The American health system often suffers from several dysfunctions related to health care fraud. The arrangements set in place to deliver efficient billing services regularly face manipulation from health workers with malicious intentions to defraud patients in hospitals and clinics. With the widespread knowledge of the persistent health care fraud practices, tax authorities have to pay attention to all the systematic transactions that occur within a medical establishment. While the measures are supposed to enhance better medical service provision, most authorities take advantage of innocent workers and blame them for fraudulent transactions that appear in the records. If you find yourself caught up in this situation, you may face several difficulties in proving your innocence in a trial court. However, with a diligent criminal lawyer by your side, you will receive prudent legal services set to secure your acquittal.

A good criminal lawyer will take you through all the essential facts to consider in your litigation case, to ensure that you understand the kinds of charges entered against you. At the Orange County Criminal Lawyer, we delve into an in-depth case analysis that lays out all you need to know about your pending trial. Additionally, we endeavor to provide you with moral support and sound legal guidance that will help you combat any future mishaps related to the current trial you face. Our offices are always open for any inquiries you may have.

Defining Health Care Fraud

The crime applies to professionals in the medical field because they are in charge of receiving all the income they collect from possible fraudulent activities that involve getting more that they deserve from patients. A broad definition of the term ‘fraud’ indicates that the activity includes presenting falsified information to receive illegal gains. In most cases, the intention of the fraudulent party to make a monetary gain. Thus health care fraud is a criminal activity that involves making false billings or claims of treatment to a patient who seeks services in a health care establishment.

Similar to other crimes, the offense can take place through several actions that all have a common underlying factor; to defraud a patient who sought medical attention. Therefore, most health care fraud cases involve making higher charging bills than expected, by adding false information that consequently increases the amounts that the claimant is expected to pay.

While most applicants provide heaps of evidence and affidavits that build a strong case against you, it is necessary to remember that an honest mistake is always justifiable, as long as you work hand in hand with your criminal lawyer. As a result, the various means of enabling health care fraud will not apply to you if you are innocent of any malicious manipulation of charging information.

Activities that Amount to Health Care Fraud

For a better understanding of the elements of the crime, you need to learn about the various scenarios that will land you on the wrong side of the law concerning healthcare fraud. Some of these activities require you to have full knowledge of what you are doing, and that you are aware of its unlawfulness. Section 550(a) and (b) of the California Penal Code prohibits engagement in any of these practices, as they are a statutory violation against the state and the individual involved. These illegal actions are:

  1. Making Exaggerated Charges to a Patient’s Account

When you intentionally increase the costs of essential medical services or medical products used in treating a patient, you commit health care fraud. A good example is when you administer procedural triage tests like recording the patient’s temperature and weight measurements, then charging outrageous fees for those two steps. The widespread application of medical practice dictates that these two steps are the primary process that prepares a patient to go in for a consultation with the doctor, and do not warrant significant charges. On the contrary, they mainly serve to provide the doctor with essential information that will help him/her to make a correct diagnosis and prescription.

Another example involves placing high and unjustified rates on the medical products you use on a patient. When a patient visits a clinic or the emergency room after a low-risk accident, the nurses attending to him/her may dress the wounds in gauze or bandages that are reasonably inexpensive in any market. Therefore, when a patient asks for an itemized bill that shows an overcharge in everyday medical care items that are not highly expensive, he/she has the right to raise a health care fraud claim against your establishment.

Additionally, subjecting a patient to other medical procedures that are unnecessary to the recommended mode of treatment may lead to a charge of welfare fraud. Offenders who involve themselves in new procedures to try and source more funds from their patients violate ethical and professional regulations that require them to exercise cautious and expeditious medical procedures. Thus, when a patient receives unnecessary medical services that are only there to add on to the billing list, he/she can successfully file a lawsuit against you.

For example, when a patient makes a consultation for mild flu but ends up undergoing too many unnecessary blood tests that are then added to the hospital bill, the action results in health care fraud. If he/she receives a second opinion from a certified doctor who disqualifies the reasons that your hospital/ clinic gave for the blood work, you may have to answer to your actions in court.

  1. Backing a False Charge Produced by a Coworker

When a person seeking medical services raises a concern about suspiciously high medical charges in the bill, he/she may seek your opinion and validation of the high costs displayed. The direct approach leaves you highly susceptible to health care fraud if you decide to affirm the charges even though you know they are false. When the patient relies on your professional take concerning an overcharge, he/she places a legal responsibility on you. Subsequently, when you answer in defense of an illegal claim, you will have committed the crime of health care fraud. The violation is contrary to section 550(b)(1). The charges are the same whether the affirmation you gave was done in person or through online communication, using emails or phone calls.

If you are unfamiliar with the rates and taxing rates that the hospital or clinic you work in applies to bill clients, we recommend putting the patient on hold and confirming the information. This way, even if you provide false information from a superior, the evidence presented in court will indicate that you acted in good faith, and did not intend to defraud the claimant.

