Health Care Fraud

When you face a charge for committing health care fraud in Anaheim, you could face extensive jail time besides a damaged reputation, permanent criminal record, and loss of your professional license. To skip these harsh consequences, you must work with a compassionate and passionate criminal defense attorney experienced in handling healthcare fraud cases.

At California Criminal Lawyer Group, our attorneys have defended clients facing similar crimes for decades. The attorneys have intricate knowledge of handling fraud cases. We are also familiar with the California court system.

Therefore,  it is best to work with our determined attorneys immediately after your arrest. We listen to your case and evaluate and develop the best defense strategies to help you fight the charges.

Understanding Health Care Fraud in California

Healthcare fraud involves filing false insurance claims to obtain profits. Healthcare fraud occurs in several forms. Common healthcare fraud in California includes medical, insurance, and drug fraud. The law classifies all these frauds as white-collar crimes.

The perpetrators of the crime can also be big companies intending to defraud insurance providers. When a fraud crime occurs, the affected person or entity can claim their money by filing a lawsuit.

What are the Elements of Health Care Fraud in California

When the prosecution team accuses you of health care fraud, they prepare a strong case and persuade the jury/judge to convict you. Note the prosecution team must prove the elements of the crime before you face conviction. It means they must prove all the elements of your case.

Proving the elements of the case light can be a challenging process. Therefore your criminal defense attorney can use the prosecutor’s loopholes to fight the case. The main elements of healthcare fraud in California include the following:

You Knowingly Tried to Commit Health Care Scheme

The prosecutor must show you are intentionally or knowingly involved in the scheme. Also, based on the situation of your case, the prosecutor can prove you attempted to commit the scheme. Remember, the prosecutor must attach evidence to support their claim. For example, they might include paperwork showing preparations to file a claim to the government entity.

These documents might be either medical receipts or letters of claim. The papers are essential since they help prove the perpetrator intended to create a scheme. Again, the prosecutor must show you were directly involved in creating the falsified content.

The Scheme Involved False Pretense

The second element the prosecutor must prove is that the scheme aims at defrauding health care. The prosecutor needs to show you participated in the pretense or fraud. Remember, fraud involves making false information or presenting untruthful details to trick someone and agree to your request.

Pretense includes untruthful facts you offer as an excuse or jurisdiction to receive benefits you cannot obtain. For example, you face charges when you lie about suffering from a terminal disease, then forge a doctor's record to support your argument.

Your Intent to Defraud

The prosecutor must show you intend to commit the crime to achieve specific goals. Proving the element is essential since it explains why you intend to commit the crime. As the perpetrator, you might be pushed by certain factors to commit the crime. These factors include exemptions, services, goods, and money.

The investigators can obtain your financial information by obtaining a financial statement. Therefore, you must speak with your lawyer immediately when you find yourself behind bars for any healthcare fraud. The lawyer will do everything possible to ensure you fight the charges.

Forms of Healthcare Fraud in California

Healthcare fraud occurs in several forms in California. Understanding all types of healthcare fraud within the state is imperative. A criminal defense attorney can assist you in knowing more about the various forms of fraud. They include:

• Billing for Unrendered Services

Billing for services not rendered is California's most common form of healthcare fraud. Many health professionals attempt to charge patients for services that have yet to be rendered. After the patient file is examined, there is no record or indicator of any medical procedure or health services recorded. So, this raises the alarm for potential healthcare fraud.

The investigators check the dates to determine whether the patient visited the named hospital during the date outlined on the insurance forms. Also, the investigators can observe the sign-in logs, appointment calendars, or any relevant record.

Many healthcare providers do not provide any documentation to support that the above patient visited the facility on the indicated dates. Remember, several patients could have foggy memories because of impairment. Other patients could also have forgotten or departed.

Thankfully, many genuine and transparent medical practitioners prefer avoiding medical health fraud. These practitioners help investigators interview both past and current employees. It is complicated to deal with a case involving billing for medical services never rendered.

Therefore, you require the legal services of an experienced criminal defense attorney. Avoid answering any question on your own since you might incriminate yourself.

• Upcoding of Services

Sometimes medical experts submit lawsuits for services not covered by insurance companies or the government. The fraud includes naming the experimental treatment or service and giving it a different name so that it might appear on the list covered by the claim.

When the investigators apprehend those doctors, the medical experts try to defend themselves by arguing they are serving the patient's best interests. In many cases, upcoding occurs when the patients are concerned about avoiding paying excessive bills out of their pockets.

Unprincipled medical experts indicate that the patients spend more days in the facility. If you are apprehended for upcoding medical services, you might be behind bars for committing health care fraud.

• Superfluous Issuance of Prescriptions

This type of healthcare fraud includes all events where a doctor issues medicine for something for which it was not intended. For example, a doctor commits health care fraud when they give extra painkillers, regardless of whether they are acquired or prescribed illegally. According to CASA, the number of abusers of prescription drugs has doubled from seven million to fifteen million.

