Fraud is defined as the intentional act of depriving someone of their property, money, or rights by making false claims, fabricating information, or engaging in both. The law recognizes various categories of fraud, including health care fraud. If you are facing accusations of health care fraud, our team of highly skilled criminal defense lawyers at California Criminal Lawyer Group is here to assist you. This offense is serious, and hiring an experienced lawyer can greatly assist in developing a strong defense plan. Our team of Fresno criminal defense attorneys is ready to support you in creating an effective defense strategy to counter the accusations leveled against you.

Understanding Health Care Fraud

Medicare fraud, also referred to as health care fraud, is a criminal act where individuals submit false information in Medicare claims to gain financial benefits or other advantages. Charges of health care fraud can be filed against healthcare providers, patients, and even insurance companies.

Despite being illegal, health care fraud remains a common crime in California. Many people are still unaware of the serious consequences associated with this offense until the guilty parties are identified. Before delving into the different types of health care fraud, it is crucial to recognize the fundamental distinction between fraud and error.

Health Care Fraud Versus A Medical Error

Distinguishing health care fraud from simple errors, omissions, or incorrect payments is crucial. To be found guilty of fraud, one must have willfully participated in an activity or plan to spread lies for financial gain. It's important to note that medical fraud is distinct from other types of misconduct, such as billing inaccuracies that result in patients being charged for services they did not receive.

Conversely, healthcare fraud occurs when a medical professional intentionally recommends surgeries or treatments that they know the patient doesn't need. They then bill the insurer for these unnecessary services to profit financially.

Consequences for Health Care Fraud

Healthcare fraud is subject to both civil and criminal penalties under federal law. The difference between the two lies in the consequences imposed. Criminal sanctions can result in jail time, fines, and the obligation to reimburse the victim for any financial losses caused by the fraudulent activity. On the other hand, civil penalties do not involve fines or imprisonment, but you will be required to provide restitution.

If found guilty of criminal healthcare fraud, the offender can expect to face severe penalties, including:

  • Incarceration

Any offense that involves making a false statement or claim about Medicaid or Medicare carries a minimum five-year jail penalty. If the deception causes physical harm to any person, a minimum 20-year prison sentence could be imposed. If the offense results in loss of life, the prison term is life imprisonment.

  • Fines

A conviction for medical fraud carries various fines. For example, individuals can be fined up to $250,000 for each false statement made on a Medicare or Medicaid claim. Organizations can face fines of up to $500,000 for fraudulent insurance claims. In cases involving ongoing fraud schemes and multiple violations of healthcare laws, businesses could be fined millions or even billions of dollars.

  • Probation

An individual found guilty of a health care fraud offense could be subject to a probationary period. While probation places restrictions on a person's independence, it is still a preferable alternative to serving a jail term. Probation terms typically last for a minimum of 12 months, but they could extend beyond that. During probation, offenders are required to maintain employment, regularly meet with their probation officer, refrain from further criminal activity, and avoid contact with known perpetrators.

  • Compensation

As part of your criminal punishment, the judge could require you to repay the money you received from your fraudulent conduct. For instance, if a doctor falsely claimed tests and exams that were never performed but still received payment for them, a judge could order the accused party to reimburse the insurance company.

Types of California Health Care Fraud

Most cases of healthcare fraud are perpetrated by criminal organizations and individuals working within healthcare organizations. The following are the most typical forms of healthcare fraud:

Billing for Unused Medical Services

In almost all cases of healthcare fraud, medical professionals or healthcare institutions file claims for services and treatments that were never provided to insurance companies or government healthcare programs. These fraudulent claims often lack any supporting documentation. While documentation is important, it alone is insufficient to establish intent in convicting someone of healthcare fraud, as mistakes can be made with records.

In addition to gathering the necessary documents, fraud examiners and detectives will diligently track down witnesses who can willingly and accurately provide all the details of the scam. Investigators could also question the patients named on the dubious claims forms to determine whether they received medical treatment. This information is crucial in clarifying the services they were provided during their hospital stay.

