In California, fraud occurs when a party makes false promises, misrepresents facts, or deceives victims intending to deprive them of their rights, money, and/or property. Under the law, there are different types of fraud. One of them is Health Care Fraud. At Orange County Criminal Defense Attorney Law Firm, we have experienced criminal defense attorneys who can defend you if you are facing charges of health care fraud. This offense is treated seriously, and having an experienced attorney can help in building an excellent defense strategy.

Understanding Health Care Fraud

Health care fraud, which is also referred to as Medicare Fraud, is a criminal offense in which an individual uses deceptions, lies, or falsehoods when filing a medicare claim to make a profit or gain some type of benefit. Health care patients, providers, and even health care insurers can be charged with health care fraud.

However, despite being a criminal offense, it is a common crime in California. Most people are still not aware of how severe the penalties for this crime are until they are convicted. However, before we can examine the different types of health care fraud, it is essential to note that there is a fundamental difference between fraud and a mistake.

Health Care Fraud vs. Mistake

Distinguishing between health care fraud from mere omissions, mistakes, or improper payments is essential. To commit fraud, you must have knowingly engaged in a scheme, plan, or activity to provide falsehoods to attain financial gain. Health care fraud is not the same as, for instance, making a mistake that ends up resulting in a patient being billed for the treatment they didn’t receive.

On the other hand, when a health care provider knowingly offers procedures or treatments that the provider knows the patient doesn’t require and then bills the insurance company for the procedures or treatments to make a financial profit, such conduct is referred to as health care fraud.

Penalties for Health Care Fraud

Federal law provides for both criminal and civil penalties for health care fraud. The difference between the two is that criminal penalties allow for prison, fines, and an order to compensate the victim for any amount of money lost because of the fraud. Civil penalties result in no jail time or fines, but you will have to pay restitution. Criminal health care charges can lead to serious consequences when convicted. The penalties you can expect include:

  1. Prison

Making a false statement or false claim concerning a Medicare or Medicaid claim can result in at least a five-year prison sentence for every offense. If the fraud results in bodily injury to any individual, there is a potential sentence of at least 20 years in prison. If it results in someone’s death, the prison penalty is a life sentence.

  1. Fines

Anyone convicted of medical fraud also faces several fines. For example, an individual who makes a false statement in a Medicare or Medicaid claim faces a fine of up to $250,000 per offense. Organizations that make fraudulent insurance claims face up to $500,000 per offense. Organizations that engage in continuous schemes involving multiple health care fraud violations can face millions, sometimes even billions of dollars in fines.

  1. Probation

A person convicted of a health care fraud crime can also face a probation sentence. A probation sentence limits an individual’s freedom. It is, however, better than serving a sentence in prison. Probation lasts at least 12 months, though sentences of more than a year are possible. Individuals on probation must comply with specific conditions such as maintaining employment, regular meeting with your probation officer, not committing any more crimes, and not associating with known felons.

  1. Restitution

As part of a criminal sentence, the judge can order you to pay back the amount of money you obtain from your fraudulent acts. For instance, if a doctor improperly billed an insurance company for exams and tests that were not performed and still received payment, the judge can order the defendant to repay this money.

Common Types of Health Care Fraud in California

The majority of healthcare fraud is committed by health care providers and organized crime groups. The most common types of health care fraud include:

  1. Billing for Medical Services not Rendered

In almost all health care fraud cases, medical providers or health facilities submit claim forms to the government health care plans or insurance companies for care and services that were never provided. The submitted patient files have no supporting documentation. However, for a person to be convicted of health care fraud, documentation alone can’t prove they intentionally did wrong as it is possible to misplace documents.

Apart from the documentation, fraud investigators and examiners will also locate witnesses who are willing to and can truthfully relate everything about the fraud. Investigators can also interview the listed patients on the questionable claims forms. This helps clear things up, as they know whether or not they visited the doctor. They also know what services they received during their visit to the hospital.

Unlike other types of fraud cases, billing for care, and services not rendered make for simple cases to present in court because the scheme is basic that anyone can understand it.

  1. Misrepresenting Dates of Service

With this type of fraud, providers often tend to make more money by misrepresenting dates of service. Each “Office visit” is then considered a separate billable service. Often, the medical services listed on the claim forms were provided, but the dates of service provision are false. The reason why providers falsify the date is to make more profits.

So, a fraud investigator will verify whether the patients’ medical file documentation matches the date of services listed on the claim form. By focusing on the “ date of service” and not the date of the submitted or signed form, an investigator can quickly tell if fraud has been committed.

  1. Billing a Non-Covered Service as a Covered Service

A person may be found guilty of fraud if they attempt to charge a non-covered service as a covered service. Usually, this act includes a doctor claiming that the non-covered service they offered is a covered service.

Example

A doctor provides a treatment that is considered experimental and is not approved by insurance companies or government health care plans. With a few taps on a keyboard or strokes of a pen, the doctor submits claim forms and gets paid for using the experimental treatment. The doctor accomplishes this by calling the treatment something else that is covered by insurance policies and plans. Hence, they could end up facing health care fraud charges.

