Since abuse and fraud cost the country billions of dollars annually, government agencies commit resources to investigate and aggressively pursue healthcare fraud cases. The agents use either previous workers or confidential informants, and negligence or incidental mistakes are considered potential fraud. The Medicaid/Medicare billing procedures and manuals are hard to understand, and misunderstandings and coding errors result in adverse consequences. For many years, Chula Vista Criminal Attorney has been fighting for the constitutional rights of health care providers. We can investigate all aspects of your case and, together with you, can develop a legal strategy using advocacy and thorough preparation tailored to acquire the most favorable case results.

Defining Health Care Fraud

Typically, patients, doctors, and healthcare facility employees commit health care fraud when they deliberately submit or make another person submit a fraudulent or false claim to insurance providers or government agencies. Health care fraud is also known as HMO fraud, Medicare fraud, health insurance fraud, or billing fraud.

To be convicted of this crime, the prosecution must prove beyond any reasonable doubt that:

  • You deliberately and knowingly executed or tried to implement a scheme, and

  • Your scheme aimed to defraud a healthcare benefit program like Medicaid or Medicare to acquire property or money owned or controlled by a healthcare benefit program using fraudulent promises, representations, or pretenses.

Typical ways defendants violate the law include:

  • Submitting a claim for undelivered benefits — Generally, physicians commit this crime by submitting claims for health care services, medical procedures, and equipment not offered to patients.

  • Submitting a fraudulent or false claim — You are guilty of HMO fraud when you perform a medical service/procedure that your patient did not require and then billed an insurer. Another example of illegal behavior is billing for a high-end medical service or procedure than the one you performed (up-coding).

  • Multiple claims — Typically, medical practitioners commit this offense by submitting numerous claims for one medical procedure. In other words, the provider double bills the insurer.

  • Submitting an undercharge without an overcharge — It happens when an individual sends a bill to an insurance company for medical services/procedures that you previously undercharged without simultaneously sending a bill for previously overcharged services.

  • Preparing a written document that supports a fraudulent claim — Normally, patients and physicians commit HMO fraud when they prepare a medical record/document and use it to support a fraudulent claim.

Penalties, Sentencing, and Consequences of Health Care Fraud

Violation of California PC 550(a) is a wobbler. The prosecution can charge you with either a felony or a misdemeanor depending on the worth of the fraudulent claim you submitted.

You will face a misdemeanor if the alleged fraudulent claim is less than $950. The charge carries the following potential penalties:

  • A maximum six-month jail sentence

  • Up to $1,000 in fines

If your claim worth exeeds $950, the crime becomes a felony. It is punishable by:

  • A five-year jail term

  • Twice the amount involved or $50,000 in fines (whichever is greater)

You risk facing an enhanced sentence of twenty years if your violation leads to another person's serious bodily injuries.

If you violate a federal health care fraud statute, you will spend up to ten years in federal prison and pay fines.

Collateral Consequences of Violating PC 550(a)

On top of the above court-ordered legal penalties, a conviction can have devastating collateral consequences like losing your medical license and the inability to secure employment in the medical field.

A conviction is a matter of public record, and it can affect your ability to attend/join educational institutions, secure housing, or find any form of employment. With so much at stake, any person accused of this crime should retain a seasoned Chula Vista defense lawyer. Immediate legal intervention can have a significant impact on your case outcome.

Common Legal Defenses to PC 550(a)

The type of legal defense you and your criminal defense attorney pursue will be dependent on your case specifics. Common legal defenses include:

You Did Not Intend to Defraud

One element of the crime that the prosecutor must prove before convicting you is the intention to defraud the medical insurer for a health care benefit. Consequently, it is a legal defense to prove you did not act with fraudulent intent. You can claim that you committed the crime by accident.

You Did Not Act Knowingly

You cannot be found guilty unless you know that your submitted claim was fraudulent.

The Police Violated Your Constitutional Rights

You can challenge your criminal charge by proving that the law enforcement agency violated your constitutional right.

Probably, the police officer:

  • Failed to read you your Miranda rights

  • Coerced a confession

  • Arrested or stopped you without probable cause

  • Conducted an illegal search and seizure

If one of these violations applies, the judge can lower the charges or dismiss the case altogether.

Health Care Fraud Investigations

Typically, the agencies below investigate health care fraud:

  • Department of Justice (DOJ)

  • Health and Human Services Office of Inspector General

  • Federal Bureau of Investigation

You may not know that you are being investigated until you receive a subpoena. Therefore, it is essential to know what to look out for, especially if you believe you are a subject of an investigation:

  • You could be under surveillance if you feel you are being watched.

  • A knock on your door — Most individuals learn that they are under investigation when law enforcers approach them and request to speak with them. These people could also be informants (people working with the police who do not need to be in uniform). An essential thing to recall is that people asking questions concerning a criminal activity could be investigating you. You do not have to answer their questions.

  • An OIG meeting — If you are a federal employee, you can learn about the investigation when an OIG (Office of the Inspector General) agent comes to see you and says there is an investigation and they would like to speak with you.

