The alternative names for health care fraud are medical insurance billing fraud, HMO fraud, Medicare fraud, Medi-Cal fraud, or health insurance fraud. The majority of people who receive health care in the United States do not pay for the services directly. Instead, they have insurance companies responsible for paying for medical services. Most people have private health insurance policies, while others rely on government medical insurance programs like Medi-Cal or Medicare. There are many opportunities for fraud in the health care system because the systems for processing payments are often intricate. Health care fraud is a criminal offense under California law, and the associated penalties are detrimental. If you are facing health care fraud in San Jose, CA, San Jose Criminal Attorney Law Firm can help you come up with the proper defense.

Increased Risk of Health Care Fraud

More than ever before, the stakeholders in the healthcare industry face an increased risk of the devastating consequences of health care fraud. Health care fraud is a form of white-collar crime. You may perform this crime if you illegitimately file health care claims to get an illicit profit. There are many forms of health care fraud at both the state and the federal level. Both the medical providers and the patients may perpetuate health care fraud. Both the state government and the federal government take health care fraud seriously. The health care providers who engage in health care fraud end up passing the costs from fraud to consumers. For every dollar spent on health care, .10 of the dollar goes to health care fraud expenses.

Successful prosecution of health care fraud often ends up in a conviction that has serious consequences. If a health care provider engages in fraud, he/she may face consequences like fines, incarceration, and even lose the right to practice in the medical industry.

Types of Health Care Fraud

There are various ways of committing health insurance fraud under California law. The consequences for health care fraud may vary depending on the specific form of fraud you commit. Some of the common types of health care fraud include:

Submitting a Claim for Benefits, You Did Not Deliver

According to the California PC550, a health care provider may commit health care fraud if he/she submits a claim for a health care service of a procedure that he did not offer. The health care provider submits the application in the name of a person who did not receive the service. In other words, this form of fraud entails submitting to an insurance company a claim for services that you did not render.

For example, you may have a medical practice for delivering babies. Most of the time, you do not show up when the patients are delivering, but you send an assistant. However, you always bill your patient's insurance companies for your services, even if you did not offer them. This may qualify as a form of health care fraud.

Submitting a Fraudulent or a False Claim

A health care provider may also face health care fraud charges if he/she submits a fraudulent or a false health care insurance claim. There are many ways of filing a fraudulent insurance claim. For instance, it is an offense to perform a service that a patient does not require and then billing insurance on the service to make a profit illegally. If you tell patients that they require to undergo specific medical procedures while they do not need them, you may be guilty of fraud if you later seek payment for the services.

You may also file a fraudulent health care fraud if you submit a claim or bill a claim that is higher than the value of the services offered to the patients. This practice often goes by the name up coding. It is also a fraudulent activity for a health care provider to apply charges to patients with insurance if he/she does not apply similar charges to patients paying out of pocket. For instance, you may be dealing with patients who often pay cash and those who pay using health insurance. When a patient who pays out of pocket misses an appointment, you do not charge them for the missed appointment. However, when a patient who pays using insurance misses an appointment, you charge them for the missed appointment. In this case, you may face charges for committing health care insurance fraud.

Submitting Multiple/Numerous Claims

You may commit an insurance fraud under California PC 550 if you submit multiple claims for the same medical services. Submitting numerous claims for a single health care service is a way of double-billing the insurance provider. If a healthcare provider overbills the insurance company for the same service, he/she performs health care insurance fraud.

Seeking Payments for Undercharges without Overcharges

It is a crime under California PC 550 to submit an insurance claim to health insurer for services undercharged in the past without at the same time sending a bill for overcharged services. While going through his/her records, a healthcare provider may discover some mistakes. The healthcare provider may notice that at some point, he/she charged a patient a lesser amount that he/she should have. Therefore, he/she under billed the insurance company. The healthcare may also discover that during another visit, he/she overcharged the same patient and ended up overbilling the insurance company. If the healthcare provider submits the under the billed amount to the health insurer, the healthcare provider should also disclose the overbilled amount. The healthcare provider will be guilty of committing health insurance fraud for failing to disclose the overbilled charges while seeking payment for the billed amount.

Making a Writing Supporting a Fraudulent or False Claim

Assisting to prepare any document that will support a fraudulent health care claim is a form of health care fraud under California law. One of the toughest parts of California's health care fraud law is that a simple act of document preparation may lead to criminal liability. If you work as a secretary in a doctor's office or as a medical billing assistant, you have to be careful when preparing medical documents. You may face charges for fraud that you did not even initiate to make a profit. The preparation of the medical documents may have been a part of your job. However, this will not prevent you from facing fraud charges. If you work for a medical provider who engages in fraudulent activities, you may also face health care fraud charges for doing what the doctor ordered you to do.

