California law prohibits conduct that amounts to health care fraud. Notwithstanding this fact, healthcare fraud is a very common crime in California. Most people are unaware of how severe the penalties are if you are convicted; they do not understand the consequences of filing a claim for a benefit they are not entitled to. There are times where a patient, or even the medical professional, accidentally requests the wrong benefit. However, it is important to note that a key component of the crime is the specific intent to defraud the insurance company; accidents will not result in a conviction. If you are convicted you will face possible jail time, and a substantial fine for your act of fraud. 

California Penal Code §550, informs the public of what constitutes health care fraud. The statute has multiple rules, which apply to different actions that could form the basis of the conviction under §550. Some of the most common actions that could result in a conviction for health care fraud include:

  • Claiming a benefit that you are not actually entitled to.
  • Submitting a claim that never actually occurred.
  • Filing multiple claims for the same benefit. 
  • Claiming you are entitled to reimbursement for more money than you actually spent. 

EXAMPLE: 

Monica is a physician, last month she claimed reimbursement for services she provided to an elderly man, Dave. After investigating Monica’s claim, the insurance company came across Dave’s death certificate. Monica will be convicted of health care fraud if she is charge by the Prosecutor. 

The law under California Penal Code §550 was created by the legislature to identify the many acts that would constitute the crime of health care fraud. A detailed analysis of the various acts that form the basis of the §550 charge is set forth below.  

Types Of Health Care Fraud:

  • Fraudulent or false claim for benefits that the Defendant is not entitled to (P.C. 550(a) (6).)
  • Claiming a benefit that the Defendant never actually used. (P.C. 550(a) (7).)
  • Submitting more than one claim for the same benefit (P.C. 550(a) (8).)
  • Claiming you spent more money than you actually did.  (P.C. 550(a) (9).)

False Or Fraudulent Claim For Payment Of A Benefit.

A person may be found guilty of healthcare fraud if they attempted to file a claim for payment of a benefit they didn’t actually receive. Usually this act includes a physician claiming they provide services that their client never actually needed; alternatively, the physician may file a claim based on treatment that they never even did. 

EXAMPLE:

Shakti is a doctor located in downtown san Diego. One day, Sammy came to Shakti with a bruised rib. Shakti gave Sammy pain killers, and sent him on his way. When I came time to bill Sammy’s insurance provider, Shakti claimed that he conducted x-ray examinations, an EKG, a blood analysis, a stress test, and even started chemotherapy on Sammy. Shakti will be convicted of health care fraud because he is seeking reimbursement on a fraudulent claim. 

Claim For A Benefit That Was Not Used.

The law in California also prohibits a claim for services that was not used by the patient this means that if a doctor or patient file a claim, where they request money from the insurance provider for services that were never provided; they will be charged with health care fraud.

EXAMPLE: 

Dr. Beyoncé has been a dentist for nearly 20 years; this last year however, she has had her assistant seeing all of her patients. When it is time to bill the insurance company however, she bills them at her hourly rate instead of her assistant’s hourly rate. This could be considered health care fraud because Beyoncé is requesting money based on the services she purportedly provided to the patients. Because she never actually provided those services, she could be convicted of health care fraud. 

Multiple Claims For The Same Benefit

California law also makes it a punishable offense to knowingly file more than one claim for payment of the same benefit, with an intent to defraud the insurance company. 

EXAMPLES:

Clark and Brandon, who are both doctors, reach an agreement where they will bill the insurance companies extra to get more money. Every time a new patient comes in Clark provides his services to the patient, and bills the insurance company for his time, after a brief period of time Brandon also bills the insurance company for his time, even though he didn’t see the patient. Brandon and Clark may be convicted of health care fraud because they knowingly filed multiple claims for the same service, and their intent was to defraud the insurance company.

Overcharges Or Undercharges Claims.

§550 also makes it clear that you may be charged with health care fraud if you file a claim for more money than the cost of the service actually was. In other words, if you are trying to increase the amount of money you receive from the insurance company by artificially inflating the cost of the services you provided, you may be found guilty of health care fraud. 