  1. Misrepresenting Locations of Service

The law in California also prohibits doctors or patients from submitting claim forms with misrepresented locations of service. This is also considered as health care fraud.

Example

A doctor at an allergy clinic prescribes injections twice a week to his patients. Instead of the patients receiving injections at the hospital, they are given a bunch of syringes filled with antigens and give them instructions to inject themselves at home. The doctor then proceeds to report in the claim forms that the injection was given at the clinic on specific days. The doctor would end up facing criminal charges.

  1. Misrepresenting the Provider of Service

It’s a scary thought that a person might impersonate a doctor and bill for treatment. This does actually happen. Medical doctors have been known to sign insurance claim forms showing they provided all the medical care, but in reality, lesser-educated health professionals actually provided the services.

In such cases, the insurance company still ends up paying for the care provided by another lesser-educated medical professional. Still, they would have paid far less if the right service provider was indicated on the claim forms.

  1. Waiving of Deductibles or Copayments

No patient ever complains when their out-of-pocket expenses are non-existent or low. Most private insurance and government health care plans don’t allow medical facilities and providers to waive patients’ copayments or deductibles. The reasoning may be that if patients pay to see doctors, they will only do it when they really have to. It can also be a way to offset some of the medical expenses.

Regardless, some healthcare providers do waive patients’ copayments or deductibles and then submit false insurance claims to make up for the difference. Some unscrupulous providers will end up adding other fraudulent services to the claims forms to help increase their legal gains. Waiving deductibles is health care fraud as it causes insurance companies to pay for expenses they shouldn’t have to pay.

  1. Incorrect Reporting of Procedures or Diagnoses

Listing an inaccurate procedure or diagnosis is essentially quite similar to being charged for a car tune-up when an auto-repair shop only changed the air filter. Unscrupulous medical providers can bill for extra services if they report false procedures or diagnosis performed.

For instance, if a patient accidentally fell, a scrupulous provider could intentionally diagnose the patient with head trauma. This will require the patient to have unnecessary CT scans and blood tests.

  1. Overutilization of Services

This type of fraud typically involves the billing of services that aren’t necessary. Unscrupulous providers use this scheme to hypochondriac patients. Exams and tests can go indefinitely or at least as long as the patient has health coverage.

  1. Kickbacks and Bribery

Like any sector in the country, the potential for bribery and kickbacks in the healthcare system is great. Medical practitioners have been known to receive payments or pay for referrals unlawfully. This eventually leads to abuse, as referrals are made for services that aren’t even required like prescription drugs, MRIs, X-rays, among others.

  1. Unnecessary or False Issuance of Prescription Drugs

Prescription drug abuse is defined as the consumption of prescription medication for reasons beyond your physicians’ intention. The most commonly abused prescription drugs are painkillers. The street value on painkillers is ten times its legal prescription value. Since painkillers are highly addictive, some patients tend to “ doctor shop” to obtain a prescription.

Other patients even go as far as stealing prescription paper pads and forging prescriptions and provider signatures. Others make pen and ink changes to the authorized quantity and refill numbers on the prescription papers. However, one of the ways medical practitioners are fighting this fraud is by using electronic prescriptions.

The Impact of Health Care Fraud

Whenever health care fraud is caught, corruption and fraud cost more than the money that a person is likely to acquire. Like a stone dropped into a pond, the effects of health care fraud in the health care system sends ripples outwards, and it nudges everything in its wake from resources to costs in the sector, and this is why the government is keen in investigating and charging suspects. The impact of fraudulent crimes in the health care system include:

  1. Overburdening the Health Care System

One of the significant effects of ordering unnecessary treatments is that it takes away valuable health resources from patients who require the treatment. According to a survey conducted in 2015, with 2,106 physicians, 20.6% of the doctors were believed to provide unnecessary medical care. This includes 24.9% of tests, 22% of prescriptions, and 11.1% of procedures.

While patients' demands and fear malpractice were said to drive most of the doctors' belief of overtreatment, more than 70% of the physicians will still, however, perform unnecessary procedures whenever it profits them. This, in turn, ends up contributing to the overcrowding of health systems and their facilities and hospitals.

However, the most obvious impact is on the patient's health, especially those who can't find the medical services they require, or those facing long waiting periods. This then leads to patients waiting for hours to access crucial treatment. Medical staff also suffer because of health care fraud. In Hong Kong, nurses in overcrowded public health systems were found to have the highest suicide rates amongst other professionals.

Receiving timely care from attentive and alert professionals is essential in any health-care system. Health care fraud keeps this from happening.

  1. Lethal or Physical Harm to Patients

Where doctors are drawn to offer their patients overtreatment with unnecessary services or procedures, sometimes those decisions can become fatal. Whether it be the demand of the doctor or patient, ordering too many medical tests increased the risk of misdiagnosing, falsely diagnosing, or overdiagnosing a disease. This can lead to harmful courses of treatments or medication being prescribed. 

