Governments care about the welfare of their people. They guarantee access to health care, regardless of whether you are employed or unemployed. Most governments do this by rolling out healthcare financial aid systems, which offer access to healthcare services at a subsidized cost. Government healthcare programs are present in California but are greatly abused through fraud. The crime of health care fraud is defined under Penal Code 550(a). Healthcare fraud attracts severe punishment, including fines and a jail term. If you face health care fraud charges, the California Criminal Lawyer Group, Bakersfield, can help you create and present a convincing defense to fight your charges.
Health Care Fraud Under California Law
Penal Code 550(a) prohibits anyone from committing health care fraud. Under this statute, you could face charges if you present fraudulent or false documents to any agency that offers medical financial aid. The main element of this crime is to use false pretenses or false information to secure benefits. The prosecutor will aim to prove fraudulent intent, among other essential offense elements. If you are under investigation for health care fraud, you should consult a competent criminal attorney who can point out if your actions are related to fraud. Your attorney will advise you on the available defenses to challenge your charges.
Healthcare fraud can occur in different ways because every defendant plans their execution differently. Your attorney will evaluate your case, assist you in understanding the accusations you face, and help you create solid defenses against the charges. It is crucial to note that healthcare fraud allegations require proper research to enable you to create a solid defense. Therefore, you need to review your case with your attorney before trial. This will give you ample time to anticipate the areas the prosecutor will focus on. It is not mandatory under California law to have an attorney represent you. However, given the potential consequences of a healthcare fraud conviction, having an attorney represent you is best. You should not try to face the prosecutor and the judge on your own.
The Elements Of Health Care Fraud
When the prosecutor accuses you of any crime, the prosecutor will create strong evidence against you to convince the judge that you are guilty of the offense. The prosecutor must prove how your actions amount to criminal conduct. The prosecutor must also comply with the criminal standard, which requires the evidence to demonstrate your criminal guilt beyond a reasonable doubt. Since the prosecutor's legal burden is heavy, your attorney could identify possible weaknesses in the evidence and create a winning defense against the accusations.
The main elements that the prosecutor must prove include:
You Intentionally Engaged or Attempted to Engage In Health Care Fraud
If the prosecutor accuses you of health care fraud, the prosecutor must first show that you intentionally or knowingly committed fraud. You could also face charges under Penal Code 550(a) if the prosecutor proves you tried to engage in health care fraud, even if you did not successfully execute the crime. The prosecutor could prove your intent to commit fraud using evidentiary findings gathered from investigation officers they collaborate with. Some evidentiary findings include paperwork showing your plan to file representations or claims with the health care department.
The documents could include:
- Medical receipts you secured after undergoing medication.
- Spreadsheets detailing health care financial aid received, or
- Letters of claim.
The prosecutor will dwell on the documents because they help to show that you created a scheme linked to the health care system.
Additionally, the law requires that the prosecutor provide evidence showing that you acted knowingly while planning health care fraud. The prosecutor must do this since it demonstrates your criminal intention.
The Scheme Constituted Fraud or False Pretenses
If the prosecutor accuses you of health care fraud, the prosecutor must provide evidence that the scheme you engaged in was meant to defraud the health care system. The prosecutor must demonstrate that you were part of the fraud or used false pretenses to defraud the health care system.
Typically, fraud involves making false promises or providing misleading information to trick an unsuspecting person into accepting your requests. For example, you could face fraud charges if you deceive a healthcare employee regarding your earning bracket for inclusion in the subsidized healthcare payment system.
False pretenses involve using any deceiving information and using this information as an excuse or justification to secure benefits that you do not qualify for. For example, you could pretend to have mental health problems and forge a doctor's report to support your allegations. In this case, you could be charged with healthcare fraud under pretense.
Intent To Defraud
Under this element, the prosecutor must highlight specific expected results from your fraudulent activities. Proving this element is crucial since it forms the motivation of your actions, showing why you tried to defraud the healthcare system.
Some benefits you could secure through healthcare fraud include access to exemptions, services, money, or healthcare goods. The prosecutor must provide significant evidence showing the benefit you obtained, leading to a subsequent loss to the health care system. For example, you could get money through fraud. In this situation, the prosecutor must prove that you came into contact with the money. The prosecutor can do so by securing details of your bank account transactions through financial statements.
Additionally, you could deceive a healthcare worker and secure some benefits from the healthcare system. The investigating officers will use any information regarding the benefits you secured through deception. For example, you could have acquired medical goods in large amounts. The investigating officers can retrieve the goods from where you have stored them and use them to support the prosecutor’s evidence.
Departments Charged With The Duty To Investigate Health Care Fraud Cases
The police will arrest you and start investigations once you are accused of healthcare fraud. The police officers will collaborate with the prosecutor to gather strong evidence against you. Several investigation departments will come in, and a specific department will be assigned to handle your case. The department assigned to your case will assume duties depending on the type of healthcare fraud you committed.