What does the Prosecutor Have to Prove?

For the prosecutor to prove beyond doubt that you engaged in fraud, he/she has to prove several elements of the crime. The prosecutor has to do more than showing that you are involved in fraudulent medical operations. The prosecutor has to prove that you were aware that you were submitting a fraudulent claim. You may only face California health care fraud charges if you were aware that the application you were handling was fraudulent or duplicated. In the case of document preparation, you must have been aware that the document you were preparing was for making a fraudulent claim. If you did not knowingly submit multiple applications for a medical service, you are not guilty of committing health care fraud.

For you to face health care fraud charges, it must be evident that you had the intent to defraud. It must be evidence beyond a reasonable doubt that you intended to defraud the medical insurance company or the insurance program. The element of intent is an essential component of many fraud crimes in California. Having a fraudulent intent means that you were aware of your actions and that you acted on purpose. It means that you were aware that you were committing fraud. If you did not specifically intend to commit fraud, you could not face charges for committing health care fraud in California.

Detection of Health Care Fraud

The government and private insurance companies incur billions of dollars every year due to fraudulent medical claims. Therefore, the government and insurance companies are actively involved in identifying health care fraud schemes. The detection efforts for health care fraud are not only extensive but also multi-faceted. Some of the detection methods for health care fraud include:


The government and private health care insurance companies encourage whistleblowers to report fraud cases. Whistleblowers may comprise of people working in the health sector and may consist of the recipients of health care services. In most cases, the whistleblower may be entitled to some monetary incentives.

An investigation by the government

It is also common for the government to detect health care fraud by conducting independent investigations. The state of California has in place some measures dedicated entirely to healthcare fraud investigation.

Technological Advancement

The internet serves as the primary source of health care fraud detection. Government agencies and other insurance companies greatly rely on the internet to mine data and to evaluate trends in analyzing claims submitted to Medicare and MediCal programs. The government and insurance agencies can detect known fraud patterns. The agencies are also able to compare ratios of alleged services to the national norms. This helps them to identify potential health care fraudsters.

Federal Law and Health Care Fraud

If you commit an offense of health care fraud, you may face federal charges under 18 USC 1347. Health care fraud is a federal crime, and the associated penalties are detrimental. According to federal law, you may be guilty of health care fraud if you knowingly and willingly execute or attempt to execute a fraudulent scheme. The aim of the fraudulent scheme should be to defraud any federal health care benefits system. You should not use fraud to obtain money or property that is under the control of a federal health care benefits system.

When dealing with federal law, you may face charges even if you were not aware that your actions violated the law. Regarding federal violations, you do not need to have knowledge of the laws against health care fraud to face charges.

Some of the common forms of health care fraud under federal law include billing for non-rendered services and representing when you offered services. It is a federal offense to waive deductibles or copayments. Other forms of health care fraud include overusing services and receiving bribery and kickbacks. A representation of where the services were performed is a form of health care fraud. Improper reporting of diagnosis and procedure is a form of fraud. It is also against the law to bill a non-covered service as covered.

According to federal laws USC 1347, if you attempt to defraud the federal health care benefit program, you may face sentencing of up to 10 years for each count of fraud. If health care fraud causes bodily injury, the imprisonment period may extend to 20 years. Health care fraud may result in physical damage if a medical provider performs an unneeded medical procedure on a patient to make a medical claim. If the violation leads to the death of a patient, the health care provider may be subject to life imprisonment under the U.S federal law.

A statute of limitations applies to the prosecution of health care fraud cases under federal law. According to the federal statute 18 USC 3282, you cannot face prosecution or punishment of any form of a non-capital offense unless the prosecution for the crime is within five years from the date of committing the offense. This statute applies to health care fraud, as well. Therefore, if five years have passed from the time you committed healthcare fraud, you cannot face charges under federal statutes.

Consequences for Health Care Fraud in California

The implications of health care fraud offenses in California may greatly vary depending on the number of fraudulent claims. The penalties will depend on whether the value of fraud exceeds $950. When you commit several health care frauds, the court will consider whether all the frauds add up to more than $950 in one year (12 months).

For fraudulent claims of $950 or less, the crime of health care insurance is a misdemeanor under California law. A misdemeanor offense may have several penalties, including a fine that does not exceed $1,000. You may also serve jail time that does not exceed six months in a California county jail.

