Health Care Fraud

Today, the government is strict on healthcare fraud. The government is trying to control the high healthcare costs recorded in the past. Thus, health care practitioners and facilities are under close watch. Healthcare facilities, doctors, or clinics can be charged in a federal court for healthcare fraud. The charges will be introduced when it is suspected that they billed an insurance service provider for procedures never undertaken.

If you or your hospital face a criminal investigation for healthcare fraud, reach out to The Los Angeles Criminal Defense Attorney Law Firm. Our capable attorneys will assess your charges and represent you in court.

What does Health Care Fraud Constitute?

As a white-collar crime, healthcare fraud is the filing of a false claim with the intent of gaining unlawful profit. This federal crime is detailed in the United States Code under Title 18, Section 1347. According to the code, healthcare fraud is a deliberate action or an execution attempt, a ploy to defraud any healthcare benefit program or receive, through fraudulent manners, any money belonging to or managed by a healthcare benefit program.

In Los Angeles, California, healthcare and related frauds are prohibited under Penal Code 550(a) PC. The code suggests that it is illegal to help, support, or partner with another person to perform fraudulent deeds like:

  • Intentional presentation or supporting fraudulent claims for compensation for harm or a loss. It also includes compensation for any loss or injury under an insurance plan
  • Deliberate filing of multiple claims for similar medical treatment by healthcare facilities - Healthcare fraud also involves filing numerous claims with many insurance service providers, intending to make fraudulent profits
  • Participating or causing a vehicle accident or collision (personal or healthcare facility vehicles), with the sole intent of presenting a fraudulent or false claim to a healthcare insurance provider to benefit
  • Deliberate filing of an incorrect or fraudulent claim to receive compensation for loss through robbery, damage or destruction, or transformation of an auto, an internal or external part of the vehicle, or removal of any part of the car
  • Deliberate preparation, supporting, authorizing, or contributing to any written material, with the primary intention of using or presenting the writing or permitting it to be forwarded, to aid in filing a fraudulent or a false claim
  • Deliberate preparation or supporting plans to make a false or fraudulent healthcare claim for compensation of a healthcare benefit
  • Intentional submission of a false claim for a healthcare benefit that was not retendered to the claimant. Here, both the doctor and the patients will be held accountable.
  • The deliberate presentation of multiple claims for compensation of the same healthcare benefit to various healthcare insurance provides with an intent to receive fraudulent profits
  • Deliberate presentation for compensation any undercharges for healthcare paybacks on behalf of a particular applicant without any acknowledged overcharges for healthcare benefits for that claimant are filed for reconciliation
  • On clauses (6) to (9), the Labor Code states that a claim for compensation of a healthcare benefit is also referred to as a claim for compensation acquiesced by a healthcare provider or on behalf of the provider of any workers’ compensation for health benefits

Health Care Fraud Schemes

Health care fraudulent actions come in different schemes like:

Practitioner Schemes

Examples of fraudulent schemes performed by practitioners include:

  • Billing by caregivers for procedures they never performed
  • Individuals receiving prescription medicine that is paid-for or subsidized with the intent of selling the medicine for profit
  • Billing for services that are not covered as covered services
  • Billing claims for services that were not rendered or filing duplicate claims for care offered
  • Changing the description of services, dates, and the identities of caregivers
  • Altering medical records
  • Intentional omissions of details in diagnoses reports
  • Incorrect reporting of care given with the intent to make a profit

Members Schemes

Health care beneficiaries can get involved in fraudulent health care activities through falsifying information given during the application for services and programs. Renting out your insurance card or using one from another person is fraudulent. Also, selling your prescribed medicine or using medical transfer vehicles like ambulances for non-medical reasons is regarded as health care fraud.

Insurer Schemes

Insurance services providers can get involved in healthcare fraud by:

  • Offering wrong information to enrollees on benefits enjoyed in health plans
  • Refuting justifiable claims
  • Understating the total money owed by the insurance provider to a healthcare facility
  • Overvaluing the costs of the insurer when compensating claims

What is the Current State of Health Care Fraud Scrutiny in Los Angeles?