In contrast to other forms of fraud, cases involving unbilled care and rendered services are easier to prove in court. The underlying strategy is straightforward, making it comprehensible to everyone.

Falsifying the Service Dates

Suppliers often attempt to profit more from this kind of scam by falsifying the dates of service. As a result, each "Office visit" is treated as a separate billable service. Unfortunately, claim forms frequently contain inaccurate dates of service, even though the mentioned medical services were indeed provided. Providers manipulate the dates to boost their earnings.

A fraud investigator can determine whether the date of services indicated on the claim form matches the information in the patient's medical file. By focusing on the "date of service" rather than the date the form was submitted or signed, an investigator can efficiently identify instances of fraud.

Charging for a Covered Service While It Is Not Covered

If a person attempts to bill a non-covered medical service as a covered service, they run the risk of being charged with fraud. This often occurs when a physician falsely claims that a service they provided, which is not covered, is covered.

For instance, a doctor could offer a course of treatment that the government or insurance companies do not approve of, deeming it experimental. By simply using a few keystrokes on a keyboard or pen, the physician can file claim paperwork and receive payment for administering the experimental treatment.

This is achieved by referring to the course of therapy as something else that is covered by insurance plans and policies. However, it is important to note that engaging in such practices can lead to charges of healthcare fraud.

Falsifying the Locations of Services

Furthermore, it is illegal for both physicians and patients to submit claim forms with false service locations. This practice is considered a form of healthcare fraud.

For example, in an allergy clinic, a physician could recommend twice-weekly injections to their patients. Instead of having the patients come to the healthcare facility for each shot, they are provided with a supply of syringes loaded with antigens and instructions on how to administer the shots at home. The physician accurately notes in the claim forms the specific days the medication was administered at the clinic. However, if the physician were to engage in any illegal activities, they would be subject to charges.

Falsely Portraying the Service Provider

The notion that someone could impersonate a doctor and request payment for services is deeply unsettling. Unfortunately, this is a genuine occurrence. There have been instances where medical doctors have falsely indicated on insurance claim forms that they provided all medical care when in reality, it was lower-level medical professionals who administered the services.

In these situations, the insurance company ends up paying for the services provided by a different, less qualified medical expert. However, if the claim forms had specified the appropriate service provider, the insurance company would have paid significantly less.

Waiver of Copayments and Deductibles

When patients have minimal or no out-of-pocket costs, they rarely complain. However, medical establishments and service providers are generally not allowed to waive copayments or deductibles for patients, as mandated by insurance companies and government health care programs. Some patients could argue that if they have to pay to see medical professionals, they will only do so when necessary. It is worth exploring options that can partially cover the cost of medical care.

However, there are instances where certain medical professionals choose to waive their clients' deductibles or copayments and compensate for the loss by submitting fraudulent insurance claims. In some cases, dishonest service providers could even include fictitious services on the claims forms to maximize their financial gains. This type of behavior constitutes health care fraud as it places the burden of covering expenses on insurance companies that should not be responsible for them.

Misreporting of Diagnoses or Procedures

Listing a faulty diagnosis or procedure is comparable to paying for an automobile tune-up when the auto repair shop only replaced the air filter. If dishonest medical professionals report performing bogus operations or diagnoses, they could be able to bill for additional services.

For example, a diligent physician would carefully diagnose an individual with head injuries if they had fallen. Unfortunately, this could lead to the patient undergoing unnecessary blood tests and CT scans.

Overuse of the Services

Usually, this type of fraud involves invoicing for unnecessary services. It is a scam that unscrupulous physicians use on people who are hypochondriacs. Indefinitely, or at least as long as the individual has health coverage, examinations and testing are permitted.

