Health Care Fraud

Health care prosecution has become one of the top priorities for California law enforcement in the past few years. A successful prosecution can result in hefty fines and up to ten years of imprisonment. At Darwish Law, we have extensive experience handling healthcare fraud cases in Santa Ana, CA, and the surrounding areas. If you’re facing any healthcare fraud charges, please schedule an appointment with us today for a detailed review of your case and learn how we can help you.

How Health Care Insurance Works in California

Most people in California pay for their health care through a government medical insurance program or a private insurance company. The process used to process health care payment through an insurance policy is normally complex, opening different means to commit fraud.

Most health care frauds are associated with government programs like Medi-Cal, designed to help older adults and low-income patients. These government programs are complicated. A routine visit to a family doctor can end up with filling out a lot of paperwork. Meanwhile, the doctor will have to stack this paperwork to be paid according to your expenses.

That is why there are possibilities of healthcare fraud, especially with the amount of money involved in this program. Amidst all the chaos and money, fraudsters are convinced that law enforcement officers cannot catch them with any fraudulent actions, hence the widespread number of health care fraud cases.

Definition and Types of Health Care Fraud in California

Health care fraud refers to any fraudulent activity associated with health insurance transactions. It can either be committed by health practitioners or by patients. However, a fair amount of these frauds is charged against medical professionals like nurses, doctors, therapists, and other people working in hospitals or medical offices.

Kickback Scheme

Kickbacks are common in the healthcare industry. It refers to receiving anything of value like gifts, equity, or cash from a healthcare facility, a pharmaceutical facility, or a doctor for referring a patient at a particular rate. It also refers to referrals made to benefit a health practitioner by:

  • Prescribing a particular medication
  • Using particular medical devices
  • Meeting a particular quota
  • Deciding on something that would benefit you in some way contrary to your medical experience or the client’s best interest.

Providing Unnecessary Medical Services

Health insurance programs like Medicare and Medi-Cal can only reimburse procedures or expenses that are medically necessary. Therefore, any suggested test, procedure, imaging, or other medical processes that are not minimally related to your condition violates healthcare insurance rules.

Failure to Accurately Charge Patients for their Prescription

Inaccurate patient prescription occurs when offering customers discounts for their prescription while charging the government or a private healthcare insurance program the full price. The pharmacy pockets the difference from what they receive from the patient’s insurance provider or government program. This is a serious violation of healthcare insurance programs and can lead to a successful False Claim Act case against the pharmacy in question. Under these rules, a pharmacy should charge insured patients with the fair market value of the drug, which is similar to the charges made to all customers.

Allowing Staff and Nurses to Perform Examinations

Medicare and Medicaid allow specific medical procedures to be performed by a doctor. However, nurses and other office staff cannot handle routine outpatient procedures while billing the government for the cost of a doctor’s time to perform that specific work. Although the patient may receive the medical procedure, the fraudulent act is done when the government is billed at the doctor’s billing rate. This is regarded as a false claim and presents a real danger to patients when handled by undertrained or inexperienced staff.


Upcoding is probably the most common form of healthcare fraud. It involves billing for a service that a doctor didn’t provide or more than the actual cost of the service. If you note suspicious charges that are not aligned to your actual visit, there are possibilities that your doctor is engaging in upcoding.

Billing for a Service That’s Not Covered

Billing for services that are not covered, particularly experimental procedures that are not approved by the government or insurance companies, can also be a form of health care fraud. In most cases, doctors involved in this crime add these unapproved procedures by coding them with something covered under the insurance policy. Therefore, they mislead the insurer and government by billing them a procedure that was not performed.

Misrepresenting Dates of Services

Health care providers can make more money when they report that patients visited them two times rather than one time. Each officer visit is regarded as a separate billable service. Therefore, the fraudster will list the services with a false date to make more money from this action.

Making Multiple Claims

Making multiple claims is also another common type of health care fraud. In this form of fraud, health care practitioners submit various claims for one medical service or make a double billing to the insurance provider.

Submission of Undercharges without Overcharges

Health care providers should send undercharges when they bill a patient a lesser amount than needed for a particular service. They should also send an overcharge made for a previous service they provided along with the undercharges. Failure to meet this requirement is a crime and can lead to prosecution.

