Healthcare fraud in California is commonly prosecuted as insurance fraud, medical billing fraud, Medicare fraud, or Medi-Cal fraud.
Investigations have increased significantly in recent years at both the state and federal levels.
Healthcare fraud cases are strictly prosecuted in California and can lead to felony charges, jail time, hefty fines, and revoked professional licenses.
Although some instances involve deliberate fraud schemes, many healthcare fraud claims originate from billing errors, clerical mistakes, or misunderstandings of complicated insurance regulations. Unfortunately, investigators and prosecutors frequently suspect criminal intent where none exists.
Because medical billing systems are complex, honest mistakes sometimes trigger criminal investigations. However, prosecutors must prove intent before a conviction can occur.
Your best chance at a positive outcome in a health care fraud case is with an experienced California criminal defense attorney at Cron, Israels & Stark. To schedule a consultation, call (424) 372-3112 or use the contact form here.
What Is Healthcare Fraud Under California Law?
Healthcare fraud is most often charged under California Penal Code 550.
Under this law, it is illegal to knowingly:
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Submit a false or fraudulent insurance claim
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Bill for services never provided
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Submit duplicate claims
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Prepare documentation supporting a fraudulent claim
To convict someone, the prosecutor must prove knowledge and intent to defraud.
Most Common Types of Healthcare Fraud in California
Healthcare fraud cases typically fall into several recurring categories.
Billing for Services Never Provided
This occurs when a claim is submitted for medical treatment, testing, or procedures that were not actually performed.
Examples include:
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Billing Medicare or Medi-Cal for appointments that never occurred
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Charging for diagnostic tests not administered
Upcoding (Billing for More Expensive Services)
Upcoding occurs when a provider bills for a more expensive procedure than the one actually performed.
Examples:
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Billing for complex surgery instead of a routine office visit
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Charging for extended treatment time not provided
Upcoding cases often involves aggressive loss calculations that increase sentencing exposure.
Double Billing (Duplicate Claims)
Submitting multiple claims for the same procedure is commonly known as “double-billing.”
Even automated duplicate submissions can trigger fraud charges if prosecutors allege intent.
Submitting False or Fraudulent Claims
This includes altering medical records or exaggerating diagnoses to obtain reimbursement.
Examples:
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Changing diagnosis codes to justify payment
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Billing under a provider number not authorized
These cases frequently rely on audits and forensic billing reviews.
Kickbacks and Referral Schemes
Kickback cases involve offering or receiving compensation for patient referrals.
Examples:
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Paying marketers for Medicare patients
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Receiving compensation for ordering laboratory tests
These cases may trigger both state and federal prosecution.
Prescription Fraud
Prescription fraud may involve falsifying prescriptions or unlawfully obtaining controlled substances.
In California, this may be charged under California Health and Safety Code 11173.
Workers' Compensation Fraud
Submitting false injury claims or billing for unperformed treatment under workers’ compensation insurance may also lead to healthcare fraud charges.
Why Healthcare Fraud Investigations Are Increasing
Healthcare billing involves:
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Complex coding systems
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Insurance preauthorization
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Diagnostic documentation
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Reimbursement calculations
With billions of dollars flowing through programs such as Medicare and Medi-Cal, enforcement has intensified.
However, complexity also increases the likelihood of administrative errors that are not criminal.
Elements of Healthcare Fraud (What Prosecutors Must Prove)
To obtain a conviction under Penal Code 550, prosecutors must prove beyond a reasonable doubt:
Knowledge
The defendant knew the claim was false, fraudulent, or duplicated.
Intent to Defraud
The defendant acted with specific intent to deceive the insurance provider or government program.
Intent is the central issue in nearly all fraud prosecutions.
Penalties for Healthcare Fraud in California
Penalties depend on the alleged amount of fraud.
Fraud Under $950 (Misdemeanor)
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Up to 6 months in county jail
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Up to $1,000 fine
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Probation
Fraud Over $950 (Wobbler Offense)
If charged as a felony, penalties may include:
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2, 3, or 5 years in county jail
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Probation with up to 1 year in county jail
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Fines up to $50,000 or double the alleged fraud
Healthcare professionals may also face:
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License suspension or revocation
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Professional discipline
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Exclusion from Medicare or Medi-Cal programs
Defenses to Healthcare Fraud Charges
Because healthcare billing systems are complex, common defenses include:
Lack of Intent
Errors or administrative oversights are not crimes without proof of intent.
Lack of Knowledge
If a defendant did not know a claim was false, criminal liability may not attach.
Clerical or Coding Errors
Billing software errors, data entry mistakes, or miscommunication can result in duplicate or inaccurate claims without fraud.
Is Filing Multiple Claims Always Fraud?
No.
The key legal question is whether the duplicate submission was intentional. If prosecutors cannot prove intent beyond a reasonable doubt, a conviction should not occur.
Healthcare Fraud Defense Attorney in Los Angeles
If you are under investigation or charged with healthcare fraud, early legal intervention is critical.
Our Los Angeles criminal defense attorneys represent:
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Physicians
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Nurses
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Therapists
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Medical office staff
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Billing clerks
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Practice owners
We analyze audit procedures, billing documentation, evidence of intent, and loss calculations to build a strategic defense.
Your professional license, reputation, and freedom may be at stake. Prompt legal guidance can make a substantial difference.
The Los Angeles-based criminal defense attorneys at Cron, Israels & Stark are here to help. Schedule your consultation today.