Bribes And Kickbacks

The healthcare system, like any other industry in the nation, carries a high risk of bribery and kickbacks. There have been reports of physicians willingly accepting money or providing payment for referrals. Unfortunately, this leads to the misuse of resources, as unnecessary treatments such as prescription medications, MRIs, and X-rays are often recommended.

False Or Unnecessary Prescription Drug Issuance

Prescription drug misuse refers to the use of prescription drugs for purposes other than those prescribed by a doctor. Among prescription medications, painkillers are the most commonly abused. It is worth noting that painkillers have a street value that is ten times higher than their legal prescription value. Due to their addictive nature, some patients engage in frequent "doctor shopping" to obtain prescriptions.

Some individuals go to the extent of stealing prescription paper sheets and forging provider signatures and prescriptions. In addition, others make unauthorized adjustments to the approved quantity and refill numbers using pen and ink. However, one effective method that doctors are adopting to combat this fraud is the use of electronic prescriptions.

The Effects of Health Care Fraud

Corruption and fraud in the health care system always result in higher costs compared to any potential financial gains. The repercussions of health care fraud have a ripple effect, impacting various aspects of the sector, similar to a stone dropped into a pond. Consequently, the government is determined to investigate and prosecute suspects involved in these fraudulent activities.

Here are some effects of fraudulent crimes on the healthcare system:

Overloading the Medical System

One of the major consequences of ordering unnecessary therapies is the removal of vital health resources from individuals who need treatment. According to a 2015 poll involving 2,106 doctors, it was found that 20. 6% of physicians were believed to be providing unnecessary medical care. This included 11.1% of surgeries, 22% of prescription drugs, and 24.9% of tests.

While many doctors attribute overtreatment to patient demands and malpractice fears, it is concerning to note that over 70% of doctors still perform unnecessary operations when it benefits them. This unfortunate practice ultimately contributes to the overpopulation of hospitals and other healthcare facilities within the health system.

The most evident effect of health care fraud is the impact on the health of patients, especially those who are unable to access necessary medical care or experience long waiting times. This leads to patients having to wait for hours to receive the treatment they need. Additionally, health care fraud also has a negative impact on medical personnel.

Receiving prompt and attentive care from specialists is crucial in every healthcare system. However, medical fraud prevents this from occurring.

Identity Theft

Identity theft, along with cyberattacks, has become a significant concern for insurance firms and consumers alike. The theft of social security numbers, credit card numbers, addresses, and other financial data can have a significant impact on individuals. Additionally, when identity-related medical problems arise, the merging of the victim's and the offender's medical data can lead to detrimental effects. This can result in serious repercussions such as incorrect blood types or the administration of wrong medications.

In one of the most recent cases of medical fraud, five individuals obtained fake prescriptions to acquire opioid medications. To obtain prohibited medications and blank prescription papers, they purchased the names of multiple doctors. These individuals have been accused of conspiring to illegally obtain and distribute controlled substances, aggravated identity theft, and conspiring to perpetrate fraud.

Death or Severe Injury to Patients

At times, medical professionals could feel tempted to overtreat patients by prescribing unnecessary treatments or procedures, but these decisions can have grave consequences. Overordering medical tests increases the risk of misdiagnosis, overdiagnosis, or incorrect diagnosis, whether due to patient or physician demand. Ultimately, this can lead to the prescription of potentially harmful drugs or treatment plans.

When a doctor identifies an abnormality, such as malignant cells, but incorrectly or intentionally interprets it as a disease that requires immediate treatment, this is known as overdiagnosis. Unfortunately, there have been cases of fatalities resulting from healthcare fraud.

In 2016, a healthcare professional was sentenced to 10 years in prison for defrauding Medicaid, Medicare, and private insurance companies of nearly $20 million. This crime stands out as the worst because it resulted in the deaths of at least two individuals. One patient underwent an elective operation despite the X-ray showing moderate congestive heart failure, while the first patient's chest imaging was misinterpreted, leading to a failure in diagnosing their congestive heart failure.