  • A subpoena — If you operate a business, you can learn about your investigation when your enterprise receives a subpoena for medical records. While you can refuse to speak with law enforcers, your practice is a different entity, and you should abide by the subpoena even when it results in legal trouble.

  • A search warrant— If law enforcers come to an individual's workplace or home and execute a search warrant, they should know that they are being investigated.

  • You received a target letter— In the letter, the U.S. Attorney's Office will notify a person that they are an investigation target. The letter includes information about the alleged crime and your entitlement to assert the right against self-incrimination under the Fifth Amendment to the U.S. Constitution.

  • The word on the street — You can also know about an investigation about you from another person. It can be a former business partner who the police contacted. Maybe a colleague heard about a person that received a subpoena. Hearing about the investigation from somebody else gives you a rare luxury of advance notice.

Steps to Take If You are Under Investigation

First, retain a qualified lawyer and work with the expert to understand what is happening. You need to know what the government is doing and what occurred to you.

If law enforcers contacted us, then they have your name. Your attorney should contact the agent working on your case. That way, the government knows that you have legal representation, and the lawyer understands what is taking place with the investigation.

If you heard from a colleague that was served a subpoena, you should discuss with your defense lawyer about calling the prosecutor or police. Your decision will depend on your situation.

Second, collect evidence together with your lawyer. Ensure you gather all emails and documents relevant to your investigation. Your attorney will discuss with you what occurred and what you know.

Probably, your colleagues or business partners are also in the same investigations and have hired attorneys. Your legal counsel can speak with them and learn more about what the prosecution is doing or what occurred. Do not send a loved one an email explaining your predicament. Instead, let your legal counsel handle all your communication. Anything you utter about the government or the investigation can get back to the prosecution and be used against you.

Third, do not alter or destroy any electronic data or physical documentation related to the investigation, even if you would act so in a normal course of business.

Finally, be patient. Investigations can be lengthy and time-consuming.

Different Stages of Health Care Fraud Prosecution and Investigation

Although there is no formal and rigid structure for fraud investigations, and every case is unique, there are common aspects of investigations.

  1. Identifying the Defendant

Investigators receive tips from an insurance company, whistleblowers, or an outcome of an audit that notify them that Medicaid fraud has been committed.

The California Health and Human Services Agency (HHS) reviews statistical data created from Medicaid and Medicare bills in search of outliers. The investigators will analyze the data and search for unusual conduct in the type or number of codes you billed associated with patient population, location, or your taxonomy. If a person thinks their medical practice is a business outlier, they should engage a defense attorney immediately.

  1. Preliminary Investigation

Law enforcers will review the available data to gather proof of evidence. It can be public details about the target or practice. For instance, the agency can analyze Medicaid billing details with death records to check whether you have billed for deceased people's treatment.

If the agents believe you committed healthcare fraud, they will interview your former employees, patients, and other healthcare providers. Moreover, they will surveil you to determine the feasible location of proof and patterns.

  1. Search and Seizure

Once your investigation is done, the law enforcers will send your case to the prosecution for an analysis. They will also request that the prosecution acquires a search warrant from the judge. The agents can only obtain the search warrant if there exists a probable cause that specific pieces of evidence are in given locations. It includes electronic proof that you used to commit the offense.

Generally, the investigators will arrive early in the morning at your practice as your patients come in and interview them. They will search your home or workplace and remove all items they consider the evidence.

Apart from the record custodian, everyone (including employees, patients, and health care providers) can leave this location. The law enforcers cannot force you to answer their questions, and you can exercise your entitlement to remain silent.

  1. Prosecution Referral

Then the prosecution will review evidence to determine its strength, whether the investigating agents should interview other witnesses before indictment and if the grand hurry must be convened. If the United States Attorney's Office believes the grand jury must be convened to indict the crime, it will present your case to the subsequent grand jury proceeding.

  1. Grand Jury Court Proceedings

A grand jury comprises sixteen to twenty-three members. The prosecution will present proof against you to the grand jury during the proceeding. The grand jury will listen to the proof and vote to return a "no bill" or indict.

If more than twelve members vote to indict, the case becomes the jurisdiction of the United States District Court and is presented to a federal judge. And if less than twelve jury members vote to indict, your case is returned for further investigation.

Generally, the proceedings are secrets, and only the grand jury members, witnesses, and the prosecution know about them. The number of times the prosecutor can go before the grand jury is unlimited.

  1. Arraignment (The Initial Court Appearance)

If the grand jury indicts you, you will be arraigned. During the proceeding, the federal judge should ensure that you enter a plea and you understand the alleged criminal charges.

Every defendant at arraignment must enter a plea of not guilty. When you enter a plea of not guilty, you request the judge to set your case for trial, where the prosecution must prove you committed the crime beyond any reasonable doubt. It does not imply that you swear that you did not violate the law.

Additionally, your bond hearing will happen on the same day. The court determines whether to release you on bond as you await trial. Most citizens who committed nonviolent crimes are granted bail.