If the fraudulent claims exceed $950, the offense is a wobbler under California law. This means that the prosecutor may charge the offense as a misdemeanor or as a felony offense. If the prosecutor chooses to charge the offense as a misdemeanor, the applicable penalties include a fine not exceeding $10,000. You may also spend up to one year in a county jail in California.

If the prosecutor chooses to charge the offense as a felony, the applicable consequences include serving felony probation with up to one-year jail time in county jail. The other sentencing option includes serving a two, three, or five-year jail time in a county jail in California. Instead of in addition to the jail time, the court may require you to pay an amount of up to $50,000. You may also have to pay an amount of double the fraud value whichever is greater.

You may end up losing your professional license after a conviction of health care fraud. If a health care professional commits health care fraud, he/she may be subject to professional discipline. In most cases, professional discipline may lead to the loss of your license to practice in California. For doctors, the professional and personal consequences of license suspension or revocation may be detrimental. For other health care professionals like nurses, the consequences of license suspension due to a criminal conviction are equally devastating.

Fighting Health Care Fraud Charges

Upon facing charges for healthcare fraud in California, it is advisable to contact an attorney immediately. An attorney can come up with ways of fighting the charges. Together with your attorney, you can take advantage of several defense strategies. Some of the common criminal defenses that you can take advantage of include:

  • You did not have the knowledge

According to California law, you cannot face charges for health care fraud unless it is evident that you were aware of your actions. You must have known that you were taking part in submitting a fraudulent or a duplicate claim, for instance. You may claim that your offense is a case of mistake of fact. The process of medical billing and health insurance is incredibly intricate. Even the elite and experienced professionals may have difficulties in understanding how the medical billing system works. Due to the complexity of the billing system, it is common to make mistakes. If you prove that you were mistaken about a critical fact and you were not aware that the claim was fraudulent, you may evade the fraud charges. You can assert that you did not commit a crime because you did not have knowledge that you were committing a crime.

  • You had No Intent

You may also assert that you did not have the intent to commit a criminal offense. Lack of intent is a valid defense under California law. You may be exonerated if the prosecutor is unable to show intent to defraud. For instance, while working as medical assistance, you may realize that your boss is planning a healthcare insurance fraud. You decide to quit your job and then blow the whistle about the fraud. However, law enforcement officers arrest you and your boss before you left. You may assert that you had no intention of committing the fraud because you planned to leave your job and report your employer.

Related Offenses

Several crimes under California law are closely related to the crime of health care fraud. The prosecutor may charge you with the related offense instead or health care fraud or alongside health care fraud charges. Some of the related crimes include:

Medi-Cal Fraud

The state of California has a public health insurance program for low-income individuals. The program is inclusive of families with children, seniors, pregnant women, disabled persons, or people with specific illnesses. Defrauding the Medi-Cal program may lead to health care fraud charges because the program is a form of health insurance. In addition to facing health care fraud charges, you may face additional charges for committing a Medi-Cal fraud. The Welfare and Institutions Code 14107 WIC prohibits the crime of Medi-Cal fraud. The WIC has its unique penalty scheme for any person who commits Medi-Cal fraud. A patient may also commit Medi-Cal fraud if the patient lies about something that affects his or her eligibility for Medi-Cal benefits.

Soliciting, aiding, abetting, or conspiring in Health Care Fraud

According to the California PC 550, you may face other charges other than preparing or submitting fraudulent claims. It is a crime to assist another person to submit a fraudulent application. It is also a violation of the law to solicit another person to submit a fraudulent application for you. If you engage in California crime of conspiracy under PC 182, and you conspire with other people to file a fraudulent claim, you may face charges. Aiding in the commission of a health care fraud may attract the same charges as committing the crime yourself.

Prescription Fraud

The crime of prescription fraud also goes by the name doctor-shopping in California. The offense is a variation of health care fraud, as outlined by the California law. You may commit prescription fraud in two ways. One way is through doctor-shopping, which entails a patient using numerous pharmacies or doctors to get several prescriptions for controlled substances. The other way of committing prescription fraud is if a doctor issues a prescription for any other reason other than for legitimate medical purposes.

Workers Compensation Fraud

The crime of workers' compensation fraud often intertwines with the crime of health care fraud. The California PC 550 outlines the submission of fraudulent claims for workers' compensation benefits. Workers' compensation benefits include reimbursement for medical costs. Therefore, you may face charges for health care fraud under PC 550 if you commit workers' compensation fraud.

Find a San Jose Criminal Attorney Near Me

The crime of health care fraud attracts hefty penalties, including imprisonment and fines. If you or your loved one is facing health care fraud charges in San Jose, CA, California Criminal Lawyer Group can help you come up with a proper defense. Contact us at 408-622-0204 and speak to one of our attorneys.