Overdiagnosis is when a physician identifies an anomaly like cancerous cells, but it is viewed either deliberately or mistakenly as a condition to warrant immediate medical attention. However, some health care fraud cases have led to death.

For example, in 2016, a health care provider was sentenced to 10 years for cheating Medicare, private insurers, and Medicaid out of more than $20 million. However, the worst part of this crime is that the falsified radiology reports resulted in the death of at least two patients. One patient had their chest imaging misread, and this failed to detect their congestive heart failure while the second patient underwent an elective surgery despite her X-ray showing a mild congestive heart failure.

  1. Identity Theft

In addition to cyberattacks, insurance consumers and companies have also been a target of identity theft. The implications for individuals can range from financial information such as credit cards, addresses, and social identity numbers that can be stolen. Medical issues that arise from identity then have serious consequences from mixing the victim's information with the perpetrator's medical information. This could lead to dire consequences related to blood types or incorrect medication.

One of the most recent cases of medical fraud involved five individuals who acquired fraudulent prescriptions to obtain opioid pills. These individuals bought the identities of doctors and several individuals in order to get blank prescription forms and restricted drugs. All five individuals were charged with conspiracy to unlawfully distribute and acquire a controlled substance, conspiracy to commit fraud, and aggravated identity theft.

  1. Increasing Health Insurance Premiums

Fraud and overtreatment have long been the primary reasons for accelerated insurance inflation. Health care fraud has cost both private and government insurers hundreds of millions over the years. This ends up causing public services to become overburdened and under-resourced. Thus affecting the standard and quality of health care.

For private insurers, the losses of health care fraud are levied amongst its consumers. Insurance companies manage risk differently from government insurers. If trends indicate that fraud activities are becoming more bolder and frequent, you can expect that the insurance premiums will be adjusted accordingly to soften their blow. This then causes an increase in health insurance premiums.

  1. Cutbacks on Benefits

As insurance premiums become costly, there is a higher likelihood that there will be cutbacks on the health benefits that insurance companies offer in employer-provided health insurance policies.

  1. Increased deductibles and Copayments

Due to health care fraud, deductibles and copayments are on the increase. More and more employees are finding themselves footing hospital bills of a higher proportion despite having health insurance.

How the Government and Organizations Fight Health Care Fraud

Because of the serious nature of health care fraud, the government and organizations have different ways of fighting it. For instance, most companies educate their employees on:

  • What is and isn’t covered in their insurance plans
  • What constitutes health insurance abuse and fraud
  • How fraud impacts them and the benefits they receive
  • How to spot health care fraud

The government places much emphasis on the following areas.

Medicare Number: Always treat your Medicare number and card the same way you treat your credit card number. Only give your social security number and Medicare number to doctors and other verified providers. Be careful when others offer free medical services after you provide your number or ask for the number before you acquire any service.

Protect your Medical Information: Be cautious if people other than medical professionals or your doctor wants to see your recommended services or medical records.

Learn More about your Medical Coverage: Be cautious if a medical provider informs you there is a way to get Medicare to cover a medical service that you know is not covered.

Never Accept Services You Do Not Require: If a medical provider pressures you into getting other services or tests you feel are unnecessary, you can either get a second opinion from another doctor or turn down care.

Be Skeptical: It doesn’t hurt to be skeptical if a medical provider says that Medicare pays for services that don’t sound medically necessary like Swedish massages, mud treatment, or dance classes. In such instances, refer to Medicare coverage rules.

Benefits of Hiring a Defense Attorney

Health care fraud may seem like a minor crime, but a conviction can cause irreparable damage to a professional’s career despite the little impact the crime had. Having a defense attorney for your case has the following benefits:

Attorneys have extensive knowledge of this system — Skilled criminal defense attorneys have extensive experience in the healthcare system. Their understanding gives the skills they require to investigate and handle your case appropriately. Having handled numerous health care fraud cases, they can put that experience and knowledge into ensuring you get a minimal sentence.

Your attorney can design a stronger defense strategy — Every health care fraud case is different, and it should have a different strategy and approach. A criminal defense attorney will measure all the circumstances and events and come up with a defense strategy that suits your case. Based on the plan, they can conduct an independent investigation, prepare for your trial, or try to make settlements.

Your fraud attorney will help to mitigate risks — Criminal cases always come with risks. Hiring a criminal defense attorney as soon as possible ensures that the risks that can arise from your case are handled. This prevents the prosecutor from strengthening the case against you.

Find a Criminal Defense Attorney Law Firm Near Me

Health care fraud can damage a medical professional’s career, even when they are innocent. That is why you need to have a criminal defense attorney as soon as these allegations arise. Orange County Criminal Defense Attorney Law Firm is here to help you by establishing the best course of action. Call us at 714-740-7848 for a free case evaluation.