There are many types of healthcare and medical billing fraud, most of which are prohibited by California Penal Code 550(a) PC. If you’re in a jam, you need the help of a skilled healthcare fraud defense attorney.
According to sources, the healthcare payment system is inherently complex, and it’s the complexity that makes committing healthcare fraud so easy. However, the methods to commit medical billing fraud aren’t foolproof.
Penal Code 550(a) PC comprises health care fraud laws that prohibit the preparation of documents to submit false or multiple claims. Medical billing fraud laws prohibit medical practitioners from billing for services not provided and exaggerating the expense of medical services provided.
What You Need to Know About Healthcare Fraud in California
Healthcare fraud can be committed by medical care practitioners and other healthcare providers, medical facility staff, and patients. It can be defined as intentionally submitting or causing someone else to submit false or fraudulent claims to government agencies and medical insurance providers.
Private medical insurance companies and government medical insurance programs like Medicare or Medicaid are vulnerable to healthcare fraud.
Potential fraud cases in California are investigated by at least eight law enforcement agencies, including state fraud prevention and state Medicaid fraud control units, the Department of Justice (DOJ) healthcare Fraud Strike Force, the Department of Health and Human Services Office of the Inspector General (OIG), the Federal Bureau of Investigation (FBI), and the Drug Enforcement Administration (DEA).
Two Statutes that Form the Basis of Healthcare Fraud in California
In addition to Penal Code 550(a) PC, healthcare fraud in California is covered by two statutes.
- California Penal Code § 549 applies to people who solicit, accept, or refer business to or from any individual or entity that intentionally or recklessly disregards whether the parties involved will file a false insurance claim. Basically, it prohibits individuals from referring a person to a medical provider solely to file an insurance claim.
- California Penal Code § 550 is more common than § 549. It prohibits intentionally filing false statements to support an insurance claim. Basically, people are prohibited from signing insurance provider documents that they know to contain false information. This includes billing for unnecessary medical procedures and inflating the degree of treatment to make it more expensive.
Different Types of Healthcare Fraud
There are several types of healthcare fraud, the most common of which include:
Submitting False Claims
This is as straightforward as it gets. Individuals submit an insurance claim they know is false. Examples include:
- Medical practitioners perform and bill for unnecessary services or procedures.
- Medical practitioners inflate costs, for instance, by performing one procedure but billing for a more expensive service, also known as upcoding.
The second example is often favored because it slips under the radar and is easy to get away with.
If you’re accused of submitting false claims, turn to a criminal defense attorney specializing in healthcare fraud.
Claims for Non-Existent Services or Phantom Billing
This is a type of false billing that is also pretty straightforward because all it requires is for an individual to submit a claim for medical procedures that weren’t performed.
In some instances, many medical practitioners bill for the same procedure that one person performed.
Double Billing or Unbundling
Double billing occurs when a medical practitioner performs a procedure or carries out a service that they bill for at least twice. For example, billing for setting a broken arm and then billing for a general check-up too.
This is not one of the common healthcare fraud methods. It tends to be an opportunistic form of fraud that results from an honest mistake.
A healthcare provider may accidentally submit a claim for less than the full cost of the procedure and send an additional bill to collect the remainder. However, any overcharges from the insurance company are kept quiet. Legally speaking, this is a form of healthcare fraud.
Other healthcare fraud schemes in brief:
- Identity swapping: Using someone else’s insurance or letting someone else use your insurance.
- Impersonating a medical practitioner: Carrying out procedures and/or billing without a license.
- Forgery: Writing and/or using forged prescriptions.
- Diversion: Selling your prescription medication to someone else.
- Doctor shopping: Visiting several medical practitioners with the same or similar complaint to receive multiple prescriptions for drugs that are considered controlled substances.
Prosecuting Healthcare Fraud Cases
To prove an accused’s guilt, prosecutors must prove the two elements of healthcare fraud.
- The defendant knew the claim wasn’t legitimate.
- The defendant intended to commit fraud.
It’s difficult to prove both elements beyond a reasonable doubt, so all your defense attorney has to do is create doubt in the judge’s and jurors’ minds.
Prosecutors also include a number of factors when putting together their case against the defendant. These include the amount of money defrauded, the number of victims, the extent to which the victims were harmed, and the advanced nature of the crime.
LibertyBell has a team of healthcare fraud defense lawyers in California to plan your defense in a way that pokes holes in all of the prosecutor’s allegations.
California Healthcare Fraud Penalties
If the amount defrauded is less than $950, it’s a misdemeanor with sentences that include up to six months in county jail and/or a $1000 fine.
As soon as the amount goes over $950, it becomes a wobbler offense. This means that the prosecutor can choose to charge defendants with either a misdemeanor or felony.
If convicted of a felony, defendants face prison sentences of two, three, or five years or probation with up to one year in county jail or fines up to $50,000 or double the defrauded amount, depending on which is higher.
If the accused is a medical practitioner accused of defrauding health insurers, their professional license might be revoked or at least suspended.
Fight Allegations with a Trusted Healthcare Fraud Defense Attorney
LibertyBell Law Group is a trusted law practice that delivers unparalleled legal defense to those accused of white-collar crime, including healthcare fraud. We’re the natural choice when you’re choosing a healthcare fraud defense attorney because we provide unique services.
Simply put, the care and effort we put into pre-trial preparation give us the basis for creating sound defense arguments. Full knowledge of the facts enables our attorneys to rebut the prosecutor’s allegations easily.
A guilty verdict will virtually ruin your future prospects. To save your reputation, contact us at LibertyBell Law Group today!
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