You could face health care fraud charges in California if you knowingly file or cause another person to file a fraudulent or false claim to a government agency or insurance company. The offense is mainly charged to health care practitioners like physicians and other staff. Sometimes patients also commit this crime. Sadly, it is a grave fraud-related offense, punishable by a lengthy prison time and hefty fines. A conviction also carries life-changing consequences, like having a damaging criminal record for life.

But you can avoid these penalties if you put up a solid defense against your charges during the trial. Competent defense services, like what we offer at California Criminal Lawyer Group, could help change the outcome of your situation. Talk to our experienced attorneys if you face health care fraud charges in Santa Ana, CA. Together, let us build a strong defense and change the outcome of your case.

Legal Meaning of Health Care Fraud

Fraud occurs when you deliberately or intentionally obtain an unauthorized benefit for yourself or another person, using deception, suppression of truth, false suggestions, and other unethical means relied upon by another person. Fraud is a crime of moral turpitude because it goes against the norms of society. California fraud laws are stringent, providing harsh penalties for anyone guilty of fraud-related offenses.

Health care fraud is widespread among health care practitioners and medical patients. It occurs when an individual submits or causes another to submit a falsified or fraudulent claim to an insurance provider or government agency. Some defendants submit fraudulent claims to government medical insurance programs, while others to private insurance companies. Examples of programs that have been severely affected are Medicaid and Medicare.

Several other names used to refer to health care fraud include:

  • Health insurance fraud
  • Billing fraud
  • Medicare fraud
  • HMO fraud

If you face charges for this offense, it helps to understand what it means, its legal consequences, and how you can fight your charges. You need skilled legal help to change the outcome of your case.

Health care fraud is a severe crime whereby different people participate in fraudulent schemes against insurance schemes, insurance plans, and health care systems. Some arrests for suspected offenders are genuine, while the others are ingenuine and could result in a wrongful conviction. If you face health care fraud charges and believe you were wrongfully arrested, hire a competent criminal lawyer to represent you in court.

During the trial, the prosecutor must prove all elements of this crime beyond a reasonable doubt. It is the only way the jury can find you guilty of your charges. These elements are:

  • That you intentionally and knowingly carried out or tried to carry out a fraudulent scheme
  • The scheme was to deceive a health care benefits program or to fraudulently obtain money or property through fraudulent pretenses, promises, or representations from a health care benefits program.

Health care fraud is committed by different people differently, depending on their position within the health care sector. Here are some of the common ways in which it happens in California:

Submitting Health care Claims for Undelivered Benefits

It is the most common way many people commit health care fraud today. They submit claims for services they have not delivered to patients for dishonest gains. Anyone who submits a claim for a health care service, procedure, or medical equipment they did not provide to the patient is guilty of this.

Example: A doctor that runs a dental office downtown is always out of the office but will bill his patient's insurance provider for doctor services. This is fraudulent since the doctor obtains money for services he has not delivered to his patients.

Submitting Fraudulent or False Claims

Other defendants submit fraudulent or false claims to obtain health care benefits they do not deserve. A physician is guilty of this if they:

  • Include services a patient does not need, only to bill the patient's insurance provider for them
  • Bill or up-code insurance companies for more expensive procedures than what they have performed on the patient
  • Not charge certain services if a patient is paying out-of-pocket, but billing the insurance company if the patient is paying through insurance.

Submitting Multiple Claims

You are also guilty of health care fraud if you submit several claims for one service. Some health care providers double bills their patient's insurance companies for dishonest gains.

Example: Mary is a famous gynecologist who treats a good number of women every week. However, sometimes she double-bills her client's insurance provider to take advantage of her unsuspecting clients. Occasionally she sends two separate bills to insurance companies with duplicate entries. Mary is guilty of health care fraud.

Submitting Undercharges and not Overcharges

Sometimes mistakes happen in hospitals, whereby a particular client is overcharged or undercharged for certain services. Sadly, some health care providers will quickly send a bill to an insurance provider for undercharges and ignore overcharges. It is another form of health care insurance fraud. If you have received more money from an insurance company than indicated in the bill, the law requires you to send back the overcharge, the same way you will demand an undercharge.

Preparing a Report Supporting a False Claim

Other health care providers and their patients knowingly commit health care fraud by preparing documents supporting a fraudulent insurance claim. You are guilty regardless of how minimal your involvement is, provided you act knowingly and with fraudulent intentions.

How Health Care Fraud Cases are Investigated

Specific federal and state government agencies are responsible for investigating cases involving California health care fraud. Some of these agencies are:

  • Health care fraud prevention agencies
  • Medicaid fraud control agencies
  • Local Medicare and Medicaid service departments
  • The office of the attorney general
  • Federal Bureau of Investigations
  • Drug Enforcement Administration

Anyone can report suspected health care fraud cases through the Inspector General's office. Public members are always urged to speak up if they suspect fraudulent activity.

