Health Care Fraud in San Diego
This is a type of white-collar crime that involves the filing of dishonest health care claims in order to turn a profit. Health care fraud is also commonly called medical insurance billing fraud, health insurance fraud, HMO fraud, Medicare fraud or Medi-Cal Fraud. These are booming areas of both criminal and law enforcement activity these days. A lot of the health care people receive in America today is paid for by someone other than the patient-whether it's a private medical insurance company or a government medical insurance program like Medicare or Medi-Cal.
The biggest reason for fraud schemes to take place is because of the complicated nature and infrastructure of the health care system. But in contrast, the confusing bureaucracy of medical bills also leads to plenty of opportunities for the authorities to accuse innocent people of health care fraud—often times for behavior that is just the result of honest mistakes. A substantial of health care fraud cases involve government programs like Medi-Cal (California's government-provided health insurance program for low-income, elderly, and disabled individuals). So it can be seen as "ripping off the taxpayers." And because of this, prosecutors can score big political points by going after people they suspect of committing health care fraud— including people who may have done nothing wrong.
Fraud May Be Committed by both a Member or a Practitioner
Practitioner Health Care Fraud:
- Individuals obtaining subsidized or fully-covered prescription pills that are actually unneeded and then selling them on the black market for a profit.
- Billing by practitioners for care that they never rendered.
- Filing duplicate claims for the same service rendered; altering the dates, description of services, or identities of members or providers.
- Billing for a non-covered service as a covered service; modifying medical record.
- Intentional incorrect reporting of diagnoses or procedures to maximize payment.
- Use of unlicensed staff.
- Accepting or giving kickbacks for member referrals.
- Waiving member co-pays.
- Prescribing additional or unnecessary treatment.
Health Care Fraud by Members:
- Providing false information when applying for programs or services.
- Forging or selling prescription drugs.
- Using transportation benefits for non-medical related purposes.
- Loaning or using another’s insurance card.
Health Care Fraud: A Break Down of the Most Common Types
Health care fraud generally involves the claims for payment of benefits that health care providers submit to health insurance companies or government health insurance programs.
California Penal Code section 550 makes it illegal to submit a claim for any sort of health care service or procedure that was not actually used by the person in whose name the claim is made. In other words, if you submit claims to a health insurance company for services that were never actually rendered, it is considered health care fraud.
You can also be charged with California health care fraud for submitting a false or fraudulent claim for health care benefits, such as:
- Performing a service that the patient didn't need and billing insurance for it.
- Billing insurance for a more expensive procedure or service than what the patient actually received.
- Applying charges to patients with insurance that are not applied to patients that pay out of pocket.
- Submitting multiple claims for the same medical service.
- Submitting undercharges without over charges. Penal Code 550 specifically makes it a crime to send a bill to a health insurer for services that were undercharged for in the past, without also sending at the same time a bill for services that were overcharged for in the past.
Medi-Cal Fraud/Medi-Care Fraud
Presenting false claims to Medi-Cal for services or merchandise, with an intent to defraud, violates Welfare and Institutions Code §14107b1. An intent to defraud is an intent to deceive another person for the purpose of gaining a material advantage over that person or to include that person to part with property or alter that person’s positions by some false statement or false representation of act, wrongful concealment or suppression of the truth or by an artifice or act designed to deceive. Intentional submission of false invoices constitutes Medi Cal fraud, as well.
Penalties for Health Care Fraud
Penal Code 550(a) prohibits most forms of health care and medical billing fraud in California.
If the allegedly fraudulent claims are worth no more than nine hundred fifty dollars in total, then the offense is a misdemeanor. In this case, the potential penalties are imprisonment in a county jail for up to six months, a fine of not more than one thousand dollars or both.
But if the claims in question total more than nine hundred fifty dollars ($950), then the offense of health care fraud is a wobbler. This means that it may be prosecuted as either a misdemeanor or a felony.
If it is charged as a felony, the maximum penalties are:
- A fine of up to fifty thousand dollars ($50,000) or double the amount of the fraud;
- Imprisonment for two, three or five years in county jail.
A health care fraud charge carries serious consequences, your criminal defense attorney will have to determine which legal defense theory will work best in your particular situation. These are some of the criminal defenses that we can assert on your behalf to help you overcome the charges for health care fraud filed against you:
- Lack of Knowledge
- Lack of Intent
- Mistake of Fact
If you are charged with health care fraud, especially if you are facing a serious fine or incarceration sentence, the best thing you could do is find a skilled criminal defense attorney, particularly find a local criminal defense attorney who knows the local San Diego judicial system. Local criminal defense attorneys know how local judges and local prosecutors work, and can use that knowledge to better represent you. While this may sound easy, but the reality is quite complicated. To make sure you get the best legal scenario possible, you should talk to a skilled criminal defense attorney. Call the Monder Law Group today at (619)405-0063 for more information.