Not long ago, the U.S. government formed task forces to look into increasing health care fraud. The task forces’ work is scrutinizing, evaluating, and prosecuting fraud suspects. Los Angeles is among the nine cities that are under strict watch.

Health care facilities and businesses should note that investigations on health care fraud are more aggressive in Southern California than in other states or cities.

A team of law enforcement officers handles health care fraud cases within Los Angeles, dubbed HEAT (Health Care Fraud Prevention and Enforcement Action Team). HEAT includes:

  • The Federal Bureau of Investigations (FBI)
  • The Department of Justice (DOJ)
  • The Office of the Inspector General of the Department of Health and Human Service (OIG)

Healthcare Fraud Laws

The laws that govern healthcare fraud in Los Angeles and the United States are:

  • False Claims Act (F.C.A). - This Act under Title 31 U.S. Code sections 3729-3733 prohibits you from filing a fraudulent claim to government authorities in Los Angeles and larger California
  • Physician Self-referral Act also referred to as the Stark Law - The Self-referral Act (42 U.S.C. Section 1395nn) prohibits health care providers from referring patients to health care facilities or practitioners whose primary interest is making profits
  • Anti-Kickback Statute - Under Title 42 U.S. Code, section 1320a-7b, this statute bans you from getting paid to refer patients to access healthcare services from the government
  • Exclusion Statute - This statute prohibits healthcare providers who have faced several criminal charges from performing healthcare-related services
  • Civil Monetary Penalty Law - The Department of Health and Human Service handles exclusions and penalties related to different crimes that involve defrauding the authorities of money

The above statutes constitute federal healthcare fraud and abuse laws in Los Angeles County, California.

What are the Major Types of Healthcare Fraud?

California’s insurance fraud statutes cover healthcare fraud and comprise of the claims for paybacks that facilities and doctors alike forward to insurers or government healthcare programs.

  1. Issuing Claims for Benefits that were not Delivered

According to the Penal Code 550, it’s a crime to issue claims for healthcare services that were not rendered to the person in whose name the billing is submitted. This means that submitting to an insurer for services not delivered is health care fraud.

  1. Issuing False Claims/ Upcoding

California laws prohibit the submission of fraudulent claims for healthcare benefits. Fraudulent claims can involve:

  • Billing claims to a healthcare insurance provider for healthcare services that don’t need insurance coverage
  • Billing for more expensive healthcare services when similar, yet cheaper procedures were rendered to patients. This fraud is also known as upcoding
  • Billing extra charges to insured patients that are not billed to patients who pay healthcare service with cash
  1. Submitting Multiple Claims/ Double Billing

Billing multiple claims is another type of healthcare fraud per Penal Code 550. Also known as double billing, multiple claims issuance occurs when healthcare providers issue claims to two healthcare programs or insurers for one service. 

  1. Performing Medically Unneeded Services

Healthcare insurance providers only compensate for services that are deemed necessary. It’s a violation of the law if your doctor recommends medical procedures that are not related to your ailment.

  1. Overlooking Overcharges and Submitting Undercharges

According to the Penal Code 550, it’s a crime for healthcare providers to bill for previously undercharged services and leaving out bills for already overcharged services.

  1. Supporting Fraudulent Claims in the Form of Writing

Writing any document with the intent of helping healthcare fraud is a criminal offense.

  1. Receiving or Paying Kickbacks in Exchange for Referrals

In Los Angeles, it’s illegal for healthcare providers to give or take any valuable commodities like money, presents, or equity from anybody. Such valuables are received to refer customers with the intent of making profits, meeting stipulated quota or using specific medical equipment.

  1. Submitting Claims Used for Personal Expenses to Healthcare Programs

Each year healthcare facilities are compensated after submitting a cost report. It’s fraudulent to include personal expenses like rent, car fuel, or school fees in the annual cost reports.

  1. Consumer Deception Fraud

It is a criminal violation as a patient to use another person’s insurance card to access treatment. It’s also fraudulent to include a non-relative in your insurance plan, submitting claims for healthcare services not received, and faking employee’s injury to get compensated for disability.