Several investigation departments can be involved in investigating healthcare fraud cases, including:
The Federal Bureau Of Investigation (FBI)
If your healthcare fraud allegations caused or would have caused significant losses in another state, the FBI could be part of the investigation. The FBI will conduct its investigations within the federal authority to gather enough evidence demonstrating your criminal involvement.
The Drug Enforcement Administration
Perhaps you committed health care fraud and received more drugs than is acceptable at any given time. Most individuals who are guilty under these circumstances aim to secure drugs to sell them unlawfully. If your case matches these facts, the Drug Enforcement Administration (DEA) will conduct the investigation. They will do so purposefully to trace and retrieve the drugs if possible. While carrying out their investigations, the DEA could subject you to several interviews, tests, and other investigation processes that seek to prove that you committed fraud.
The State’s Office Of The Attorney General
The Attorney General plays an essential role in the federal government by helping to investigate fraud in the health care system. The Department of the Attorney General can carry out individual investigations or delegate the duty to officers within the docket.
The Department of Justice's (DOJ) Health Care Fraud Strike Force
The Strike Force was first established in March 2007 as a joint investigative and prosecutorial effort to deal with Medicare fraud. This department consists of inter-agency personnel composed of prosecutors and investigators that deal with individuals engaged in fraudulent activities, including:
- Health care fraud.
- Mail fraud.
- Bank fraud.
- Wire fraud, among others.
The strike force often uses advanced data analysis techniques to identify erroneous billing levels in health care fraud. The strike force is based in cities with high levels of billing fraud, targeting emerging schemes, fraudulent practices, and suspicious billing patterns.
Other Departments
Other departments charged with the responsibility of investigating healthcare fraud include:
- The Department of Health and Human Services Office of Inspector General (HHS-OIG).
- Local Medicare and Medicaid services departments.
- State Medicaid fraud control units.
- State healthcare fraud prevention units.
Activities That Qualify As Health Care Fraud
The prosecutor will focus on the three main elements of healthcare fraud while handling your case:
Presenting a False or Fraudulent Health Care Claim
Healthcare fraud charges revolve mainly around preparing and presenting fraudulent healthcare claims. You could secure health care forms illegally and present them under false pretenses to receive health care benefits allocated to eligible people.
For example, you could have colluded with a healthcare worker to secure the healthcare claim form. You could also have secured the details on the precise information to enable you to qualify for the benefits. You could also have assumed the identity of an unsuspecting eligible person and secured their benefits when they least expected it.
False claims usually involve untrue or fabricated statements to help you receive undeserved benefits. You can use a false supporting document to justify your claims to the health care system.
Writing a Supporting Document to Aid a Fraudulent Claim
You could face healthcare fraud charges if you help actualize a fraudulent plan. You could commit this crime by agreeing to create a supporting document promoting healthcare fraud.
For example, a physician could assist you in documenting a false report regarding a severe condition. The physician could have done this to enable you to qualify for health care services available to patients suffering from the condition. In this case, you could be guilty of defrauding the healthcare system because you do not genuinely suffer from the qualifying condition.
You could also be guilty of fraud if you write a supporting document to facilitate the acquisition of health care benefits. However, the prosecutor’s accusations against you can only be admissible if the prosecutor proves that you were aware that the documents you made would be used to commit healthcare fraud.
Presenting Health Care Claims for Undelivered Benefits
The judge could charge you with health care fraud if you submit claims for undelivered benefits. This case could arise when you conspire with a healthcare employee to target innocent people who qualify for healthcare benefits. In this situation, you commit fraud by taking away the people's eligibility for the benefits and using them as your own.
You could also be guilty of fraud by directly demanding health care claims even when you know you are not eligible. You could have bribed someone or used false information to be enlisted among the qualified individuals, thereby denying the rightful eligible beneficiaries.
Presenting Several Health Care Benefit Claims
A health care system permits people to only present claims to obtain benefits under one account. You can only secure health care benefits in the form of medication, services, or money once after approval of your submission. Making and submitting several healthcare claims is fraudulent. You could commit this crime when you commit identity theft and use several individuals’ identities to receive multiple health care benefits.
Alternatively, the judge could charge you under this category if you recruit others by creating false online profiles to obtain several benefits on your behalf. If this happens, the prosecutor will gather the necessary evidence to demonstrate that you planned and executed the many requests for health care benefits.
Penalties For Committing Health care Fraud
Healthcare fraud is usually charged as a wobbler crime. You could face misdemeanor or felony charges. You will face charges and penalties depending on the degree of loss you caused and whether you have a previous conviction for healthcare fraud. You will face misdemeanor charges if you defraud the healthcare system of money or property worth less than $950. Other potential penalties include a fine that does not exceed $1,000. You could also face a jail term that does not exceed six months in a county jail.