What Are The Elements Of Health Insurance Fraud?

In order to be convicted of health care fraud, the Prosecution must prove two elements beyond a reasonable doubt. First, the Prosecutor must show that the Defendant was aware that the claims they filed were false or fraudulent. Second, the Defendant had the intent to defraud the insurance company when they made the false claim. 

Since the elements of this crime must be proven beyond a reasonable doubt, it is important to have an understanding of what those elements mean. The attorneys at Orange County Criminal Attorney have ample experience representing clients in a wide range of criminal charges, including health care fraud. With their exceptional knowledge and skill, your OCCA attorney will build the best case available with the facts of your case and fight for your acquittal or a reduced penalty if you are convicted of the crime. A detailed analysis of the elements of a §550 violation are set forth below.

What Does “Knowledge The Claim Was Fraudulent Or Fake” Entail?

A Defendant can only be convicted for violating §550, if he Prosecution can prove that they actually knew that their claim was fraudulent or false. For example, if there is a busy doctor’s office, and there are 5 people whose job I is to file claims with insurance companies after a patient receives treatment at their facility, and all five of them, unaware that someone else had already done it, file the same claim for reimbursement, the Prosecutor will not be able to maintain he charge against them because none of them knew that a claim had already been filed by one of their colleagues.  

What Is An Intent To Defraud?

Next, the Prosecution must prove that the Defendant had an intent to defraud the insurance company when they filed the false o fraudulent claim. As a practical matter, this will be a pretty simple task for the Prosecution to prove since there are not many reasons someone would knowingly file a false claim, other than to obtain money.

The Courts have made clear that there is an intent to defraud if the purpose of the action is to deceive another entity to cause a loss, or damage, to that persons property rights. Additionally, the definition of loss is anything that can be valued in dollars and sense form the victim, in this case actual money from the insurance company. 

What Penalties Will I Face If I Am Convicted Of Health Care Fraud?

If you are convicted of health care fraud in California you may face a charge in the form of a misdemeanor, or a charge in the form of a felony the distinction will be based on the value of what you obtained by defrauding the insurance companies. The distinction is based off the same distinctions that determine whether you are guilty of petty theft, or grand theft. It should be noted that, as a matter of course, the Prosecutor will charge you with theft along with the charge of health care fraud; this is nothing to be alarmed by. 

  • If you are charged with misdemeanor health care fraud you may face incarceration of up to one (1) year in jail, or a fine of up to ten thousand ($10,000), or a combination of both incarceration and a fine. 
  • If you were charged with felony health care fraud you may be penalized up to ten thousand ($10,000) dollars, and sentence to jail for a period ranging from two (2) , three (3), or five (5) years. 

What Legal Defenses Can My OCCA Attorney Raise If I Am Charged With Health Care Fraud?

As mentioned above the crime of health care fraud can be charged as either a felony or a misdemeanor depending on the value of what you defrauded the insurance company out of. If the value is less than $950, you will likely be charged with a misdemeanor. If the value is over $950, you will probably be charged with a felony. Regardless of the form of your conviction, I will appear on your criminal record, which appears whenever somebody conducts a background check on you. As a general rule of thumb, most employers routinely conduct a background check on people they are considering hiring for a position with their company. Employers tend to shy away from employees with a criminal history. This is made truer when the crime is a felony. Additionally, since this crime involves theft and honesty, employers may be particularly hesitant to hire you into their company. If you have been charged with health care fraud in California, contact an attorney at Orange County Criminal Attorney immediately. Having an OCCA attorney with you throughout the entire process will maximize your chances of receiving a favorable verdict, a lesser charge, or a lesser penalty. You OCCA attorney can raise a number of defenses to defeat the Prosecution’s case against you for health care fraud including:

  • You did not have the requisite knowledge that the claim was false of fraudulent. 
  • You never intended to defraud the insurance company