  1. Unbundling

This healthcare fraud involves billing every step of treatment offered to the patient as if it were a separate treatment.

What are the Penalties for Health Care Fraud

Healthcare Fraud is a federal crime that attracts different forms of penalties. Our Los Angeles criminal defense attorneys offer insight on possible sentences you could face. Criminal convictions hang on the dollar value of the healthcare law violated.

If you are convicted of healthcare fraud, you risk a maximum jail term of 10 years. But your jail term can increase to 20 years if there is compelling evidence of severe bodily harm. Life prison term is imposed if the fraudulent deed led to death.

The Federal Sentencing Guidelines state that healthcare fraud crime charges start with a base offense level 6 (of 43). A five-year jail term or $250,000 fine is imposed if you are sentenced under the FCA. Defiance of the Anti-Kickback Statute will see you go to prison for five years or pay $25,000. Harsher sentences are imposed on persons who flout the Civil Monetary Penalty Law.

Note that, as a physician, you risk having your license and permit revoked when facing healthcare fraud charges adding to criminal fines and imprisonment. This means that in the future, you cannot offer services in any federal healthcare facility or to beneficiaries of healthcare programs.

Claims of Up To $950

According to California law, healthcare fraud that involves fraudulent claims of up to $950 is regarded as a misdemeanor.

Penalties imposed on misdemeanor per California healthcare fraud include:

  • Criminal fines of $1000 or less; or
  • Jail time of up to six months

Claims of $950 And Above

Fraudulent claims that amount to $950 or more are regarded as “wobbler” in California law. Prosecutors can file the healthcare fraud charges as a California felony charge or misdemeanor.

Some of the penalties imposed in Los Angeles for misdemeanor include:

  • Jail time of up to one year, or
  • Criminal fines of not more than $10,000

If the prosecutors file the charges as a felony, the possible penalties include:

  • Jail time of two, three, or five years, or
  • Jail time of one year plus probation

Also, if convicted for healthcare fraud as a felony, you may besides or instead get fined:

  • An amount that’s twice the fraudulent claims, or
  • Up to $50,000 in fines

Revocation of Professional License

Typically, healthcare experts are the most accused persons with healthcare fraud, closely followed by insurance providers, and lastly, patients/ clients. You risk losing your professional license as a healthcare expert if convicted of healthcare fraud.

What are the Possible Legal Defenses?

Today, the U.S. government works with multi-agencies to handle healthcare fraud cases. These agencies are thorough with investigations and can reach out to former employers to get inside information.

Some previous employers or colleagues out of ignorance or deliberate intentions can offer misleading information to the authorities. Thus, there is a significant chance that negligence or honest errors are regarded as healthcare fraud.

Given the weight these allegations carry, it’s imperative that attorneys interview any employer/ colleague (previous or current) that offered information to the investigators. Also, a thorough analysis and evaluation of the documents that are used in the investigation of healthcare claims should be done.

We help interview ex-employers and ex-colleagues before employment records are submitted to the government. Our attorneys will inform the former colleagues of their rights.

At times many defendants are entangled in healthcare fraud cases. Defendants may include doctors, managers, or even accountants. Defense attorneys need to talk to the defendants to help with auditing billing records, and the assessment of billing records requires auditors experienced with healthcare fraud.

Other documents that need reviewing include memoranda, reports, financial records, and internal documents. With these, the defense can establish the possible outcome of the healthcare fraud speculations. When facing healthcare fraud charges, don’t manipulate justice or interfere with witnesses. By doing so, you risk further federal charges even after you are found innocent of the existing fraud allegations.

Investigators are fast becoming wary of justice obstruction and have since developed smart tactics to capture these defendants. The investigators issue a document subpoena and then seize the trash of the defendants for the following month to check if crucial documents were discarded. Be careful not to fall victim to the tactics.

The Mistake of Fact or Lack of Knowledge

You cannot be fined or serve jail time for healthcare fraud if you are not aware that you partook in issuing fraudulent claims.

