Health Care Fraud is commonly known by other names such as health insurance fraud, medical billing fraud, health insurance fraud and Medi-Cal Fraud. The complicated and confusing bureaucracy associated with the payment process has lead to authorities accusing innocent providers and beneficiaries of health care fraud. In many instances these are just the result of honest mistakes.
Common Examples of Fraudulent Conduct
Health Care Fraud is an intentional attempt by some providers, and in some cases beneficiaries, to receive unauthorized payments or benefits from the program. This fraud can take many forms, but the most common instances involve knowingly billing for services not performed, billing for more expensive services than the ones the patient actually received (known as “upcoding”), providers billing for the care of more beneficiaries than they can actually serve, and submitting a second duplicate claim for services already paid for.
Other less common offenses include aiding and abetting, or conspiring to commit health care fraud, and prescription drug fraud.
Medi-Cal Fraud
Medi-Cal is California’s government-provided health insurance program for low-income, elderly and disabled individuals. Many claims of fraud, and criminal complaints of wrongdoing involve this program, and the California Department of Health Care Services has organized a “Stop Medi-Cal Fraud” campaign designed to encourage the reporting of suspected fraud.
Fraud Defenses
Typical defenses to health care fraud allegations include lack of intent, lack of knowledge and mistake of fact. As previously stated, the convoluted rules and procedures surrounding the Medi-Cal payment billing process make making honest mistakes inevitable. As in all cases, the prosecution has the entire burden of proof. Distinguishing between an honest mistake and an intentional fraudulent act is extremely difficult and generally requires the establishment of a pattern of practice, or scheme. The best prosecution cases involve multiple instances of over billing or upcoding, and testimony from third party witnesses such as office administrators and assistants. Furthermore, most doctors and owners of medical practices are not directly involved in the medical billing process. Therefore, in addition to the billing discrepancies prosecutors must demonstrate that the owners orchestrated, or initiated the fraud.
Fraud Penalties
Health care fraud penalties are dependent upon the amount at issue. Fraud claims involving Nine Hundred Fifty Dollars ($950.00) or less are misdemeanors, and penalties include up to 6 months in prison and/or a fine of not more than One Thousand Dollars ($1,000). If the fraud claims exceed more than One Thousand Dollars ($1,000) the offense can be a misdemeanor, or a felony. If charged as a felony the maximum penalty is a fine of up to Fifty Thousand Dollars ($50,000) or double the amount of the fraud, and/or imprisonment for up to 5 years in jail.
In addition, medical professionals, doctors, nurses and others could lose their licenses as a result of committing health care fraud.
Contact Us
In the event you or your company has been accused of health care fraud no need to panic. There are numerous defenses and explanations to these difficult to prove allegations. I suggest you contact the Brod Law Offices and schedule a no cost, no obligation, case analysis with one of our attorneys without delay.