• Presenting False Health Care Claim

Presenting false healthcare fraud is among California's most common forms of healthcare fraud. The perpetrators of the crime unlawfully obtain the health care forms and then offer them to the government entity to defraud the insurance company.

False healthcare claims involve using untrue statements to obtain benefits. Also, the situation consists of using false supportive evidence. The penalties are harsh. So, when you find yourself in a similar situation, ensure you seek legal help from your criminal defense attorney.

• Writing Supportive Evidence to Aid the Fraudulent Claim to Succeed

A healthcare provider can face charges for committing healthcare fraud when they attempt to or aid in the commission of the fraudulent act. The crime occurs when a medical health provider agrees to develop supportive evidence to promote the crime.

For example, a nurse writes a false document about a patient as a supporting document amounts to aiding health care fraud. Therefore, the responsible party is responsible for the acts. However, the perpetrator can only be found guilty when the prosecutor proves they were aware of their actions.

Penalties for Health Care Fraud in California

In California, healthcare fraud occurs when a medical officer presents a falsified document to a private or government security plan with the intent to obtain compensation. Remember that frauds fall under several categories, meaning the penalties also vary based on the circumstances surrounding the fraud.

The prosecution team can only convict you after proving you participated in any form of healthcare fraud in the state. Your intent to defraud the government entity must also be clear. The prosecution team must show you knew you were submitting falsified information to the government entity.

When found guilty of committing health care fraud, the penalty will depend on the amount of money falsified. You can face a misdemeanor conviction when the falsified amount is $950. You also remain behind bars for six months.

When you commit two or more forms of healthcare fraud within 12 months, the value is combined, and when it amounts to $950, the prosecutor classifies the crime as a wobbler. So, you can either face a misdemeanor or felony charge.

A misdemeanor charge leads to a 1-year jail term. A felony conviction attracts a 2, 3, or 5-year jail term. Based on the nature of the crime, the judge can choose to suspend your professional license. Therefore, your professional reputation can be hurt.

The law also states that aiding or conspiring to commit healthcare fraud attracts similar charges. The court does not treat any case about healthcare fraud lightly. As a doctor, you could even lose your medical practice.

Fighting HealthCare Fraud Charges in California

After the prosecutor completes their case, the court starts a defense hearing. The hearing allows you to challenge the prosecutor's argument. Ensure you work closely with a competent lawyer right away. Ensure you speak with the attorney early enough to give them enough time to conduct their investigations.

Remember, the defense hearings might happen in a single session or extend to multiple sessions when the debate is heated. During this period, you want to avoid any contradictions. Ensure your attorney directs you on what to do. The following are the legal defenses your criminal defense attorney can use to fight the charges:

No Intent to Defraud

Intent is a critical element to prove in every criminal case. However, you must present evidence to show you have no intention to defraud. The prosecutor has the difficult task of proving intent. Lack of purpose implies that you were unaware of what you were doing.

The defense is effective when you present supporting evidence. The evidence will help show the act resulted from a genuine mistake. For example, you might submit multiple claims accidentally when you need to be made aware of the online system. If this is your case, you can argue that you were unfamiliar with the online system.

Further, you might have requested another person to help you navigate the unfamiliar online system. The person might have engaged in fraudulent acts while you were unaware. Ensure you provide evidence to show you were unfamiliar with the online system. When you do so, the court will consider dropping your charge.

Violation of Your Rights

Sometimes the facts surrounding your case show your acts were unlawful. Nevertheless, the law allows you to defend yourself if the police violate your constitutional rights, especially during your arrest. For example, when the arresting officers force you to confess to the offense, this defense can work in your favor.

The defense might, however, not dismiss your general punishment. Still, your attorney might persuade the judge to be lenient when making the punishment based on the malpractice or constitutional violation by the police officers.

Remember, the prosecutor can have enormous evidence against you, but when you question the credibility of the evidence, the court might even dismiss the evidence.

You Never Knew the Your Acts were Fraud

You can use the defense of lack of knowledge to fight the charge. If the defense is successful, your arguments can help you skip legal responsibility, meaning the court can drop your charges. Lack of knowledge shows you never played an active role in the scheme, even though you possibly assisted in committing the crime.

Remember, the employees who play a part in preparing the health care details will most likely face accusations of the crime. Ensure you present enough evidence to dissociate you from the commission of the offense, and instead, you become an innocent person. It would be best to work closely with a skilled criminal defense attorney to achieve this. The attorney will offer the legal assistance you require.

You Acted out of Duress

You might have committed healthcare fraud under duress. For example, your boss orders you to present fraudulent information so that they can avoid paying workers' compensation. If you prove to the court that your acts were involuntary, the court can consider dropping the charges or dismissing the case.

Other Related Offenses

Healthcare fraud can be charged alongside other related crimes. These crimes include:

1. Medical Fraud

Medical fraud occurs when someone lies about their eligibility for state-funded programs or a medical officer attempts to bill the insurer when they submit fake statements or claims for payment benefits. These fraud crimes target the following:

• Seniors.
• Persons with disabilities.
• Low-income adults.
• Pregnant women.
• Families with children.

