Submitting False Insurance Claims
California health care fraud cases have many different names, but all have similar illegal behavior. Some of the names include medical billing fraud, insurance fraud, Medicare fraud, and Medi-Cal Fraud. The number of health care fraud accusations and prosecutions has significantly risen over the past decade.
Most patients will pay for their health care costs through a private insurance company or a medical insurance program offered by the government. The administrative procedures for processing health care payments are often confusing and complex, influencing many people with ill motives to commit fraud.
However, this complex medical billing system has also created a situation where innocent people are being accused of health care fraud because they made an error on the forms, but it was an honest mistake.
Many healthcare fraud cases are directly connected to government programs such as Medi-Cal, which is primarily designed to help low-income and elderly patients.
America's health care system is often debated, and there are many different opinions. However, most people agree the overall design is too complicated.
For example, a routine physical at a doctor's office will typically involve the patient completing many different forms. Likewise, the doctor and staff will have their forms to complete that include billing statements based on complicated actuary tables.
In all the chaos and confusion in medical billing procedures, fraudsters believe their illegal actions will go unnoticed as they fall through the cracks in the system. Our California criminal defense lawyers will cover this topic in more detail below in this article.
What Are the Basic Types of Health Care Fraud?
Generally speaking, health care fraud occurs in many different forms, such as the following:
- billing for services patients did not receive;
- submitting false or fraudulent insurance claims;
- billing for more expensive services a patient received;
- submit duplicate billing claims for the same procedure;
- preparation of documents to support fraudulent claims;
California Penal Code 550(a)(1) PC makes it a crime to “knowingly present, or cause to be presented, any false claim for the payment of a loss or injury, including payment of a loss or injury under a contract of insurance.”
This describes the most common form of health insurance fraud: claiming benefits under a health insurance plan for an injury that is not legitimate—for instance, submitting a claim for benefits under a policy that protects them from injuries sustained on the job when the injury occurred at home.
Penal Code 550(b)(1) PC makes it a crime to “present any statement in support of or opposition to, a claim for payment knowing the statement contains any false or misleading information concerning any material fact.”
This subsection penalizes the making of false or misleading statements to claim improper benefits. For instance, when someone knowingly provides false information on a questionnaire from an insurance company about their policy.
Additionally, Penal Code 550 PC prohibits submitting a claim for health care services or procedures not received by someone named on the claim. Simply put, submitting claims to a health insurance company for services never delivered is a type of health care fraud.
Further, Penal Code 550 PC health care fraud law also covers a situation where someone submits multiple claims for the same medical service, known as “double billing,” the insurance provider.
Typically, health care providers are charged with violating PC 550, such as doctors, nurses, therapists, medical secretaries, and clerks. If someone creates a document to support a fraudulent scheme, it's also considered part of the fraud. In some cases, people within the medical office unknowingly violate the law.
How Are Health Care Fraud Cases Prosecuted?
To convict someone of PC 550 health care fraud, the prosecutor has to prove, beyond a reasonable doubt, some crucial factors called the “elements of the crime.”
Defendant knew the claim was false or fraudulent – It must be proven you knew that the claim you submitted was fraudulent. Otherwise, you can't be guilty of health care fraud.
Defendant had an intent to defraud - You can't be convicted of health care fraud if the prosecutor cannot prove, beyond a reasonable doubt, that you intended to defraud the medical insurance company or the insurance program. In other words, the prosecutor has to show you had criminal intent, not a mistake.
The intent is the primary factor in almost all fraud crimes in California. If reasonable doubt can be created on this factor, you might have a good chance of avoiding a conviction.
What Are the Penalties for a Conviction?
If you are convicted, the health care fraud penalties are harsh. In rare cases involving less than $950 loss, it's a misdemeanor with the following penalties:
- up to six months in county jail,
- a $1000 fine, or both.
Any fraud over $950 is a “wobbler” that can be charged as a misdemeanor or felony. If convicted of a felony health care fraud case, the penalties include:
- two, three, or five-year sentences in jail,
- probation with up to one year in county jail,
- fines up to $50,000 or double the amount of the fraud itself.
If the defendant is a health care professional, they will be facing having their professional license suspended or revoked. The related crimes in California include Health and Safety Code 11173 HS prescription fraud and workers' compensation fraud.
How Can You Fight Health Care Fraud Allegations?
If you are under investigation or already charged with health care fraud, we need to review all the details to determine the best defense strategy. The common defenses against health care fraud are lack of intent, lack of knowledge, and simple mistakes.
Recall that a prosecutor must prove someone set out to commit fraud. Also, recall the discussion above about all the confusion in the health care system procedures.
If you are accused of filing multiple claims for the same procedure, was it fraud or oversight made by an office clerk? Perhaps there was a lack of intent to commit the offense. Maybe we can negotiate with the prosecutor for reduced charges or get the case dropped.
Through prefiling negotiations, we may be able to persuade the District Attorney from filing formal criminal charges in the first place, called a “DA reject.”
Cron, Israels, and Stark are based in Los Angeles County, and we represent people across Southern California. Our firm offers a free case consultation by phone or by filling out our contact form.