Alternatively, you could face felony charges if you defraud the healthcare system of money or property above $950. The penalties you could face include a fine that does not exceed $50,000 or double the amount you defrauded. You could also face a jail term that does not exceed five years in state prison.
Defenses For Health Care Fraud Charges
The defense hearing will begin after the prosecution concludes its case. You and your attorney will have an opportunity to present your defense. You should always work on your defenses in advance with your attorney.
Depending on the number of defenses you intend to present, you could present your defenses in one or several court sessions. However, you should present one or two primary defenses to avoid contradicting yourself. Your attorney will assist you in identifying the best defenses based on your case's circumstances.
Some of the defenses you could present to challenge your Penal Code 550(a) charges include the following:
You Acted Under Duress
You could defend your actions by claiming you were under duress or coercion. You can also point out that you committed healthcare fraud on behalf of another person. For example, your employer could have coerced you to present fraudulent information to the healthcare system, threatening to terminate you if you failed to comply. An employer can facilitate fraud to avoid paying workers' compensation.
Depending on the facts of your case, you can change the defense to fit your circumstances and convince the judge that you did not act voluntarily. You could receive an acquittal or a substantial sentence reduction if your evidence is compelling.
Your Constitutional Rights Were Violated
Even when facing healthcare fraud charges, you still have constitutional rights that law enforcement must uphold. You can claim that the police mistreated you, especially if the treatment violated your constitutional rights. An investigating officer could coerce you to confess to the offense or provide self-incriminating evidence before the hearing. You have the right to raise these issues at the defense hearing.
Although your attorney cannot save you from facing penalties, he/she can convince the court to be lenient with the punishment due to the constitutional violations and malpractice by the police. This defense is only permissible if the prosecutor has overwhelming evidence against you but acquired it illegally.
You Were Not Aware That Your Acts Were Fraudulent
Sometimes, you can present a lack of knowledge as a defense to avoid legal liability. Lack of knowledge implies that you did not actively participate in health care fraud, despite aiding in the fraud. Freelancers and workers who take part in different duties related to preparing health care documents are likely to be accused of this offense, and they can employ this defense.
For example, you can avoid criminal liability if your duty is to key in figures in spreadsheets without additional information on what the details are for. However, you must provide sufficient evidence showing that you were not privy to the details related to healthcare fraud.
You must gather enough evidence that dissociates you from the crime but, instead, demonstrates that you are an innocent bystander. You can succeed with this defense if your attorney guides you on the statements, witnesses, and documents to present in court.
You Did Not Intend to Defraud The Health Care System
Another option that could increase your chances of a favorable outcome is adopting a strategy to show that you had no intent to defraud the healthcare system. Lack of intention means you did not know your actions were wrong. However, this defense can only be valid if you prove that the actions leading to the alleged fraud were genuine errors or borne out of ignorance. For example, you could have accidentally submitted your claim more than once. Perhaps you were unfamiliar with the health care benefits online claim system. If this is the case, you can claim that your fraud accusations resulted from your unfamiliarity with the online system.
Additionally, you could have asked another person to make applications to assist you in navigating unfamiliar online systems. The person could have acted fraudulently without your knowledge, and you only learn about the fraud when you receive information regarding your criminal charges. In this case, you must provide sufficient evidence to create a defense and convince the judge of your innocence.
Unlawful Search And Seizure
When you are accused of health care fraud, the police could storm your residence to search your computers and cell phones, so you do not have the chance to erase the evidence. However, a search beyond a warrant's scope or without a valid warrant is unlawful. If the police use the evidence acquired through illegal searches and seizures against you, you could request that the court exclude the evidence from your case.
Insufficient Evidence
The prosecutor who files your healthcare fraud case is burdened with all the elements of your offense beyond a reasonable doubt. The prosecutor can verify the facts of your crime through substantial and physical evidence gathered to support the criminal accusations. However, you can present a lack of evidence as a defense if the prosecutor fails to prove one element.
Lack of evidence could mean the prosecutor will not manage to prove your involvement in health care fraud. It could also mean that your actions did not amount to fraud. The court could easily dismiss or reduce your charges if the prosecutor has a weak case against you.
Find a Criminal Defense Attorney Near Me
If the prosecutor accuses you of healthcare fraud, you will face consequences based on the facts of your case. Hiring a skilled and experienced criminal defense attorney could improve your chances of a fair outcome and help you secure your freedom. The best attorney will give sufficient time and attention to your case and conduct research to support your defense strategy. At the California Criminal Lawyer Group in Bakersfield, we have experienced criminal defense attorneys who can help you fight healthcare fraud charges. When you choose us, you can expect the best legal guidance that will assist you in securing the best outcome for your case. Call us at 661-750-8230 to talk to one of our attorneys.