The law prohibits people from obtaining medical benefits they do not qualify for by making false documents. Also, the law prohibits false declarations about eligibility for these benefits. The prosecution team must, however, prove the following elements before you face conviction:

• You obtained benefits through false documents or statements.
• You do not qualify for the benefits.

The penalties you face for medical fraud depend on the value of the fraud. You face a misdemeanor charge when the value of the fraud is less than $950. The penalties for the misdemeanor charge include the following:

• Summary probation.
• Curt fines.
• Six years jail term.
• Reimbursement of the obtained benefits.

The other form of medical fraud is a violation of WIC 14107. According to the law, it is illegal to:

• Present payment of fraud bills for furnishing products or services covered by medical
• You intentionally present false details to obtain approval for the healthcare product or services
• Submitting a false declaration to receive significant compensation than what you are eligible for under the medical program

Remember, when you face charges involving a medical fraud program with a plan likely to attract tremendous or severe injuries to many individuals, you face an enhanced jail term of 3 years.

Also, when a person dies during the commission of the crime, you face second-degree murder charges in California. A conviction for the charge can attract a jail term of up to 15 years.

WIC 14107.2 outlines the punishment for the suppliers of medical goods and services. According to the statute, it is illegal to obtain, offer, pay, or solicit compensation as a kickback to:

• Order, lease, or buy services or products covered by California medical program.
• Refer a patient to a medical expert for products or services covered by the program.

When you are a first-time crime offender, you face a wobbler charge. A repeat offender faces a felony charge; the misdemeanor charge results in a jail term of up to 1 year. Alternatively, a felony charge attracts a jail term of 16 months, 24 months, or 36 months.

A conviction for medical fraud can be devastating. That is why you should seek legal help from a California criminal defense attorney. The attorney will help you develop strong defenses to fight the charge. The following are the potential defenses your attorney can apply to fight the charges:

• Insufficient evidence to convict you.
• You had no intent to commit the crime.

2. Workers Compensation Fraud

According to California laws, workers who suffer injuries while on the job are entitled to compensation from their employer's insurer. Worker compensation can occur when:

• An employer lies about the working situations and conditions to avoid substantial insurance premiums.
• A worker lies about their employment status or injury to obtain significant compensation benefits.

Workers compensation fraud overlaps with healthcare fraud in some instances. According to the law, the crime is a wobbler. So the prosecutor can file either misdemeanor charges or felony charges. A misdemeanor charge attracts a 12-month jail term, while a felony charge attracts a 2, 3, or 5-year jail term.

You still stand a chance to fight the charges. A well-experienced criminal defense attorney can use the following defenses to help you succeed in the case:

• Insufficient evidence from the prosecution team.
• No intent to commit the fraudulent acts.

3. Prescription Fraud

Prescription fraud is outlined under HS 11153 and 11173. HS 11173 outlines fraud that involves patients, while HS 11153 focuses on medical experts like nurses and doctors. You violate the law as a patient when you attempt, take, or buy the prescription using falsification, deceit, or fraud.

When proving the case, the prosecution team demonstrates that you tried to receive or received the controlled substance. You can also face the charge even when the prescription drugs are absent. It is also optional for you to succeed in committing the crime. The drugs in question must include the following:

• Valium.
• Ritalin.
• Vicodin.
• Morphine.

HS 11153 prohibits doctors and nurses from issuing prescriptions not legitimated for medical purposes. The medical healthcare providers listed in the statute are psychiatrists, nurses, dentists, and doctors. The prosecutor must prove you knowingly committed the fraudulent acts.

As a doctor, you cannot face conviction for a crime when you treat the patient in good faith. However, when a nurse or doctor is guilty of a crime, they face a felony or misdemeanor charge. The misdemeanor charge attracts the following penalties:

• One-year jail term.
• Summary probation.

Alternatively, a felony charge attracts the following penalties:

• 16, 24, or 36 months jail term.
• Felony probation.

To consent to the charges for doctor shopping, you never used deceit or fraud to receive the drug. Also, you can argue that you are a victim of police entrapment. You might even claim you were advocating the alleged drugs for non-medicinal purposes.

When the defenses are successful, you will not lose your professional license. However, working closely with an experienced criminal defense attorney would be best.

Contact an Attorney Near Me

The law in California heavily punishes the perpetrators of fraud crimes. As the perpetrator, you might lose your professional license despite facing other civil and criminal consequences if convicted of health care fraud. Although healthcare fraud occurs in many forms, many lack sufficient evidence. That is why you must work immediately after your arrest.

At California Criminal Lawyer Group, we are ready to assist you. If you seek legal services in Anaheim, our attorneys are looking forward to working with you and ensuring you obtain the best possible outcomes in your case. Contact us at 714-766-0965 and speak with one of our determined criminal defense attorneys.