If you are suspected of committing health care fraud, you will be under investigation by any of the concerned units. You will learn about the investigation when:

  • You realize that there is a valid search warrant against you from a judge.
  • You receive a target letter from the Department of Justice indicating that you are a target of a grand jury investigation.
  • You receive a grand jury subpoena indicating that the government wants to initiate a criminal investigation against you.
  • You receive a civil investigative demand requiring you to submit crucial information regarding health care fraud.

Defending Yourself Against Health Care Fraud Charges

The consequences of a conviction for health care fraud are grave. You will receive time in jail or prison, be required to pay a hefty fine, and have to deal with a damaging criminal record. But you can fight your charges to avoid these and other consequences of a criminal conviction. You need to engage the help of a competent criminal lawyer to help you plan a solid defense. Fortunately, the law provides defense strategies your lawyer can use to have the court drop or reduce your charges. The best of these strategies are:

You Did Not Act Knowingly

You are guilty of health care fraud if you act knowingly. For instance, if you knowingly submit a fraudulent claim to an insurance company or intentionally include benefits that a patient did not receive. Without this knowledge, you are not guilty. Knowledge is crucial when it comes to fraud-related cases. The jury can quickly find you guilty if the prosecutor can prove that you knowingly planned to defraud an insurance company or health care program. But you could have unknowingly submitted a false claim or included a wrong benefit because someone else prepared it. In that case, the court will dismiss your charges.

You Did Not Have Fraudulent Intentions

The prosecutor must also prove that you acted with fraudulent intent for the jury to declare you guilty of health care fraud. Without this intent, the court can dismiss your charges. The prosecutor must prove that your actions were only aimed at defrauding an insurance company or health care program. Sadly, proving intent is a challenge prosecutors face in cases like these. The judge will drop your charges if the prosecutor cannot confirm all elements of the case beyond a reasonable doubt. Your lawyer can use this to convince the jury that, even though you acted the way you did, your intentions were different from defrauding the insurance provider.

False Accusations

Your lawyer can use this defense strategy if someone else accuses you of an offense you did not commit. People are falsely accused of fraud all the time. Someone you work with or a patient can blame you for fraud because of what you did or failed to do. Your lawyer's responsibility would be to convince the jury that you did not commit fraud and that someone lodged a false accusation out of revenge, jealousy, or to get even with you. If successful, the court will dismiss your charges.

Police Misconduct

Your attorney could use this defense if the police did not follow the proper procedure while investigating and arresting you for health care fraud. The law provides a detailed guideline that law enforcement officers must follow when performing their duties. For instance, they need a clear search warrant to search a person or their property. They also need an arrest warrant to arrest you. If the police searched and seized some of your documents without a warrant, you can use this defense in court to have all evidence they gathered against you inadmissible in court.

The police also require probable cause to make an arrest. An arrest without probable cause is illegal. Thus, the court can dismiss your charges if an officer stops and arrests you for health care fraud with no probable cause.

Sometimes the police force a confession out of defendants, which is also illegal. Other times the arresting officer fails to read a defendant's Miranda Rights. Whatever the misconduct, the police will have violated your rights, and that is sufficient defense to have the court drop or reduce your charges.

You Acted Under Duress

Your attorney could use this defense strategy if someone else caused you to commit the offense. Sometimes people in higher authority force or threaten their junior staff to commit white-collar crimes like fraud. If that happened to you, your lawyer only needs to prove in court that you committed health care fraud as charged, but you were compelled to do so because someone else forced or threatened you with dire consequences. Your lawyer must convince the jury that:

  • Someone made an immediate threat of severe physical injury or death against you.
  • You had a reasonable fear that the person or a third party would carry out the threat.
  • You had no proper way to avoid the impending harm but to commit health care fraud.

If your lawyer does this successfully, the court will dismiss your charges, and the police will pursue the actual perpetrator.

It Was A Misunderstanding

Some accusations come as a result of a misunderstanding. A misunderstanding between a healthcare facility and the insurance company can result in serious charges, resulting in time in jail for one or more healthcare professionals. For instance, if a hospital is not clear about the services or procedures a particular patient received in their facility, the patient's insurance provider can misunderstand that as a way for the facility to defraud it.

Your lawyer must have all the case information to plan a solid defense that will result in a dismissal of the criminal charges. The court will dismiss the charges if your lawyer clears the misunderstanding.

Consequences of a Health Care Fraud Conviction in California

Penalties for a health care fraud conviction in California depend on the value of the false claim the defendant submits to the insurer. The offense is generally a wobbler, meaning the district attorney can prosecute it as a felony or misdemeanor.

