Health Care Fraud

Fraud is mostly interpreted in the statute as a deliberate falsification of information created by one individual and passed to the next with awareness of its inaccuracy. The said individual falsifies information with the motive of making the second person take action, which then results in physical damage or injury. The scam may as well be defined as an exclusion or purposeful negligence to declare material reality; which in turn makes other explanations deceptive.

Health care fraud is an offense that comprises the claims for compensation of settlements that health care workers present to health security firms or to government health security plans. This type of crime naturally falls under the social security scam laws in California and is applicable to the medical care labor force.

Medical care scam is more than often referred to as Medi-Cal Fraud, health cover billing fraud, Medicare fraud, medical insurance fraud, or HMO fraud. 

In California, the majority of the medical care rendered to the residents is usually financed by somebody else other than the ailing person themselves. This is one of the major reasons that has led to an increase in crimes that are related to the health sector over the past several years. The frameworks that are put in place for processing the payment for medical care are frequently also very complex. This has created a lot of opportunities for a scam which criminals have taken advantage of.

The complicated organization of medical checks has also led to plenty of openings for the administration to blame innocent individuals of medical care scam, often for actions that happen to be the effect of honest errors.

1. Claiming requests for settlements that were never provided

   In the California statute, under Civil Code 550 it is unlawful to hand in a request for any type of medical care facility or procedure which was not in fact utilized by the individual in whose title the request is made.

   In short, it is regarded as a crime in the event that you hand in claims to a health care provider for resources that were essentially at no time provided.

2. Presenting forged or incorrect applications

   If you provided a deceitful application for medical care settlements you could also be indicted for Health care fraud in California. Instances, where you as a medical worker might be prosecuted, include; charging security cover for a costlier operation than what was administered to a sick person, performing a service that was not necessary on a patient then charging insurance for it, and enacting charges on insured patients but not those who pay directly.

3. Submitting numerous claims

   This form of Health care fraud also falls under Civil Code 550 and prohibits workers in the medical field from forwarding other than the required number of claims for a similar medical amenity. This could also be considered dual charging the cover provider.

4. Sending in undercharges but not overcharges

   If earlier on you made a mistake and charged your patient a lesser than required amount for a service or treatment provided, you can submit undercharge requests to their cover providers. It is considered fraud if you fail to submit overcharge bills that occurred of which you are aware of.

5. Put together a written document backing up deceitful requests

   You could be arraigned in court if you took part in the preparation of any papers that would be used to defend a fake medical care request. This act covers anyone involved in the making of the fraudulent documentation and not solely medical care workers.

In order for a prosecuting attorney to convict you of a health care scam, they need to do more other than prove to the court that you took part in any of the different types of Health care fraud defined above. They need to establish beyond reasonable doubt several elements of the said offense if the court is to find you guilty.  

1. The aim to swindle. It is necessary that a prosecuting attorney shows past any shadow of a doubt that your motive was bent on defrauding an insurance program, or a health cover company. This should be demonstrated as a significant component of the charges brought against you.

   In the majority of cases, you cannot be found guilty of engaging in a scam, if your precise aim was not to commit the said scam. This includes medical care scams.

2. Realization of the claim being untrue or fabricated. According to the California fraud statutes, under no circumstances should you be declared guilty of a scam if you had no knowledge of the medical care application being deceitful. You could only be condemned of a medical care scam in California, if you were aware of the application being submitted to be a fake one, or that the papers you put together would be utilized to present a fake claim.

Supposing that you were to be found guilty of committing Health care fraud, the punitive action to be taken will depend on if the total sum of the deceitful demands adds up to, or is more than nine hundred and fifty ($950) dollars.

If this happens to be the case with your indictment, you are charged with a misdemeanor in accordance with the California Health care fraud statutes. This will see you face a maximum of six (6) months in the district jail, legal fees not exceeding one thousand ($1,000) dollars, or both.

If you, however, are indicted for more than a single fraudulent application, then the law will consider if all the requests total over nine hundred and fifty ($950) dollars and within the course of one (1) year.

In the event that the total claims equal a sum of nine hundred and fifty ($950) dollars, the offense is treated as a wobbler. In the state of California, a wobbler implies that the crime could be tried either as a felony or a misdemeanor depending on situations surrounding the incident.

On the belief that a medical care scam pertaining to a sum of over nine hundred and fifty ($950) dollars is prosecuted as a misdemeanor, you face a legal fee not exceeding ten thousand ($10,000) dollars, a maximum of twelve (12) months in the district jail, or both.

If, however you are indicted of the medical care scam as a felony, you will face a term of two (2), three (3) or five (5) years in the district jail or probation with a jail sentence not exceeding twelve (12) months. In addition, you might get slapped with legal fees twice the total sum of the scam or a maximum of fifty thousand ($50,000) dollars depending on whichever amount will be greater.

For far more serious medical care scam charges, you could end up losing or having your professional license suspended. Regardless of your job description in the medical field, having your professional license revoked jeopardizes your career and overall reputation.

If you work in the medical field and find yourself accused of a health care scam, there are a few ways which you could use to defend yourself during a court proceeding. Some of the very common ways include:

1. You had no intentions of committing fraud.

   If you possibly made an honest mistake and had not intended to defraud anyone of their hard-earned possessions, the public prosecutor cannot indict you with Health care fraud. It is important that your intentions from the very start were to carry out a con if you are to be found guilty of a medical care con.

