Insurance Fraud and Regulatory Compliance

Insurance fraud is vigorously investigated and prosecuted in the State of New Jersey. The most common types of investigations and prosecutions are health care fraud and property damage claims.

Insurance companies, the Department of Banking and Insurance (“DOBI”) and the Office of the Insurance Fraud Prosecutor (“OIFP”) investigate providers of health care services, as well as people who receive services when allegations of fraud have been made. Audits by insurance carriers and investigations by DOBI and OIFP implicate regulatory provisions under the New Jersey Administrative Code and privacy concerns under the Health Insurance Portability and Accountability Act (“HIPAA”). Lyons & Associates works proactively with health care providers to review and confirm regulatory compliance, the maintenance of proper records required by law, and compliance with the rights of patients to maintain the confidentiality of personal health care information.

In addition to potential investigations by the various government agencies, audits by insurance carriers should be handled carefully with the advice of counsel. If an insurance company suspects that there may have been fraud by a provider or consumer, it has an obligation to refer the matter to the Office of the Insurance Fraud Prosecutor.

The regulation of providers in the health care industry is extensive and complicated. It is critical to follow the provisions in the New Jersey Administrative Code in regard to the maintenance of patient records and to be careful in billing and coding practices when submitting claims. There are severe criminal penalties for health care fraud, and both providers and consumers must be careful in the processing and submission of claims. “Recklessly” submitting false health care claims is also a criminal offense in many states including New Jersey.

The criminal prosecution of insurance fraud is such a high priority that the legislature created an “Insurance Fraud Detection Reward Program”, creating an incentive bounty for any member of the public to report suspected insurance fraud.

The collateral consequences of a criminal prosecution may result in debarment of providers in the Medicare/Medicaid system, and/or and potential disciplinary action by the professional licensing boards with jurisdiction over health care professionals.

Lyons & Associates handles Medicaid and Medicare fraud investigations, the defense of allegations of insurance fraud, and provides preventive services by confirming regulatory compliance. 

If audited by an insurance company, or investigated by DOBI, or the OIFP, any provider or consumer would be well-advised to consult with counsel prior to given any interviews, statements, or providing any records.

The New Jersey insurance fraud lawyers at Lyons & Associates, P.C. will vigorously defend those rights and ensure that you get a fair trial and the outcome that you deserve. To learn more or to schedule a free consultation, call us at 908-575-9777 or contact us online