PC 550 (a)
Healthcare Fraud in California
Healthcare fraud in California occur in a number of contexts, but most often occurs in relation to Medi-Cal, and ensnares doctors, nurses, and other healthcare professionals. Penal Code section 550 (a).
Section 550 (a)
Section 550 (a) lists a range of unlawful conduct. An example of some, but not all forbidden conduct, is as follows:
- Knowingly presenting any false or fraudulent claim for the payment of a loss or injury
- Knowingly presenting multiple claims for the same loss or injury
- Knowingly causing or participating in a vehicular collision, or any other vehicular accident, for the purpose of presenting any false or fraudulent claim.
- Knowingly presenting a false or fraudulent claim for the payments of a loss for theft, destruction, damage, or conversion of a motor vehicle, a motor vehicle part, or contents of a motor vehicle.
- Knowingly preparing, making, or subscribing any writing, with the intent to present or use it, or to allow it to be presented, in support of any false or fraudulent claim.
- Knowingly making or causing to be made any false or fraudulent claim for payment of a health care benefit.
The key to understanding the above is the definition of fraud. Fraud is lying to, or misleading, someone about important facts in order to obtain a benefit one would not otherwise be entitled to. This includes lying to obtain coverage or medical devices, even if you are very sick and need care.
The above also makes it possible for billing clerks to be punished for fabricating or processing knowingly false claims. The bottom line is if you are involved with preparing or submitting false information to collect from an insurance company, you should consult a licensed criminal defense attorney.
Example: Alice, a billing clerk at a doctor’s office, feels bad for one of the patients that she encounters at her office who suffers from severe leg pain. To ensure that the patient will be able to get a walker she otherwise would not have gotten, Alice improperly bills the patient’s insurance company.
Alice has likely committed healthcare fraud. She submitted false information to ensure that the needy patient got the equipment the patient needed. It is irrelevant that the patient was in pain, or that the patient needed it, the clerk submitted false information to obtain a benefit for someone that would not have been given otherwise.
If the false claims equal $950 or less, then the offense is a misdemeanor and is punished as follows.
- Up to 6 months in county jail
- A fine of up to $1,000
- Or both
If the false claims total $950 or more, then the offense is a “wobbler,” meaning it can be charged as a misdemeanor or a felony at the sole discretion prosecutor depending on the circumstances. If charged as a felony it is punishable by:
- 2, 3, or 4 years in prison
- A fine of up to $50,000
- Or both
This does not include any probation or restitution that may be ordered.
Consult a licensed criminal defense attorney to determine how your case will be charged, to discuss possible defenses, and to discuss how to exercise your constitutional rights.
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