Health Care Fraud

As mentioned above, the crime of Health Care Fraud is set for in California Penal Code §550(a)(6) – (9), and there are four (4) distinct methods of committing this crime. The underlying concept however involves:

1. The Defendant filed a Health Insurance Claim;
2. The Defendant knew the Health Insurance Claim they filed was false; AND
3. When the Defendant filed the false Health Insurance Claim, they intended to defraud the insurance company.

It is a core concept of the criminal justice system that the Prosecution proves every element of the crime they are seeking to convict the defendant of beyond a reasonable doubt. As such, a common approach taken by many attorneys is to simply negate the Prosecution’s case against their client; this is frequently a cookie-cutter approach. At Los Angeles Criminal Lawyer, we believe that a one size fits all approach is both unethical and unreliable. After your initial consultation with LACL, we will hand-craft a theory of defense unique to you and your case. With nearly three decades of combined experience, exclusively representing individuals accused of criminal conduct, LACL has a proven track record of obtaining favorable results for their clients. At Los Angeles Criminal Lawyer, we take pride in providing the very best service to our clients, and we understand that part of an attorney’s job is to keep their clients informed about their case. The remainder of this article will focus on: (1) The general elements of Health Insurance Fraud, (2) The specific ways someone can commit Health Care Fraud, (3) The penalties associated with a conviction for Health Care Fraud; and (4) What Los Angeles Criminal Lawyer can do to assist you if you have been accused of Health Care Fraud.

Health Care Fraud is a specific intent crime, which makes the burden on the Prosecution harder to meet. The first aspect of every variation of Health Care Fraud is that the Defendant actually knew that the claim they were submitting was false in one way or another. If the Defendant was unaware they were submitting a false claim, they simply cannot be convicted.

EXAMPLE:

Denise works at a busy dentist’s office as an administrative assistant along with several other individuals. On a particularly busy day, Denise receives a document directing her to file a claim to an insurance company for $10,000. Denise did not know that her co-worker had already filed the claim, but had forgotten to file it, and filed a claim for the exact same client as her co-worker. Denise cannot be convicted of Health Care Fraud because she did not know that she was filing a false claim.

If your attorney is able to convince the District Attorney that there is simply no evidence of your knowledge that the claim was false, they will dismiss the case against you outright. In the event your attorney is unable to persuade the district Attorney, they will present a persuasive argument to that effect in front of the jury. Again, if the Prosecution cannot prove that you had knowledge that you were filing a false claim, you have not committed Health Care Fraud.

Once the Prosecution has proven that the Defendant had knowledge that they were filing a false claim, they must then prove that the Defendant filed the false claim with the specific intent to defraud the insurance provider. Intent to defraud is an action where the objective of that act is to cause a loss, or damage , to another entity’s property rights. Fraud also occurs when someone acts with the intent to deceive.

As detailed above, there are four (4) methods of committing Health Care Fraud. Keeping in mind the requirement that the Defendant know they filed a false claim with the intent to defraud the insurance company, the next portion of this article will focus on the specific forms of Health Care Fraud.

There are four (4) types of Health Care Fraud:

1. Filing a claim for payment on a benefit, when the Defendant knew the claim was fraudulent;
2. Filing a claim for a benefit that was not utilized;
3. Filing multiple claims for the same benefit; AND
4. Filing a claim for additional money as a result of an undercharge

The penalties for these crimes are all identical, the difference between the variations is who filed the claim. Health Care Fraud charges can be brought against doctors and patients alike. These statutes are designed to apply to anyone who could commit Health Care Fraud. The next portion of this article will discuss the various forms of Health Care Fraud.

California Penal Code §550(a)(6) - False Claims

An individual can be found guilty of §550(a)(6) if they attempt to obtain payment for a benefit they never actually utilized. This generally occurs when a doctor asserts that they performed a necessary procedure on the patient, which was really unnecessary. Another common method is a doctor claiming they are owed payment from an insurer for a service they never performed.

