Clinics, practitioners, and administrators can easily become the target of health care fraud allegations. These accusations are not always accurate and can involve honest mistakes or poor record-keeping without any intention to commit fraud. Unfortunately, the penalties for health care fraud are substantial.
Even a first-time fraud charge can be a felony. If you or your practice have come under suspicion, do not risk jail time. You need to talk to a Los Angeles health care fraud attorney with the Simmrin Law Group. We understand the complex world of the healthcare industry and fraud investigations.
What Counts As Health Care Fraud in California?
Health care fraud means submitting any false claim for payment. These submissions can include a care claim that wasn’t actually provided or that was provided in a way other than that for which was billed.
When done intentionally, these kinds of false claims are illegal. They are seen as defrauding either an insurance company or a government program such as Medi-Cal (state level) or Medicare (federal).
In most cases, the people targeted by fraud investigations are providers, including doctors, dentists, nurses, nurse practitioners, physical therapists, chiropractors, and administrators.
Many cases of alleged health care fraud are charged under California Penal Code Section 550. PC 550 is California’s health care fraud law. However, there are a variety of more specific charges that can be used, especially in cases of Medi-Cal fraud and workers’ compensation fraud.
For a free legal consultation with a health care fraud lawyer serving Los Angeles, call (310) 896-2723
Examples of Health Care Fraud
Health care fraud can come in many forms. Some specific examples of health care fraud include:
- Performing a service or procedure that the patient did not actually need and submitting a claim for it
- Submitting a claim for a service that was never provided
- “Upcoding” or submitting a claim for a more expensive procedure when a cheaper one was performed
- “Double billing” or submitting more than one claim for a single service
- Submitting claims related to undercharging/overcharging schemes—you are not allowed to overcharge a patient for a service to “make up” for accidentally undercharging them in the past
However, it is important to know that you can be convicted even if you were not the one perpetrating fraud. For example, both of the following can result in a health care fraud conviction:
- Knowingly preparing any documents or submitting any statements supporting a false claim
- Conspiring in the fraud, which includes being complicit (or knowing about it and failing to report it)
As a result, you can be charged even if you were only an accessory to the fraud and never wanted to be directly involved in it. Indeed, you can face a conviction even if you did not benefit from the scheme in any way. You need to talk to a health care fraud lawyer in L.A.
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What Are the Penalties for Health Care Fraud in Los Angeles?
The penalties for health care fraud depend on the charge you face. However, under the most common health care fraud charges, you can end up facing either a misdemeanor or a felony, and all sentences include potential jail time. The specific charge you face will depend on how much money was involved in the alleged fraud.
If the dollar value was $950 or less, you are looking at a misdemeanor. However, if the dollar value was more than $950, the offense could be charged as a felony. In the latter case, which charge to pursue is up to the discretion of the prosecution.
Realistically, because of the pricing of many procedures, most health care fraud charges involve more than $950 in value. This is especially true since a series of smaller frauds can be charged as one felony count if they add up to more than $950 in any 12-month period.
Misdemeanor Penalties: $950 or Less
Low-cost misdemeanors result in the most lenient penalties for a health care fraud conviction. Potential consequences include:
- Up to six months in jail
- Up to $1,000 in fines
- Summary probation
Misdemeanor Penalties: More Than $950
Both the length of a jail sentence and the financial penalties can increase significantly for a high-cost misdemeanor charge. They can include:
- Up to one year in jail
- Up to $10,000 in fines
- Summary probation
Felony Penalties: More Than $950
When health care fraud gets prosecuted as a felony charge, the potential penalties can be severe. If convicted of a felony, you may face:
- Up to five years in prison
- Up to $50,000 in fines or twice the value of the fraud, whichever is larger
- Formal probation
The cash fines are generally in addition to being forced to repay the amount defrauded to the aggrieved party.
However, for many health care professionals, jail and fines are not the only threat. Convictions for fraud can result in having your professional license suspended or completely revoked. It can also result in censure within the medical community.
A felony conviction carries complications of its own. These convictions can affect your basic rights, your ability to find employment, and even whether you can earn professional licenses in the future.
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How Does a Lawyer Fight a Health Care Fraud Charge?
There are several things to remember if you are facing a fraud accusation.
First, remember that these investigations are complicated, and it can be hard to prove the fraud at all. Fraud investigators often miss legitimate cases of fraud, and insurers may never know when they are being wrongly billed. On the flip side, legitimate providers get accused of fraud all the time either because of an honest misunderstanding or billing errors that were accidental, not intentional.
Second, remember that the key to a fraud conviction is intent. The prosecutor has to prove that you knew the claim was fraudulent or false and that you intended to defraud an insurer or insurance program.
The burden of proof upon the prosecution gives your L.A. health care fraud lawyer substantial latitude in building your defense. It’s unnecessary to prove that all claims were legitimate, only to attack the fraudulent intent. Examples of successful defenses include:
- Lack of knowledge
- Lack of intent
- Lack of evidence
Lack of Knowledge
Sometimes, a doctor makes a mistake or doesn’t realize that something has already been billed. In other cases, someone working in the practice codes the claim as the doctor indicated without having firsthand knowledge of what services were performed. These actions do not count as fraud.
Lack of Intent
You may not have intended to defraud an insurance program at all. The errors could have been accidental, or you may not have realized they were errors. There are also cases where the accused had already felt uncomfortable with the billing practices and had evidence that they intended to report the fraud and were arrested before this was possible.
Lack of Evidence
Prosecutors often rely on records to show that services were not billed properly. However, that evidence does not establish intent. Simply attacking the lack of evidence in a case can be enough to get it dismissed or to win outright.
The defense that’s best for your case depends on what exactly happened. A good white-collar crime lawyer in Los Angeles can fight back against the prosecutor and help you get the best possible outcome.
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Accepting a Plea Bargain for Health Care Fraud Charges
If facing criminal charges for health care fraud there is a good chance that the prosecution will offer you a plea bargain in an attempt to settle your case quickly and not have to fight it out at trial.
A plea bargain might be your best path forward if the evidence against you is strong. However, it is critical to have your attorney review any deal before you accept. Also, despite what the prosecution may claim, the first offer will rarely be the best you will get. Your attorney can help negotiate a better plea deal that works for you.
Negotiating a felony charge down to a misdemeanor could mean avoiding serious prison time and possibly result in your serving no time behind bars at all. Probation and a fine that is small compared to what you would have to pay for a felony conviction can make going to court not worth the risk.
However, taking a plea deal is not always the best path forward. Your Los Angeles health care fraud attorney can help advise you of when you are likely to be better off by taking your case to trial.
Talk to a Los Angeles Health Care Fraud Lawyer for Free
Don’t let a health care fraud charge ruin your practice, your career, or your life. The Simmrin Law Group can help you. We have a background in working with white-collar clients who face criminal penalties, as well as consequences for their careers or business.
Let our Los Angeles health care fraud lawyers give you a free consultation to discuss the best way to attack your case. Fill out our online contact form or call us today.
Call or text (310) 896-2723 or complete a Free Case Evaluation form