However, the court can deny bail if:

  • You have property outside the country

  • You have considerable contacts overseas

  • You threatened witnesses or tried tampering with proof

  • You have previous criminal convictions

  • You have previously missed scheduled court hearings

If one of these factors applies, it is wise that your lawyer prepares a solid defense proving that you are not a flight risk and do not threaten the community.

If released on bail, the court will require you to comply with the following terms and conditions of release:

  • Staying away from specific people and places

  • Surrendering your driver's license and passport (abiding with travel restrictions)

  • Not possessing any weapon

  • Following curfews

  • Not violating any other law

The prosecutor will also restrict your power to prescribe any controlled substance and prevent you from billing Medicaid or Medicare.

  1. Case Trial

If the case proceeds to trial, your lawyer will use expert testimony to establish your claim was not fraudulent. They will also file motions and make objections to weaken the evidence against you, increasing the possibility of achieving a favorable case outcome.

How a Criminal Defense Lawyer Can Help You

Hiring a skilled defense lawyer upon learning of the investigation plays a significant role in the case outcome. Only an attorney experienced with criminal fraud charges can understand and efficiently address issues arising during the prosecution. All stages of your case require legal assistance and counsel.

Here is how your criminal defense lawyer can help you:

Negotiate a Plea Agreement that Covers Every Repercussion

More often than not, plea agreements limit the defendants' ability to challenge any sentencing recommendation. The plea deals can include provisions limiting the accused's ability to fight for less severe penalties, even when they offer incredible help to the prosecutor or rehabilitate themselves before sentencing. Depending on the case circumstances, your lawyer can help you decide whether to accept the deal and negotiate the terms.

Advises You on How to Avoid Additional Criminal Charges

The government can interpret attempts to destroy evidence, threatening witnesses, or discussing the case facts with your co-defendants as criminal conduct, resulting in more severe penalties and charges. Retaining a lawyer can help you avoid careless communications and document maintenance mistakes.

They Have Experience and the Necessary Resources to Navigate through the Criminal Process

Generally, a Medicaid fraud case is characterized by overwhelming paperwork, including corporate records, physician notes, correspondence, internal memos, and wire tapes. Presenting and analyzing many pieces of evidence can lead to a wrongful conviction carrying harsh penalties if any document is mistakenly disregarded or lost. A legal counsel with experience and resources can effectively gather the relevant documents and records and preserve them.

Assist Medicaid Fraud Case Investigators

You can receive a lenient sentence if you help the government official prosecute the Medicaid fraud. For instance, you can testify against your accomplice at trial in return for the prosecutor recommending less severe penalties. Depending on your case facts, your defense lawyer can contact the government in the case's early stages and advise you on what to tell the prosecution.

Since you and your defense attorney are a team working towards achieving your best possible case outcome, here is what you should do:

  • Comply with what you agreed to do

  • Prepare a written chronology and summary of events

  • Tell the legal counsel everything

  • Not expect the lawyer to be your friend

  • Notify the attorney of new case developments

  • Provide requested details promptly

  • Respect the lawyer's schedule and time and tell them if you will be unavailable

  • Assist with leg work and research that does not require legal training

  • Understand that your lawyer should keep what you tell them confidential

Frequently Asked Questions

Health care fraud defendants often find themselves confused and overwhelmed. The criminal justice process is complicated, legal terms and phrases are unfamiliar, and the criminal charges carry daunting penalties. Here is a list of some commonly asked questions:

  1. How Can I Prevent HMO Fraud?

Healthcare providers can avoid several HMO fraud cases by ensuring the submitted patients' information is accurate and the medical services and procedures are executed in the patients' interests. Before evaluating your patient and when submitting any medical information, ensure the following:

  • You treat the actual patient and verify their eligibility using photo identification

  • The recommended medical procedure is necessary

  • The treatment sessions' duration and dates are accurate

  • You have accurate diagnostic codes

  • You performed the billed service

  1. How Does Healthcare Abuse Differ from Healthcare Fraud?

People often use these phrases interchangeably, yet they are different.

Health care fraud is a deliberate deception or misinterpretation of services or procedures known to the organization or person to be false and involves unauthorized reimbursement to a medical agency.

On the other hand, health care abuse is a practice or incidence that deviates from the code of conduct in the medical practice.

  1. What Does Exclusion Mean in Your Investigation?

An exclusion can be a devastating collateral consequence of a PC 550(a) conviction. Exclusion is an administrative action taken by the OIG that bans health care facilities or practitioners from participating in government healthcare programs.

It means you will stop making payments for services or equipment you ordered or provided. It also applies even if you did not directly offer the patient care.

Find a Skilled Fraud Crime Defense Lawyer Near Me

As Medicaid fraud becomes prevalent, more lawsuits are brought against patients, doctors, and health facility employees. Also, the laws linked to the cases are complicated. If you face allegations or are under investigation, you should retain an experienced and knowledgeable criminal defense lawyer lest you risk losing your reputation, business, finances, freedom, and likelihood.

At Chula Vista Criminal Attorney, we can explain the laws and potential penalties, review the case to uncover essential evidence and legal defenses, and aggressively advocate on your behalf to achieve the best possible case outcome. Please call us at 619-877-6894 to schedule your initial free consultation.