Health Care Fraud
The crime of healthcare fraud is one of the most common crime committed in California. People nowadays do not know how serious can be asking for a overcharged benefit or asking for a false benefit. Sometimes, the patient or the medical professional mistakenly file and seek for a wrong benefit or filed the wrong document, however if a patient or the medical professionals have the specific intent to defraud an insurance company for purposes of gain economic advantage, this person could be guilty of health care fraud, in which could be punishable by imprisonment. Furthermore, it is important to explain that could be a crime to fraud a government health insurance program.
The California Penal Code, under the section 550, defines what is considered health care fraud in California. The rules applied to different types of conduct, in which someone could be convicted of health insurance fraud. The most common offenses that could lead a person to a conviction are the following:
- Claimed for a false benefit.
- Submitted a claim that the defendant did not use.
- Claimed for payments of the same benefit
- Claimed payment of a overcharges claims.
Example: Gloria is a in house physician, one day she claimed and seeked to the insurance company for services that she performed on John. However, the insurance company discovered that John died 10 years ago.
In this case, Gloria could be convicted of health care fraud, since she submitted a false claim to the insurance company.
Under the section 550, the legislative created a variety of conduct that could qualify a health care fraud offense. Let's explain with details those types of conduct and the requirements that could lead a person for being charged of health care crime.
TYPES OF HEALTH CARE FRAUD:
- False or fraudulent claim for payment of a benefit (P.C. 550(a)(6).)
- Claim for a benefit that was not used. (P.C. 550(a)(7).)
- Multiple claims for the same benefit. (P.C. 550(a)(8).)
- Overcharges or undercharges claims. (P.C. 550(a)(9).)
1. False or fraudulent claim for payment of a benefit.
A person could be charged of health care fraud for seeking a fraudulent or false claim for health care benefits. Usually, those types of conducts include, providing services that the patient did not need and seeked to the health insurance care a refund, or over claim the payment of a benefit to the health insurance company, or having different type of charges for patients with insurance, in which is not applied to other patients.
Example 1: Dr. Sami is a doctor in California. Usually, he tells his patients that they need to make a raio-X, even if the patient does not need to do this exam, he will ask for for the raio-X anyway. Sami asks for the exam to get the health insurance reimburse.
Under California rule, Sami could be charged and convicted of health care fraud, since he falsely asked for an exam that the patients did not need it.
2. Claim for a benefit that was not used.
California makes illegal a submit a claim of a health care service that was not used by the patient, meaning that, if a doctor or a patient submits a claims, requesting the money from the service, and actually, the services has never been provided, the doctor or the patient could be charged as a health care fraud.
Example: Dr. Clara has been practice for more than 10 years, but for the past year she usually send her assistant to see the patients. And, in the end of the day she claims her patients' insurance companies for her services.
In this case, even though the patient was assisted, the doctor conduct could be considered a crime in California, since it was not the doctor who provided the services to the patient.
3. Multiple claims for the same benefit
In California, the statute established: "(a) It is unlawful to do any of the following, or to aid, abet, solicit, or conspire with any person to do any of the following: (8) Knowingly present multiple claims for payment of the same health care benefit with an intent to defraud. " In other words, it is also a crime if a person seek for multiple claims out of the same service provided.
Examples: Yoshi and his assistance agreed to conspire against the insurances companies. They usually submit the payment of a benefit separately. Yoshi's assistance submits the payment for a service provided and after two months, Yoshi seeks for the same service another bill to the insurance company.
In this case, Yoshi and his assistance could be convicted of health care fraud, since the intent to defraud the insurance company seeking for the same service provided several times.
4. Overcharges or undercharges claims.
The California Penal Code under the section 550 established "(a) It is unlawful to do any of the following, or to aid, abet, solicit, or conspire with any person to do any of the following: . . . (9) Knowingly present for payment any undercharges for health care benefits on behalf of a specific claimant unless any known overcharges for health care benefits for that claimant are presented for reconciliation at that same time." In other words, the doctor or the patient "claimed payment for undercharges for health-care benefits for a specific person without presenting for reconciliation, at the same time, any known overcharges for benefits for the same person"
Example 2: Cardozo is a dentist, he is usually charges his patients less than for what they need, but when he files and claim for insurance company payment, he seeks for a higher rate that is actually is.
