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Health Care Fraud in California

Review of Health Care Fraud Cases in California

Health care fraud in California is often called insurance fraud, medical billing fraud, Medicare fraud or Medi-Cal Fraud. The amount of health care fraud allegations and criminal prosecutions have risen sharply over the past several years.

Health Care Fraud Cases in California
Many health care fraud cases in California are directly related to Medicare or Medi-Cal Fraud.

Most patients pay for their health care through either a private insurance company or a government medical insurance program. The procedure for processing health care payments are normally complex, which opens the door to commit fraud.

However, the complexity of medical billing can also open a door for an innocent person to face allegations of health care fraud after they committed an error, but it was an honest mistake.

Many health care fraud cases are related to government programs such as Medi-Cal, which is designed to help low-income and elderly patients.

The health care system in America is often the subject of much debate, but the one thing everyone is in agreement on is that the system is complicated.

Even for a routine visit to the family doctor, you can often wind up filling out numerous pages of forms. Meanwhile, the doctor has his own stack of paperwork to complete, and bills get figured and paid based on complicated actuary tables.

It is no wonder that estimates put annual health care fraud costs somewhere between $68 billion and $230 billion. Amid all that chaos, fraudsters are simply convinced they won't get caught.

For those of us less well-versed in the game, though, what exactly is the white collar crime of health care fraud? 

Our Los Angeles criminal defense lawyers are providing more information below.

Basic Kinds of Health Care Fraud

Of course, there are always new schemes, but generally speaking, health care fraud comes in one of three varieties:

  • billing for services a patient never received;
  • submitting false of fraudulent claims;
  • billing for more expensive services than a patient received;
  • submitting duplicate billing claims for the same procedure;
  • preparing a document to support a fraudulent claim;

California Penal Code 550 PC makes it a crime to submit a claim for health care services or procedures that was not actually received by the person who is named on the claim.   

California Health Care Fraud
Health care fraud cases often include billing for services the patient never received.

In other words, submitting a claim to a health insurance company for services that were never delivered is a form of health care fraud.

Another common form of health care fraud under Penal Code 550 PC is when someone submits multiple claims for the same medical service, which is commonly known as “double billing” the insurance provider.

Usually, it is health care providers themselves who are charged, such as doctors, nurses, therapists.

However, PC 550 states that records clerks and medical secretaries can be charged as well.

In fact, just creating a document supporting a fraudulent scheme is considered fraud, which means it's possible to get caught up in criminal activity without even realizing it.

Prosecuting Health Care Fraud Cases

Ironically, the same chaos that makes it tempting to commit health care fraud makes it tempting to prosecute health care fraud.

With so much confusion, doctors can and do make mistakes. It isn't unusual for prosecutors to try and make a name for themselves as “defenders of the taxpayer” by going after anything that even resembles fraud.

And again, with so much paperwork flying around, they can often build a case no matter the realities of the situation.

Elements of the crime

However, in order to convict someone of someone of health care fraud, the prosecutor must be able to prove two crucial factors that are commonly known as the “elements of the crime.”

In other words, before a prosecutor can obtain a conviction, they must prove beyond any reasonable doubt the following:

Prosecuting California Health Care Fraud Cases
The prosecutor must be able to prove you knew the claim was false and had an intent to defraud.

Defendant knew the claim was false or fraudulent

You can't be convicted of health care fraud in California unless it can be shown you knew that the claim you were submitting was fraudulent or a duplicate claim, or the documents you prepared would be used to submit a false claim. 

Defendant had an intent to defraud

Further, you can't be convicted of health care fraud if the prosecutor is unable to prove, beyond a reasonable doubt, that you had a specific intent to defraud the medical insurance company or the insurance program. 

Intent is the primary factor is almost all fraud crime in the state of California. If reasonable doubt can be created by your defense lawyer, then you might have a good chance at avoiding a conviction.

Penalties for a California Health Care Fraud Conviction

Health care fraud penalties are severe. In California, cases involving less than $950 are treated as misdemeanors and can be punished by:

  • up to six months in county jail,
  • a $1000 fine, or both.

Fraud over $950 can be treated either as a misdemeanor or felony which is known as a “wobbler.”

If convicted of felony health care fraud, the penalties include:

  • two, three, or five year sentence in county jail,
  • probation with up to one year in a county jail,
  • up to $50,000 in fines or double the amount of the fraud itself.

Further, if the defendant is a health care professional, then they could have their professional license suspended or revoked.

The related crimes for health care fraud in California include Health and Safety Code 11173 prescription fraud, and workers’ compensation fraud.

Defending California Health Care Fraud Cases

Finally, though, all the chaos in the health care system can also work to a defendant's advantage.

The standard defenses against health care fraud are lack of intent, lack of knowledge, and simple mistakes.

Defending California Health Care Fraud Cases
Contact our firm to discuss the details of the case.

In short, prosecutors must prove an individual set out to commit fraud. Yet again, amid all the confusion in the health care system, that can be a high standard to meet.

Is filing multiple claims for the same procedure an instance of fraud, or merely an oversight made by an overworked office clerk?

In the end, precisely because health care fraud is such a complex crime, it can often be successfully defended.

If you are facing accusations of health care fraud, then you need to contact our experienced team of criminal defense attorneys to review the case.

Prefiling intervention by our law firm might be able to convince the prosecutor from filing formal charges before court. 

Eisner Gorin LLP is a criminal defense law firm with a record of success defending individuals who were accused of health care fraud throughout Southern California.

Contact our office online or by phone at (310) 328-3776.

We speak English, Russian, Armenian, and Spanish.

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