2. You had no prior knowledge that you were being engaged in a scam.

   As per the stipulated law, a judge cannot find you guilty of committing a medical care scam if you had no knowledge of the crime taking place. If someone had tricked you into getting involved in the wrongdoing, a competent attorney will help get you out of the mess.

1. Medi-Cal scam. In the state of California, there exists a program dubbed Medi-Cal that aims to help the low-income folks including households with kids, the disabled, elders, individuals with specific ailments, as well as expectant mothers. It is considered a medical care scam when you try and defraud Medi-Cal since it is considered a medical security program. Moreover, if a patient provides false information regarding their eligibility for Medi-Cal benefits, they could also be held in violation of Medi-Cal scam.

   In addition, the California Well Being and Institutions under statute 14107 WIC explicitly forbids Medi-Cal scams. It goes as far as having its punishment structure laid out for any offenders.

2. Supporting, requesting, or colluding in a medical care scam. In accordance with California Civil statute 550, you do not have to necessarily submit deceitful applications by yourself to violate the medical care scam statute. You could still be indicted for the said offense if you requested, colluded with, or aided a second person to send in a fraudulent application on your behalf.

   The legal actions taken for Health care fraud are also applicable to anyone indicted for any of the activities stated above.

3. Medicine fraud. In California, it is popularly referred to as medic shopping. It generally involves a patient exploiting different medics to get different prescriptions for regulated medications or a medic supplying medication for motives other than genuine therapeutic purposes.
   
   
4. Employees’ settlement fraud. As an employee in California, you are entitled to the employees’ settlement cover in the event that you got hurt while still at work. Seeing as employees’ settlement scams have increased over the past few years, the state of California ensured that they included the offense under Civil Code 550. This means you could be easily indicted for Health care fraud if you presented false information regarding your employee settlement.

   In addition, the employees’ settlement fraud also includes; an employer providing false details about their work environment with the aim of getting their insurance quality reduced, and an employee falsifying an injury with the intentions of receiving employees’ settlement payments.

1. If you have doubts regarding any medical care scams being carried out against you, or in your place of work, there are several ways in which you could reach out and inform the concerned authorities. Some of them include:

1. Calling your insurance to provide directly will help clear your doubts.
2. Filing a grievance with the California Health Board.
3. Visiting the STOP Medicare Fraud website and providing the necessary information.
4. Getting in touch with The California Cover Fraud Agency.

What can I do to prevent Health care fraud?

Just to be on the safe side of the law and protect your health care benefits at the same time, there are several ways in which you can help avoid medical care scams.

1. Read the rules and benefits reports provided by your insurance company. This will ensure that you, in fact, obtain the medical attention for which your cover was billed. Essentially, cross-examine any funny-looking charges that may appear on your medical paperwork.
   
   
2. Make sure that you are always up-to-date. This is regarding the medical care amenities you get. Additionally, it is advisable that you keep a proper account of your health care, and thoroughly evaluate all health care statements that you receive.
   
   
3. Finally, ensure that you safeguard your medical cover ID card. The same way you would protect your credit card is exactly how you should keep your medical cover ID card safe. In the unfortunate event that you misplace your cover ID card, it is advisable that you file the matter with your insurance agency promptly.
   
   
4. Reveal fraud. Make sure that you contact your insurance providers with immediate effect if you have suspicions that you might be a sitting target of a medical insurance scam. Most guarantors nowadays provide the chance to tell of supposed scam online via their website.

How do I meet the requirements for Medi-Cal insurance?

Medi-Cal can best be described as a project that provides low-cost medical coverage for kids and grown persons with narrow pay and resources. To find out if you meet the requirements for Medi-Cal, you will need to fill an online application that is available on their website or in person by visiting their county offices. After the application process, you will receive a notice in your mail within forty-five (45) days informing you if you qualify for Medi-Cal cover or not.

How much does health care fraud cost the state?

In accordance with the National Health Care Anti-Fraud Union, medical care scam costs the country about sixty-eight ($68) billion dollars every year. This is close to three (3%) percent of the entire country's two ($2) trillion dollars in medical care expenditure.

What is considered Health care fraud?

Medical care scam is considered a serious offense. It's committed when a dishonest health care provider or patient deliberately presents or induces a second individual to present incorrect or deceptive material for use in defining the total sum of medical care settlements payable to them.

Am I expected to reimburse Medi-Cal?

According to the California statute, you are not required to pay back Medi-Cal funding back even after you die. Same for every other social program, from Covered California, women, infants, and children (WIC). You are not expected to pay those back.

What is the difference between Medi-Cal and Insured California?

Medi-Cal provides affordable medical consideration to entitled residents of California with a meager income. Insured California, on the other hand, is the state's medical cover scene where residents of California can acquire medical plans and obtain monetary aid if they meet the set requirements. The medical strategies accessible via Covered California and Medi-Cal both provide a comparable set of vital benefits.

If you are charged with health care fraud, it does not necessarily mean that it is the end of the road for your career. By having our well-versed fraud attorneys defend your case, your reputation could be redeemed and your record could remain spotless. We have the legal know-how and persistent drive that is needed to get a result at your hearing. Call our Vista Criminal Lawyer at 760-691-1551 to talk to one of our lawyers concerning your health care fraud case.