Medi-Cal is designed to help people. Nonetheless, countless people in Los Angeles find themselves targeted by accusations of fraud. They range from regular healthcare patients who were confused by the system, to providers and patients who made a bad mistake—one that can affect your life for years. If you have been charged with Medi-Cal fraud, do not risk facing the charge alone. You need to talk to a Los Angeles Medi-Cal fraud lawyer.
The Simmrin Law Group can help you. We understand the complex Medi-Cal system and we know how to defeat fraud charges. We have dedicated our firm to helping those who have been accused, and we have a history of winning cases. Let us give you a free consultation. Fill out the form to the right or call us at 310-997-4688 and get your free consultation today.
What is Medi-Cal fraud?
Medi-Cal is a state-run program (not federal) that helps people get access to affordable medical care. In order to be eligible for Medi-Cal, you either need to qualify as low-income or you need to fit certain other categories, such as:
Senior citizens
Women who are pregnant
Foster children
For these groups, Medi-Cal effectively acts like a free insurance program. That means there is a benefit both to the patient (who gets free or reduced-cost care) and to the medical provider (who receives payment for their services from the state). This creates the possibility for both patients and providers to abuse the system.
Under the law, individuals (patients) can commit Medi-Cal fraud in several ways:
Knowingly making false statements so that you (or someone else) can qualify for Medi-Cal benefits
Knowingly making false statements regarding a claim in order to get it paid
Knowingly submitting a claim for a benefit you never used, i.e., collecting the money but not getting the medical care in question
Medical providers (and other businesses) can also commit Medi-Cal fraud by:
Requesting or offering a kickback in exchange for referrals or purchases covered by Medi-Cal
Presenting false or misleading claims for medical services or products to defraud Medi-Cal
Submitting false information to get more compensation than you would otherwise get under Medi-Cal
Misrepresenting a business, or attempting any scheme, in order to defraud Medi-Cal
Depending on the circumstances, Medi-Cal fraud can be charged under several different laws. Occasionally it is charged as general healthcare fraud, or even as workers compensation fraud. However, in most cases it will be one of the charges that specifically relate to Medi-Cal fraud. We’ll cover each one and its penalties below.
What are the penalties for an individual committing Medi-Cal Fraud in Los Angeles?
If you are a patient accused of Medi-Cal fraud, you will usually be charged under a law known as Welfare and Institutions Code Section 14014. Being charged with this kind of fraud does not necessarily mean that you personally benefited from the fraud—it’s common for someone to lie on behalf of a family member, for example, to help them get approved. In this case it is the person who committed the fraud, not necessarily the family member who received benefits, that faces criminal charges.
Likewise, you can be charged even if you never received money or benefits. Simply the attempt to defraud the system is enough.
Charges under this law can be either a felony or a misdemeanor. The deciding factor is (mostly) the amount of money involved. If the amount was $950 or less, it’s always a misdemeanor. If it was over $950, it’s up to the prosecutor to decide whether to charge it as a misdemeanor or a felony. They will consider your criminal history as well as the circumstances of your case.
Misdemeanor penalties:
Up to 6 months in county jail (or 1 year if the amount was over $950)
Informal (unsupervised) probation
A fine of up to $1000
Felony penalties:
Either 16 months, 2 years or 3 years in county jail
Supervised probation
A fine of up to $10,000
Additionally, you will be required to repay the amount “defrauded” from California.
What are the penalties for medical professionals committing Medi-Cal Fraud in Los Angeles?
The main circumstance where medical professionals are charged is when they submit false or exaggerated claims to be paid by Medi-Cal. This can include outright falsifying the claim, or changing minor details like whether the doctor saw the patient personally or whether a PA under them saw the patient. If the goal was to get more money than allowed by Medi-Cal, it can count as fraud.
This kind of fraud will be charged under Welfare and Institutions Code Section 14107, which can be either a misdemeanor or a felony, as chosen by the prosecutor.
Misdemeanor penalties:
Up to 1 year in county jail
A fine of up to 300% the amount defrauded
Informal (unsupervised) probation
Felony penalties:
Either 2, 3 or 5 years in state prison
A fine of up to 300% the amount defrauded
Supervised probation
You will face additional penalties if the accusation involves any kind of fraud scheme where people were put at risk of great bodily injury. For example, imagine that the doctor at a small practice routinely has her assistant see patients, in order to maximize how many the practice can see—and charges Medi-Cal as if all of them were seen by the physician. If one of these patients goes on to develop a serious condition or complication, potentially because of a misdiagnosis or not getting proper care, the physician may face an enhanced sentence. The enhancement is an extra 4 years in prison for every patient who was harmed.
What are the penalties for Medi-Cal bribes and kickbacks?
The Medi-Cal system creates many opportunities for kickbacks. Salespeople, healthcare suppliers and drug manufacturers could offer bribes if doctors use their products. Doctors or providers could then repeatedly prescribe the drug or procedure even if patients don’t need it. In these cases, the supplier typically gets paid by Medi-Cal and shares some of that profit with the doctor.
These types of cases are charged under Welfare and Institutions Code Section 14107.02, which may be a misdemeanor or a felony if it’s a first offense, but is always a felony for repeat offenders.
Misdemeanor penalties:
Up to 1 year in county jail
Felony penalties:
Either 16 months, 2 years or 3 years in county jail
These penalties can also carry substantial fines and fees as well as probation.
How can a lawyer fight a Medi-Cal fraud charge?
“Fraud” is not as open-and-shut as it often looks. Both patients and providers do get mistakenly targeted with fraud accusations, and there are defenses that both can use. The most common defenses are:
Lack of fraudulent intent—you didn’t know your statements were false, or the false claims were a product of poor record-keeping or another honest mistake.
Lack of evidence—if the prosecutor cannot prove their case, you cannot be convicted and the case could even be dismissed.
When we take on a Medi-Cal case, we start by launching our own investigation into what happened. In some cases the evidence against you was not gathered legally, or contains errors. We can use that to your advantage and help you win your case.
Talk to a Los Angeles Medi-Cal Fraud Lawyer for Free
Medi-Cal fraud is not a minor charge. One conviction can ruin a career or a life. Let us help you. The Simmrin Law Group will 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.