Elements of the crime
For someone being convicted of health care fraud, the prosecution must prove two main elements of the crime. In other words, the prosecutor need to prove that the defendant had knowledge that the claim was false and that the defendant had intention to defraud the insurance company. Also, for the purpose of this crime, the victim can be also a governmental agency, a corporation, a business, an association or a body politic.
Let's explain in details those elements of health care fraud for better comprehension. These conditions are essential for someone being convicted, if the prosecution does not prove these elements, a person should not be convicted of health care fraud. San Diego Criminal Attorney will work to prove the innocence of its clients.
Knowledge that the claim was false or fraudulent
A defendant can only be charged and convicted of health care fraud if she/he had knowledge about the false claim that was submitted to the health care insurance. The prosecution must prove the defendant's full knowledge about the fraud.
Intent to defraud
For someone being convicted of this type of fraud, the defendant must had the intention to defraud another person or the insurance company. Further, the conduct of "fraudulently" means: any type of act that intended to cheat, gaining an unfair advantage for another person or entity. A person only could be convicted of fraud if the prosecution can prove under the beyond a reasonable doubt that the defendant intended to defraud the victim.
The Courts have established that someone intends to defraud if he or she "intends to deceive another person either to cause a loss, or to cause damages to, a legal, financial or property right." Furthermore, the definition of cause a loss is regarding any type of money, goods, services or any that have economic valuable for the victim, in this case the insurance company.
In the case that someone just filled up a form intending to defraud but did not claim the payment for the insurance company, this person could also be guilty of health care fraud, since the knowledge and the intent are enough to convict someone of this type of crime.
The offense of health care fraud can be punishable as either misdemeanor or a felony, depending on the facts of each case. That is called wobbler in California, the prosecution has a option to charge the defendant with both crimes. If the fraudulent claim is nine hundred fifty dollars ($950) or less, the offense is going to be charged as a misdemeanor, if it is more than nine hundred fifty dollars ($950), the fraud is treated as a wobbler.
If the offense was charged as a felony, the punishment could be aggravated, by a fine not exceeding 10 thousand dollars ($10,000) or by imprisonment in county jail not from 2 years to three (5) years, or both the fine and imprisonment.
However, If the offense was charged as a misdemeanor, the punishment is by a fine not exceeding ten thousand dollars ($10,000) or by imprisonment in county jail not exceed (1) year in county jail, or both fine and imprisonment.
Legal defenses against health care fraud charges
A health care fraud is a misdemeanor crime in California Law, if a person is convicted with this type of crime, the crime is going to be on the person's criminal records. If you are looking for a job and the employer does a criminal background check and there is an offense registered, it is likely that the employer won't hire someone with a misdemeanor background. If you have been charged with Health care fraud, you should promptly look for a Lawyer. San Diego Criminal Attorney has a great deal of success defending our clients and we can help you build legal defenses that it could be used to contest these types of charges. If you would like more information, please contact our successful staff to help you with your legal problems.
To contest the charges, San Diego Criminal Attorney would be able to use the following legal defenses:
- Lack of knowledge/ mistake of fact.
For someone being convicted of health care fraud, the prosecution must show that the defendant knew about the fraud claim. However, sometimes a doctor or a patient could make a mistake and fill the application form in a wrongful manner, sometimes the health insurance bill could be complicated and a reasonable person could be commit a mistake while filling it up. A person could not be convicted of health care fraud unless, this person knew about the fraud.
- No intention to defraud.
The prosecution must prove into court that the defendant had a specific intent to defraud another person. If a person lacks of fraudulent intent, he/ she should not be guilty of this type of offenses.