Clinics, practitioners, and administrators in Los Angeles 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—and 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 lawyer.
The Simmrin Law Group is here to help. We understand the complex world of the health care industry and fraud investigations. We have a background in working with white-collar clients who are facing not only criminal consequences, but consequences for their career or business. Let us give you a free consultation to discuss the best way to attack your case. Fill out the form to the right or call us at 310-997-4688 and get your free consultation today.
What counts as health care fraud in Los Angeles?
Health care fraud means submitting any kind of false claim for payment. This can include claims of care that wasn’t actually provided, or that wasn’t provided in the way that it was billed for. When done intentionally, these kinds of false claims are illegal and 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 and nurse practitioners, physical therapists, chiropractors, and administrators.
Many cases of alleged health care fraud are charged under a state law known as Penal Code 550 , 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 worker’s compensation fraud.
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 actually 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’s 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 “keeping your head down”)
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, even if you didn’t benefit from it in any way.
What are the penalties for health care fraud in Los Angeles?
It depends on how you are charged. 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 money much was involved in the alleged fraud.
- If the dollar value was $950 or less, you will face a misdemeanor.
- If the dollar value was more than $950, you could face a misdemeanor or felony
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.
The penalties for each charge are:
- Misdemeanor penalties—$950 or less
- Up to 6 months in jail
- Up to $1,000 in fines
- Misdemeanor penalties—more than $950
- Up to 1 year in jail
- Up to $10,000 in fines
- Felony penalties—more than $950
- Either 1 year in jail plus probation, or
- 2,3 or 5 years in jail, and
- A fine of up to $50,000 or twice the value of the fraud, whichever is larger
The cash fines are generally in addition to being forced to repay the value of the fraud.
For many health care professionals, however 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. And a felony conviction carries complications of its own, affecting your basic rights, your ability to find employment, and even whether you can earn professional licenses in the future.
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. Likewise, legitimate providers get accused 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 two facts to get a conviction:
- You knew the claim was fraudulent or false, and
- You intended to defraud an insurer or insurance program
This gives your lawyer substantial latitude in building your defense. It’s not necessary to prove that all claims were legitimate, only to attack the fraudulent intent. Examples of successful defenses include:
- 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. This does 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 has 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—but 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 lawyer can fight back against the prosecutor and help you get the best possible outcome.
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. Let us give you a FREE consultation to help you get started. Fill out the form to the right or call us at 310-997-4688 and get your free consultation today.