Orange County Healthcare Fraud Defense Attorney

Please note that the Law Office of Michael Guisti is a Criminal Defense Firm and we do not represent Victims of Fraud. We represent those who have been arrested for or charged with a Fraud Crime.

Defend Your Rights If You've Been Accused of Healthcare Fraud (Penal Code 550(a) PC)

Healthcare fraud occurs when an individual or business that offers healthcare service or insurance knowingly falsify documents or transactions for personal gain. The charge, which can take many forms, could lead to a prison sentence of 10 years as well as harsh fines. Accusations are usually the result of an investigation on the part of federal authorities. Therefore, it is important to contact an OC criminal attorney as soon as you suspect you are under investigation for medical fraud.

Many people who are accused of healthcare fraud are unaware that they may have committed any offense. Whether you are in individual claimant or a business/employer accused of offering fraudulent services, you must act quickly in order to defend against the charges.

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Understanding Healthcare Fraud

Healthcare fraud is a criminal act that violates California Penal Code 550(a) PC. Under this law, it is considered fraud if a member of the healthcare industry knowingly presents information that they know to be false for their personal gain, such as monetary compensation. Often times, this involves falsifying documents in order to receive more money from insurance companies or insurance companies.

Because many patients pay for treatment through federal insurance policies like Medicare and Medicaid, as well as state programs like Medi-Cal, these cases often directly involve the government and can lead to federal charges. These cases may be investigated by the FBI or through a Medicare audit. However, even if the alleged crime was committed against a private insurance company, the charges against you should be taken extremely seriously.

That being said, there are ways to fight these charges. The burden of proof is on the prosecution, meaning your attorney can go point by point through your case to discredit their arguments. In a California court, a district attorney must prove the following to secure a conviction of healthcare fraud:

• You knowingly submitted a false claim
• With the intention of committing fraud against an insurance carrier or patient.

If the prosecution cannot prove that you knew you were committing fraud or that you intended to commit fraud, then they cannot convict you of a crime. But what constitutes healthcare fraud can vary depending on the situation.

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Types of Healthcare Fraud

Healthcare fraud can take many forms and originate from different sources including the claimant (patients), the provider, the insurance company, or the medical professional. However, because most insurance claims are processed by healthcare providers, charges are often filed against medical professionals and workers.

Under California Penal Code 550(a) PC, the key charges involving healthcare fraud include:

• Submitting a claim for treatment that was never provided
• Submitting a claim with false information or fraudulent statements
• Submitting multiple claims for the same treatment
• Underbilling a claim (charging an insurance company less than what a treatment is normally worth) and then overcharging a claim (charge more than a treatment is normally worth)
• Preparing a document that supports healthcare fraud

The healthcare industry is extremely complex, with most doctor’s offices seeing dozens of patients each day while hospitals may receive hundreds of patients. A claim can become misplaced or filed twice, payment information can be mixed up, and treatment files are lost. These common mistakes can lead to accusations of healthcare fraud and significant charges if a professional is falsely convicted.

Actions that can lead to a charge of healthcare fraud include:

• Phantom billing
• Providing unnecessary treatment
• Falsifying provided services
• Billing for services not provided
• Billing for medication/equipment not purchased
• Kickbacks
• Stealing from a healthcare benefit program
• Fraudulent statements

Alongside traditional forms of healthcare fraud, there is also the possibility that you can be charged with medical identity theft.

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Medical Identity Theft

While identity theft is the act of stealing another person’s information in order to make fraudulent charges, statements, or purchases, medical identity theft involves stealing another individual’s medical information with the intent to commit insurance fraud. This can be as simple as one person taking another person’s insurance card in order to pay for treatment or a medical professional using one patient’s insurance information to cover another patient’s treatment. Typically, it is done in order to receive reimbursements on treatment or prescription medication.

In any situation, medical identity theft is illegal and can lead to significant charges. This is because stealing another person’s insurance information can put them at risk of not receiving proper treatment. California courts may choose to charge this crime as a wobbler, meaning you can face either:

Misdemeanor Identity Theft: Up to one year in a county jail and/or a fine of up to $1,000 fine.

Felony Identity Theft: Up to three years in a state prison and/or a fine of up to $10,000.

In addition, you may be charged with a theft crime, which can vary between petty or grand theft depending on the amount of money involved.

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Penalties for Healthcare Fraud

Even if you are not charged with medical identity theft, you may still face significant charges for healthcare fraud. Prosecutors do not take these charges likely and will utilize the full power of the law to punish you, whether or not you are guilty. However, healthcare fraud charges will vary depending on the amount of money involved. If the alleged amount of money stolen was $950 or less, then these charges are a misdemeanor. If the alleged amount of money stolen was greater than $950, then these charges can lead to either a misdemeanor or felony conviction.

A successful conviction of healthcare fraud can result in:

• Misdemeanor Healthcare Fraud: A sentence of up to six months in a county jail and/or up to $1,000 in fines.
• Felony Healthcare Fraud: A sentence of up to two, three, or five years in a state prison and/or up to $50,000 in fines.

In addition, if you are a medical professional, you could also have your licensed suspended, ruining your career.

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How an Attorney Can Help You

No matter the charges against you, you still have time to build a defense strategy, but you will need to act fast. Securing proper legal representation is the most important step to fighting the charges against you and protecting your rights. With the aid of our lead attorney, you may be able to receive a lighter sentencing or have your charges dropped altogether, ensuring you do not serve any jail time or lose your license.

In a healthcare fraud case, your attorney may defend you by arguing that:

• There was no intent to commit fraud, and it was a filing error
• You were not aware that the claim was false or had been duplicated
• Another medical professional committed fraud using your name or information
• There is not enough evidence to secure a conviction

In addition, your attorney may be able to negotiate with the district attorney to drop the case due to insufficient evidence. But first, you must get in contact with Law Office of Michael L. Guisti to learn how our legal team can represent you.

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Take Action to Defend Yourself Today

Healthcare fraud is a serious matter of federal charges. It is important for you to avoid taking matters into your own hands. Not only do federal authorities have far more resources to use in their investigations, but they are also protected by laws that prevent anyone from obstructing federal investigations into healthcare fraud.

Because of the many parties involved in the healthcare process, it is very possible for an innocent party to be caught in the middle of and even accused of participating in an illegal scheme. If you are such an individual, Law Office of Michael L. Guisti is prepared to defend your case against wrongful accusations such as these. The ramifications of conviction could have permanent implications on your record and reputation—for professional entities, it could even mean the loss of license or ability to practice. It is important for you to act quickly in seeking the truth by consulting with a capable OC fraud defense attorney.

Contact our Orange County defense attorneys at (714) 530-9690 today to discuss your situation and your options for possible defense.

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Additional Information

• Falsely Charged With COVID-19 Healthcare Fraud? We Can Help