Preparation of a Writing that Supports a Fraudulent Claim

You can face health care fraud charges if you prepare a document that supports a fraudulent health care claim. This charge is usually made against professionals like doctors’secretaries or other professionals working in medical offices.

Elements that Prosecutors Must Prove in Common Health Care Fraud

Prosecution of health care fraud is covered under California Penal Code Section 550. Under this statute, prosecutors must prove two crucial elements to hold one liable for health care fraud. These elements include:

You Knew that Your Claim was False or Fraudulent

Prosecutors can only charge you with healthcare fraud in California if you are aware that the submission you were making was fraudulent or duplicated. You can also be charged if you knew that a health care practitioner used a false document in a false claim.

You Had the Intention to Defraud

Prosecutors should also prove beyond reasonable doubt that you had the intention to defraud an insurance program or company based on your actions. “Intent” is a primary factor in this kind of charge. Therefore, if you reasonably did not intend to defraud an insurance program or company, there are chances of acquittal in your case.

Penalties for Health Care Fraud in California

The penalties for health care fraud depend on whether the value of the amount involved in the fraudulent claim is less or more than $950. If multiple claims are made, the critical question will be whether the claim sums to more than $950 within 12 months.

Penalties for Claims of $950 or Less

A claim of $950 or less is a misdemeanor. It carries the following penalties:

  • A maximum fine of $1,000
  • Custody in county jail for a maximum of six months

Penalties for Claims More than $950

A fraudulent claim that’s more than $950 is a wobbler in California. Misdemeanor charges are punishable by a maximum of one year of custody in county jail and a maximum fine of $10,000.

A felony charge is punishable by:

  • Probation with a maximum of one year of custody in county jail
  • Custody in county jail for 2, 3, or 5 years

The court can also charge you double the amount involved in the fraud or a maximum fine of $50,000, depending on which amount is higher.

Loss of Professional Licenses

People involved in health care fraud, particularly health care professionals, can have their professional licenses revoked or suspended as part of their punishment. This usually includes doctors and nurses involved in health care fraud.

Legal Defense Strategies for Health Care Fraud

Your attorney can use several legal defense strategies to defend you from your healthcare fraud allegations. Coming up with the right legal defenses is not a cookie-cutter approach or a do-it-yourself approach. It requires you to sit down with your attorney, learn about the details of your healthcare fraud and let them know what happened. At this point, your attorney will be in a position to figure out how best to defend you. Here are common legal defense strategies you can rely on.

Mistake of Facts or Lack of Knowledge

As explained above, prosecutors can’t charge you with health insurance fraud if you did not know about the duplicate or fraudulent submission. Since medical billing involving health insurance is a complicated process, a medical professional can make a mistake. The court might acquit you of your charges if you prove that you genuinely mistook facts related to the health insurance billing process.

Lack of an Intention

Lack of intent is another crucial legal defense strategy for your allegations. If the prosecution can’t prove your intention to defraud, you will be acquitted of the charges.

Mistake of Identity

Some healthcare fraud might arise in a situation where someone steals a medical professional’s identity. This doesn’t mean that the victim had face-to-face contact with the suspect. Mainly, if most of the transactions made between the health insurance program and medical professionals are made electronically, there are chances of mistaken identity.

In most cases, the police can mistakenly identify a particular person as a perpetrator after a hasty investigation. Your attorney should look for an alibi if you aren’t involved in the crime.

Misunderstanding of Facts

An accusation for healthcare fraud can also arise from a misunderstanding of facts. An insurance company might assume that you are taking advantage of them, but in a real sense, you lacked the necessary information at that particular time.

If your arrest and prosecution resulted from a misunderstanding, your attorney can help you clear things up by explaining your circumstances in court.

Insufficient Evidence

Sometimes overzealous prosecutors can charge a defendant with a particular crime with insufficient evidence contrary to the requirement of proving things beyond a reasonable doubt. If the prosecutor charges you with healthcare fraud without enough evidence, your attorney should review the case and point out potential weaknesses in the charges. If it is clear that there is not enough proof, your attorney should have your case dismissed.