False claims worth $950 or less are prosecuted as misdemeanors. If you receive a misdemeanor conviction for health care fraud, you will likely receive the following penalties:

  • Misdemeanor or summary probation, or
  • A maximum of six months in jail
  • Court fines of not exceeding $1000

Fraudulent claims worth $950 or more are mainly felonies. A felony conviction for health care fraud is punishable by:

  • Two, three, or five years in prison
  • Felony or formal probation
  • A maximum of $50,000 in Court fines or double the amount on the fraudulent claim (whichever is more)

Violating federal health care fraud statutes attracts a longer prison sentence of up to ten years, plus a heftier fine.

If the offense caused another person's severe physical injury, your prison sentence would go up to twenty years.

Probation after a Health care Fraud Conviction

Probation allows you to spend part of your prison or entire jail time out of incarceration. The judge could place you on probation after a conviction for health care fraud. The judge decides whether to give you probation or to incarcerate you.

You could be placed on misdemeanor probation if your conviction for health care fraud is a misdemeanor. Misdemeanor probations last between one and five years, depending on the circumstances of your case and your criminal history. You will be under the direct supervision of the court while on misdemeanor probation. The judge will order you to return to the court periodically to submit your progress reports. You will also receive probation conditions, set according to the details of your case. You must abide by these conditions throughout the probation period. If you violate any probation condition, you could face an additional misdemeanor charge for it, punishable by extra time in jail.

If you face felony charges for health care fraud, the judge can place you on felony probation to serve part or the entire prison time out of prison. When that happens, you will be placed under the supervision of a probation officer. The officer will ensure that you abide by all probation conditions set by the judge at the beginning of your probation. If you violate any of those conditions, the officer will report to the court, and the judge will hold a probation violation hearing. From the hearing, the judge can:

  • Revoke your probation and send you to jail or prison for the entire term provided by the law
  • Reinstate probation but give you a stern warning against further probation violations, or
  • Reinstate probation but with stricter probation conditions

Here are some of the probation conditions you could receive for health care fraud in California:

  • Ensure that you pay all court fines and assessment fees related to the underlying case
  • Pay restitution to the victim(s) if it applies to your case
  • Remain within the court's jurisdiction to make it easy for the court or probation officer to make follow-ups
  • Not to violate any crime or face arrests while on probation
  • Not to violate any probation condition set by the judge

Other Consequences of Conviction for Health Care Fraud in California

A criminal conviction in California is a big deal. It affects your life in several ways, including your career and social life. People are likely to treat you differently after a criminal conviction. Nobody wants to be associated with an ex-convict. Thus, it can affect how you relate with the people around you, including your family and friends.

A criminal record also affects how you receive certain services. For instance, you could experience difficulties finding a property to rent or lease. Landlords are skeptical about renting or leasing to ex-convicts. They will do a quick background check on you once you submit your application and can make decisions based on their findings.

Also, employers conduct background checks on people seeking jobs. They will quickly deny you an opportunity you qualify for if you have a fraud-related criminal background. Thus, it becomes a challenge to find suitable employment after a conviction.

Your health care fraud conviction could also impact your gun rights. Californians have the right to acquire and possess a firearm, especially in specific conditions, like having a felony conviction on your criminal record. The sentence will affect your gun rights if you receive a felony conviction for health care fraud. You will not be able to buy or possess a firearm for several years or life, depending on the details of your case. If you already have a gun, you must surrender it to law enforcement.

Fraud is also a crime of moral turpitude, as it goes against the values of a society. As such, it has serious immigration consequences. If you are an immigrant and are already living in California, the immigration department could deport you after a conviction for health care fraud. They will also mark you as inadmissible into the United States. That will affect your efforts to enter the country in the future.

Expungement of Your conviction Record

Expungement laws in California are under Penal Code 1203.4. The law allows defendants to plead guilty or no contest or to re-enter a plea of not guilty to an offense they have already received a conviction for, for the court to dismiss the case and seal the conviction record. When the court grants your expungement petition, it releases you from the many negative consequences of the conviction. You can start life afresh as if you never received the sentence in the first place.

Expungement is allowed for defendants with criminal convictions for misdemeanors and felonies. But, you must meet specific conditions to qualify, including completing probation or jail/prison term for health care fraud. You must also not be serving time for another criminal offense or facing criminal charges for another crime. If you meet the qualifying criteria, you can petition the court to expunge your criminal record where the conviction occurred.

Find Competent Santa Ana Criminal Attorney Services Near Me

Do you face health care fraud charges in Santa Ana and are worried about the outcome of your case? A skilled criminal lawyer can explain your charges' gravity and options and help you plan the way forward. They could also arrange with you a solid defense to fight your charges in court. We walk with our clients from the start to the end of the legal process at California Criminal Lawyer Group. We could also use the best defense strategies to obtain a fair outcome for your case. Call us at 714-844-4151 today to speak to our team of experienced criminal defense lawyers.