  1. Double-Charging a Patient

Some patients are unaware of the provisions that allow them to request an itemized bill to confirm that there is no double-charging of products or services. If a predatory medical establishment identifies such customers, they may decide to take advantage of them and introduce a double-bill every time they visit the clinic or hospital. The occurrence is prevalent in hospitals where the patient came in very disoriented or is a senior citizen who lacks someone to help out with the entire billing and clearing system.

Additionally, clinics that offer therapy sessions may develop a trust strategy that gives their clients a good first impression, followed by exploiting the relationship by charging services and products twice. Since you are aware of the good rapport that exists between you and the claimant, you are sure that they cannot easily suspect your double charging activities.

Most offenders also target patients who have a comprehensive insurance cover, since it is harder to detect any drastic cuts made by the hospital unless the claimant makes a deliberate check on past transactions. While the insurance company has the personnel to ensure the claims are valid, common cases also involve cooperation with the insurance agents tasked with this responsibility. The corruption will, therefore, promote health care fraud by giving it a smooth operation field. Consequently, by the time the claimant realizes the ongoing health care fraud, you may have pocketed thousands from the patient.

  1. Developing Different Charging Systems for Insurance Users and Patients Who Pay in Cash

A patient is more likely to detect a fraudulent operation when he/she pays upfront from a bank account or in cash. Since such people tend to be more cautious of the expenses they set aside for each service or activity, they may request a comprehensive billing report that indicates all the charged procedures or services as well as medication issued.

On the other hand, customers who use their insurance covers to access medical procedures and therapy sessions may be less cautious about the various transaction costs incurred after each visit to the hospital or clinic. For example, after a delayed visit to the dentist, you may authorize a charge to the patient who failed to show up that covers a regular consultation visit. Such a decision promotes health care fraud incidents that may take years of detection by the claimant.

Elements that the Prosecutor Must Prove Before a Conviction

Following court hearing guidelines and the rule of law, a proper conviction order only comes after a determination of the defendant’s guilt is beyond any reasonable doubt. The prosecutor will collect all sources of evidence that contribute to the case submissions to presents in court. He/she must determine that you, as the accused, satisfied all elements of the crime of welfare fraud for you to receive any penalties. The details of any criminal action must include Actus Reus and Mens Rea. The first terms define the actual physical activity that consists of the crime. In contrast, the latter describes the criminal intention that is necessary for the accused to carry out the illegal activity. Specific to the crime of healthcare fraud, these are the essential elements that are necessary for the judge to hold you guilty:

  1. You Knew that Your Actions Led to Health Care Fraud

The prosecutor must prove that you were aware of the consequences that actions brought, which would lead to defrauding an innocent third party. Incriminating evidence often arises from the actions and circumstances that occurred just before the crime. For example, if you were present when a patient was receiving medical attention and took note of all the services and medical products that he/she received, you are responsible for any false statements handed over to the patient.

Your liability may strictly be imposed on you by protocol, especially if you are a senior worker in the establishment where the crime occurred. Alternatively, when you voluntarily agree to work under a grand fraud scheme organized by your superiors or supervisors at work, the prosecutor may also source information that proves your indulgence in the crime.

The primary sources of information that a prosecutor gathers come from witness statements as well as documented evidence in the form of receipts and invoices that you sent. Channels of communication that you have with the other suspects involved in the crime may also become relevant, especially if you hold online meetings to plot new fraud system implementations. Thus, phone call logs and messages can offer the prosecutor brought evidence to point out your knowledge of an existing fraudulent activity.

An aggravating factor to your case arises when you deny such knowledge, while evidence indicates that you knew of the unlawful nature of your operations. When the prosecutor produces explicit evidence against you, your criminal lawyer will guide you through several ways of presenting mitigating statements.

  1. You Took Part in any of the Actions that Lead to Health Care Fraud

This second requirement satisfies the actus reus element that the prosecutor must demonstrate. In the presented evidence, the opposing party must demonstrate the actions you engaged in that contributed to welfare fraud. For example, if you work in a hospital/ clinic finance division, there must be a trace of all mathematical alterations that you made in the charging system. Proof of this detail will create a direct link between you and the criminal action to defraud the claimant.

For example, deliberate changes made on the system could introduce a setting that charges a product or service twice but only lists it once in the bill list. Another excellent example of evidence that the prosecutor may collect and use against you is when you create a unique digital setting that identifies patients who use insurance covers to cater to their medical expenses. When you can make such a detection, you can identify who to impose the health care fraud on, because they cannot easily detect it.

Secondly, any witness statements from the prosecutor’s side that affirm the claimant’s statements against you can push your case further into the deep end. In a scenario where the claimant states that you supported a false charge by utterance or by written words, any witnesses around the claimant will corroborate their evidence, much to your detriment. However, you should remember that most witness statements tend to be inaccurate or corrupted. Therefore, your criminal lawyer can poke holes and reveal a ruined plot by the claimant when your innocence is compromised.