Rising Costs for Health Insurance

For a significant period, the primary factors contributing to the rise in insurance inflation have been fraud and mistreatment. Health care fraud has resulted in the loss of hundreds of millions of dollars for both government and commercial insurers over the years. Consequently, public services are burdened and lack adequate funding. As a result, the quality and standards of medical care are adversely affected.

Private insurers' policyholders bear the losses incurred by healthcare fraud. Government insurers and insurance businesses manage risk differently. If trends indicate that fraud operations are becoming more prevalent and audacious, it is expected that insurance rates will be adjusted to mitigate the impact. Consequently, the cost of health insurance increases.

Reductions in Benefits

When insurance premiums rise, there is a greater chance that insurance companies will reduce the health benefits offered in employer-provided health insurance plans.

Raising the Deductible and Copayment Amounts

Copayments and deductibles are on the rise due to health care fraud. Even with health insurance, an increasing number of workers are discovering that they bear a greater portion of their hospital expenses.

How Organizations and the Government Combat Health Care Fraud

Both organizations and the government employ different methods to combat healthcare fraud, given its seriousness. For example, most businesses provide training to their staff on:

  • What their insurance plans cover and don't cover.
  • What is considered fraud and abuse of health insurance.
  • The effects of deception on individuals and the advantages they enjoy.
  • Ways to recognize health care fraud.

The government pays a lot of attention to the following areas:

  • Medicare Identification Number

Treat your Medicare card and number with the same level of attention and care as you would your credit card number. Only provide your Medicare and Social Security numbers to trusted physicians and approved healthcare providers. When someone offers you free medical services, exercise caution and consider requesting their credentials before accepting any treatments.

  • Keep Your Medical Information Confidential

If someone other than a medical practitioner or your doctor requests access to your medical records or recommended treatments, it is advisable to proceed with caution.

  • Find Out More About Your Health Insurance

If a healthcare professional tells you that there is a method to get Medicare to pay for a treatment that you know is not covered, proceed with caution.

  • Never Take Up Services That Are Not Necessary

You have the option to refuse care or seek a second opinion from a different physician if a medical professional pressures you into receiving further treatments or tests that you believe are unnecessary.

  • Be Skeptical

If a healthcare professional claims that Medicare covers services like Swedish massages, mud treatments, or dance classes that don't seem medically necessary, it is advisable to be skeptical. It is recommended to refer to the Medicare coverage rules in such cases.

Advantages of Engaging a Defense Lawyer

While healthcare fraud could not appear to be a serious crime, a conviction can have a lasting impact on a professional's career. Hiring a defense lawyer for your case offers several benefits, including the following:

Lawyers are Familiar With The Legal System

Professional criminal defense lawyers have a deep understanding of the medical field, which enables them to effectively research and handle your case. Their extensive experience and knowledge in handling health care fraud cases will ensure that you receive the best possible outcome, potentially resulting in a minimum sentence.

Your Lawyer is Capable of Putting Together a Solid Defense

Since each incidence of healthcare fraud is unique, it requires a tailored strategy and methodology. A skilled criminal defense lawyer will carefully analyze all the facts and circumstances to develop a defense plan that is specifically designed for your case. They could explore various options such as settling, preparing for trial, or conducting a separate investigation, depending on the defense strategy.

Your Fraud Lawyer Will Assist With Mitigating the Risks Involved

There are risks associated with criminal cases, which is why it is important to engage the services of a criminal defense lawyer as soon as possible. Doing so ensures that the potential dangers associated with your case are properly managed, preventing the prosecution from building a stronger case against you.

Find a Fresno Criminal Defense Attorney Near Me

Even in cases where a medical worker is innocent, their career could suffer due to healthcare fraud. As a result, it is crucial to hire a criminal defense lawyer as soon as these accusations are made. At California Criminal Lawyer Group, we are here to assist you in finding the proper course of action. To discuss your case in more detail, you can give our Fresno lawyers a call at 559-712-8377.