to these cases.

The line between intentional fraud and administrative error is thinner than prosecutors often acknowledge. Billing code disputes, documentation gaps, and good-faith interpretations of complex regulatory guidelines — including Medicare and Medicaid reimbursement rules that even compliance professionals find difficult to navigate — are routinely charged as criminal conduct when they are not.

At Nonaj Law, we scrutinize whether the government can actually prove intent, and we build defenses around what the evidence genuinely shows. Contact us today for a confidential consultation.