Penalties of the Crime of Health Care Fraud

When the judge finds you guilty, he or she follows the provisions of the Penal Code to issue punishment. The crime of healthcare fraud leads to several alternative punishments that all depend on the amount of money you swindled from the claimant. As a result, health care fraud is a wobbler crime, which means that you may face felony or misdemeanor charges.

When the total amount you obtained from the fraud amounts to $950 or less, you will face misdemeanor charges. The penalty for the crime as a misdemeanor involves:

  • payment of a $1,000 fine.
  • a six-month jail term in county jail.

The presiding judge also has the discretion to issue both punishments if he/she sees fit. Aggravating factors play a significant role in promoting such hefty penalties, especially when you are linked to multiple instances of fraud.

When the amounts you obtained from the fraudulent operations exceed $950, you are eligible for felony or misdemeanor charges. In this case, the penalties you receive heavily rely on your conduct in relation to the offense, and whether or not you were a mastermind behind the fraudulent scheme.

If you face misdemeanor charges, you should expect:

  • up to one year in county jail.
  • $10,000 fine payment, or both

As a felony, you will face the following punishments:

  • Repayment of double the amount you obtained from the fraud, or a fine of up to $50,000. The higher penalty amount applies, whichever one it is between these options.

  • You could also face a one-year county jail term with mandatory probation or face two to five years in the county jail without parole.

You should always remember that the presiding judge carries a lot of discretionary powers in issuing the penalties. Therefore, they may vary from one case to another.

On top of the probable convictions, licensed professionals may face more adverse effects that involve work license suspension or revocation. The board in charge of your medical field of practice will strip you of any rights and freedoms to run your business until you re-apply for an administrative hearing. Afterward, the board will inform you of its final decision, which determines whether or not you get your license back.

When your case involves gross fraudulent activities that rob the claimant of a significant amount of money, you will find it challenging to re-apply for your license. However, you may request the services of your criminal attorney in the administrative hearings for better representation presentation of your submissions.

Defenses to the Accusations of the Crime of Health Care Fraud

  1. You Were Working Under Duress

If you are an employee under a large medical establishment like a reputable hospital, you will find established rules that govern the entire system. While some of these rules enable the smooth running of clients’ record-keeping, admitting new patients, and reviewing upcoming medical appointments, there are several malicious rules exclusive to specific members of staff. For example, if you work in the finance and insurance unit of a hospital or clinic, your supervisor may introduce you to their illegal, fraudulent operations that work to overcharge clients or include false information on their billing documents.

Although you may be against the use of these illegal methods to obtain an extra monetary gain, you may face undue pressure and threats from your colleagues and superiors to comply or lose your job. Consequently, if you have no other viable source of income, you have little space to resist. Your criminal lawyer must prove that you faced legitimate coercion and an unconducive work environment when you resisted engaging in the fraudulent activities. Any mode of communication that the people issuing threats used to send you unfriendly messages will be useful in proving your innocence. Therefore, if you can provide e-mail details, phone call logs, or text messages that show your innocence, you will mitigate your case significantly.

  1. You Made a Genuine Mistake of Fact

Sometimes, human error is inevitable, although it might cost you a lot in the long run. When your case involves entering wrong information concerning the claimant’s total bill, you can raise this defense to introduce the aspect of the mistake of fact. For example, if the claimant has a name similar to a different patient, you may open up the other person’s file by mistake and use the information to create a list of services and products to charge to the claimant. Consequently, he/she will notice the inaccuracies and file a lawsuit against you.

Your criminal lawyer should demonstrate that your actions arose from a genuine error in using the information available. You can mobilize all the evidence you will need to prove that you operate in ethical and lawful actions normally and that a confusing set of facts brought about the error of fact. A genuine claim with valid evidence will alleviate any doubts that would otherwise convict you.

  1. There was an Absence of Criminal Intention

Providing this argument as evidence lays its basis on the two points of argument mentioned above. If you were not conscious about an error you made or were forced to commit the crime, you lack the intention to do it. Thus, the point of argument purposes to strengthen the other defenses your criminal lawyer presents, for an assured win.

Find a Criminal Lawyer Near Me

Most defendants who face health care fraud charges have nothing to do with the crime, but end up as suspects because of the complicated tracking systems in place. You may carry out genuine operations as expected of you and still face several accusations that link you to the crime. At Orange County Criminal Lawyer, we work hard to ensure that you receive a just trial that sets you free from all penalties and license revocations you may otherwise face. After scheduling a meeting with us, we will take you through the legal steps you need to know in order to prepare you for trial. Our team will be happy to hear from you and offer the best legal services to cater your needs. Call us today at 714-262-4833 for a free consult.