Healthcare billing involves complicated procedures. Thus, the odds for experienced caregivers to make billing mistakes remain high. Healthcare billing involves very complex processes. These erroneous occurrences can be seen as healthcare fraud. But, if you were unaware that the claim was a criminal violation, the jury cannot convict you.

Lack of Intent

Lack of intent is yet another legal defense to healthcare fraud charges. Like other crimes, the federal government or prosecutors need to prove beyond a reasonable doubt that the accused persons indeed committed healthcare fraud crimes. Fraud is committed on purpose and not on accident.

What Happens If You’ve Been Charged with Healthcare Fraud?

Owing to the severity of penalties imposed for committing healthcare fraud in Los Angeles, our clients want the best outcome. Every criminal case is unique. The jury’s sentencing is also particular to a case. It takes in various factors like intent, injury to patients, the number of claims involved, compelling evidence, and the government’s interest in the specific healthcare type.

Contact our team the instant you find out that you or your facility are under investigation for healthcare fraud. Time is of the essence. We’ll help you avert criminal prosecutions early enough.

Defending Healthcare Fraud

Criminal defense attorneys with many years’ experience go a long way to help avoid or reduce the weight of penalties. For instance, our team offers customers the benefit of skill sets, experience, insights, and many others. You want to use the services of attorneys who will:

  1. Offer Immediate Involvement

Early involvement of expert attorneys like ours increased the chances of having your criminal charges cleared. Here, an expertly crafted defensive plan is used to answer your questions upon engagement.

Common questions from clients about the nature of healthcare-related criminal cases include: how long might the investigations take? What are the possible outcomes (positive and negative) from the investigations? What parameters does the government employ to prove that you have violated healthcare fraud?

  1. Zero in on Lack of Intent

As per the constitution, before you’re convicted of healthcare fraud, the government should prove that you are guilty of the charges. Thus, the prosecutor must present enough proof before you can be prosecuted for healthcare fraud.

For instance, erroneous billing causes many practitioners to face criminal charges. Often, these errors are considered as ill-will or malicious intent. However, experienced attorneys understand that many billing errors are a result of mistakes, fresher staff, and little staff supervision. Your attorney should ensure that the fraud charge is not premised on a simple mistake.

Our attorneys focus on this fact strictly and will only allow your case to proceed until the government present concrete proof.

  1. Complex Defenses

You want to use attorneys who can handle sophisticated fraud cases in a court of law. Competent attorneys have experience handling healthcare fraud cases. These attorneys know how to decode and take advantage of legal gaps and constitutional exclusions. Also, experienced attorneys can win complex charges before reaching the court desk or even in the court.

  1. Safeguarding your Reputation

Baseless and speculative accusations can significantly affect your professional and personal status online and offline. You want a criminal defense attorney who does not only defend you in court but also from negative publicity. Examples of strategies our attorneys can use include:

  • Averting defamatory reporting by seeking court ruling to bar the media from reporting the speculations, and
  • Approaching reputable media outlets to allow you to air your side of the story

What Complexities Come with Healthcare Fraud?

Healthcare givers and facilities can wrongfully face charges. Wrongful prosecution is caused by misunderstandings, managerial omissions and faults, and misjudged actions. For instance, when a healthcare provider makes an honest mistake when inputting a transaction can face Anti-Kickback charges.

You can get wind of a healthcare fraud charge against you or your facility through family and friends. Qui tam actions existing in the FCA allow accusers to file lawsuits and present the allegations in federal courts confidentially. These qui tam actions are often controversial, but rest assured since our attorneys’ team offers in-depth guidance.

Find a Los Angeles Criminal Defense Attorney Specializing in Health Care Fraud Near Me

The government is stern about the rampant healthcare fraud cases. Given the high levels of scrutiny from the government, you want to make no mistakes when picking the right criminal defense attorney for you. Reach out to us at The Los Angeles Criminal Defense Attorney today and talk directly to our able attorneys. Our attorneys are ready to discuss your criminal charges confidentially. Call us at 310-564-2605 to help have criminal charges against you for healthcare fraud dropped or reduced.

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