If someone threatened you to act against your better judgment and engage in healthcare fraud, the jury might find you innocent of the charges made against you. However, you should note that common “pressure” does not make you eligible to use this legal defense strategy.

Good Faith Belief that The Transaction was Legitimate

Your attorney can prove that you believed in good faith that you were not committing healthcare fraud. The defense must raise a compelling argument explaining how you thought that the transaction made was legal and rightful to use this defense successfully.

Expiration of the Statute of Limitation Period

There are particular time limits in which a prosecutor must file a charge of health insurance fraud. The prosecution cannot bring forward any case even after gathering compelling evidence against the defendant. However, you should note that if you concealed the fraudulent activity in any way, the period of the concealment would ultimately count forward in the time of limitation. Therefore, the case will exceed the time provided by the statute of limitations.

A defendant can only rely on the expiration of the statute of limitation period if the prosecution discovered the fraud charges. Generally, the period of limitation of a charge of fraud in California is four years.

Crimes Related to Healthcare Fraud in California

Particular crimes are related to healthcare fraud in California. These crimes can either be prosecuted along with the healthcare fraud or in lieu of the charges. These crimes are as follows:

Aiding, Abetting, Soliciting, or Conspiring in Health Care Fraud

California Penal Code Section 550 does not only make it illegal to submit or prepare a false claim, but it also makes it illegal to:

  • Solicit someone else to make a false claim submission
  • Assist someone in the submission of a false claim
  • Partake in a conspiracy with other people to make a false claim

A conviction for the above actions attracts similar penalties as submitting a false claim.

Medi-Cal Fraud

Medi-Cal is a governmental health insurance program that covers pregnant women, seniors, people ailing from specific diseases, and low-income earners. Since Medi-Cal works as a healthcare insurance program, any fraudulent transaction made can result in health care fraud.

Medi-Cal fraud attracts similar charges as health care fraud but can result in additional charges. Welfare and Institution Code Section 14107 is the statute in California that sets out the penalty scheme for Medi-Cal fraud.

Please note, patients who cheat about something that influences their eligibility for this specific type of insurance are also liable for this type of fraud.

Prescription Fraud

Doctor shopping or prescription fraud is another form of health care fraud in California. There are two common forms of this type of fraud. These include:

  • When a patient depends on several pharmacies or doctors to seek several prescriptions for a controlled substance
  • When a doctor issues a prescription contrary to the rightful medical purposes

Prescription fraud is a wobbler in California. A misdemeanor is punishable by a maximum of one year in county jail. Felony prescription fraud is punishable by 16 months, 2 years, or 3 years of custody in county jail.

Health and Safety Code 11368: Alteration or Forgery of a Prescription

Forgery or alteration of prescriptions occurs when a person has a prescription for a narcotic drug, forges a signature to obtain a narcotic drug, or possesses narcotic drugs obtained through a forged prescription.

Violation of this statute is a wobbler. A misdemeanor is punishable by custody in county jail for six months to one year. A felony carries 16 months, 2 years, or 3 years of imprisonment.

Worker’s Compensation Fraud

In California, workers who are injured while working are eligible for compensation under the Worker’s Compensation Program. Any form of illegal transaction associated with compensating injured workers is referred to as workers’ compensation fraud. It is a common type of fraud in California. Therefore, you can face healthcare fraud allegations for making this kind of submission.

Other types of this fraud include the following:

  • When a worker lies about his or her injury or employment status to receive compensation benefits fraudulently
  • When an employer lies about the conditions of a workplace to minimize the insurance premiums
  • When a healthcare practitioner helps someone receive worker’s compensation benefits fraudulently

Find A Healthcare Fraud Attorney Near Me

An arrest and conviction for healthcare fraud can have a devastating impact on your profession. From nurses to doctors, an accusation can ruin your career even after ultimately disapproving the facts of the crime. Apart from the damage done to your reputation, a conviction can find you serving time behind bars. If you have been arrested for any form of health care fraud in Santa Ana, CA, and its surroundings, contact Darwish Law right away to fight your criminal charges. You can schedule an appointment by calling us at 714-887-4810.