Example:

Dan is a physician in Downtown Los Angeles. Mike went to Shakti because he was exhibiting cold-like symptoms. Dan gave Mike cough medicine, and told him to contact his office if the symptoms continued. Dan reported to the insurance company that he had conducted an EKG, an MRI, and an x-ray on Mike, and asked to be reimbursed for the cost. Dan has violated §550(a)(6) because he is seeking reimbursement for a service he never performed, and he submitted the request or payment for the purpose of defrauding the insurance company.

California Penal Code §550(a)(7) – Claims for Benefits That Were Not Used

Another form of Health Care Fraud occurs when an individual seeks reimbursement for benefits that were never provided or received.

Example:

Dan has been a pediatrician for nearly thirty (30) years, and has developed an expertise in his field that has resulted in substantial clientele. As a result of the increased client base, Dan hires an assistant to help lighten the load. Dan requests payment from the insurance provider, and bills at his hourly rate instead of his assistant’s hourly rate. Dan has violated §550(a)(7) because he is requesting payment for a service that was never provided; his personal attention to the patient.

California Penal Code §550(a)(8) – Filing Multiple Claims for the Same Benefit

Another form of Health Care Fraud occurs when the Defendant knowingly submits multiple claims to insurance providers for reimbursement on the exact same benefit.

Examples:

Dan is a doctor in Downtown Los Angeles. After a particularly busy month Dan gets around to submitting claims for reimbursement from the insurance providers. Since there was so much billing to do, Dan lost track and filed two claims for the same benefit. Dan will not be convicted of violating §550(a)(8) because he did not knowingly file the multiple claims, it was an accident.

California Penal Code §550(a)(9) – Submitting A Claim for an Incorrect Amount

Another form of Health Care Fraud occurs when a physician submits a claim to an insurance provider for an amount that is incorrect, and the physician knows that amount is incorrect.

Health Care Fraud in California can be brought as a misdemeanor or a felony, depending on the amount the Defendant attempted to defraud the insurance provider for. For sentencing purposes, Health Care Fraud will be brought as a felony if it would have been grand theft. Health Care Fraud will be brought as a misdemeanor if it would have been petty theft. The sole distinction between petty theft and grand theft is whether or not the amount the Defendant attempted to defraud the insurance company for is over $950. If the value is under $950, the crime is a petty theft, if it is over $950 it is a grand theft; again, this dictates whether the charge is brought as a misdemeanor or a felony. As a practical matter, the Prosecution typically attempts to also convict the Defendant of theft crimes as wellⁱⁱⁱ.

If you are convicted of Health Care Fraud, and it was brought as a misdemeanor, you will face incarceration in county jail for a period not more than one (1) year and/or a fine not exceeding ten-thousand ($10,000) dollars.

If you are convicted of Health Care Fraud, and it was brought as a felony, you will face incarceration in county jail for a period ranging from two (2), three (3), or five (5) years and /or a fine of up to ten-thousand ($10,000) dollars.

Depending on the amount of money you attempted to defraud the insurance company for, Health Care Fraud can be brought as either a misdemeanor or a felony. If the amount of money you attempted to defraud the insurance company for is under $950, the violation of §550(a)(6)-(9), will be brought as a misdemeanor. If the amount of money you attempted to defraud the insurance company was more than $950, the violation of §550(a)(6)-(9) will be brought as a felony. The moment you discover you are under investigation for, or are arrested for, Health Care Fraud it is imperative that you contact Los Angeles Criminal Lawyer. Contacting LACL early on in the process will vastly improve your chances of a favorable outcome to your case. Providing your LACL attorney with ample time and information to build a strong defense to your case will allow them to negotiate persuasively with the District Attorney to dismiss the charges against you, or reduce the charges against you. If that does not work, your LACL attorney will utilize their years of experience and diligent preparation to present a cohesive, thorough, and persuasive defense to the jury. In the event you are convicted, Los Angeles Criminal Lawyer will advocate for a lesser sentence. Keeping you out of jail is our top priority.