The government guarantees access to healthcare, including those who cannot afford to pay out of pocket. To do this, it has rolled out a Health Care financial aid system that provides access to health services with subsidized payment. Although the systems are functional in California, they are subject to abuse through fraud. Subsequently, healthcare fraud is described under the Penal Code and attracts legal penalties for anyone found guilty. When you face the charges, you want to contact a criminal defense lawyer to help you prepare and present defenses to the crime.

At Los Angeles Criminal Attorney, you will partner with a skilled and experienced legal team that has handled criminal defense matters for years. Upon receiving your case, we will assess the facts and build strong defense strategies. Our goal is to help you raise your chances of a favorable case outcome and secure either an acquittal or a sentence reduction. Therefore, working with us is an excellent choice to help obtain justice.

What Health Care Fraud Entails

The Penal Code prohibits health care fraud under section 550(a), making it illegal to present false or fraudulent documents to any agency that provides medical financial aid. The core element of healthcare fraud is using false information or pretenses to obtain benefits.

Therefore, fraud is the main aspect that a prosecutor aims to prove, among other critical factors to the crime. Based on the analysis, you want to work with an attorney who can point out whether your actions are linked to fraud or whether you have a chance to raise plausible defenses.

Healthcare fraud may occur in various ways, as each accused person plans their execution differently. Your criminal defense lawyer will study the case facts and help you establish the types of accusations you face towards developing strong defense arguments.

Overall, healthcare fraud accusations require thorough research to prepare strong defenses, so you want to go over the case facts with your attorney as clearly as you remember them. Doing so before the trial begins gives you ample time to anticipate what the prosecutor is likely to focus on and counter it.

Departments Mandated to Investigate Health Care Fraud Cases

Once an aggrieved party raises the alarm about potential fraud in the healthcare system, they will alert law enforcement officers to begin investigations. Through the findings, the investigating officers will partner with the prosecutor handling your case to build arguments against you.

Various investigation departments may involve themselves in the process, and you want to identify the potential officers who will engage you. The officers assume their roles depending on the type of healthcare fraud you are accused of and the state where you allegedly committed the crime.

Some key investigation departments involved in healthcare fraud cases are:

The State’s Office of the Attorney General

An Attorney General represents the federal government in states and plays a vital role in helping with investigations related to defrauding the healthcare system. The Attorney General's department can undertake individual investigations or delegate the work to officers within the docket.

The Drug Enforcement Administration

Some healthcare fraud cases involve defrauding the system to obtain more drugs than is acceptable at any given time. Most accused persons under these circumstances aim to obtain the drugs to sell them illegally.

Subsequently, the Drug Enforcement Administration (DEA) involved itself in investigations if your case matches these facts to trace and recover the drugs if possible. During the investigations, the DEA may subject you to multiple tests, interviews, and other investigation procedures that seek to uncover the veracity of your accusations.

The Federal Bureau of Investigation

Additionally, the FBI involves itself in investigations if your healthcare fraud accusations were to cause potential effects beyond your state of residence. Therefore, the department undertakes investigations within the federal capacity to ensure they obtain evidence that shows your criminal involvement.

Overall, other investigation departments may involve themselves in your case, provided your accusations attract relevant attention to their field of practice. You will receive the information beforehand to learn about the officers who will investigate you directly.

Elements of Crime for Health Care Fraud Accusations

Once the prosecutor takes over your case, they prepare strong arguments against you and persuade the judge/jury to convict you. Noteworthy, the prosecutor carries the burden of proof in criminal cases, meaning that they are in charge of demonstrating how your actions amount to a criminal offense.

Additionally, they must adhere to the criminal standard of proof that requires the prosecutor’s evidence to show their criminal culpability beyond a reasonable doubt. Since the legal burden is heavy on the prosecutor, your criminal defense team can identify potential loopholes in the prosecutor’s arguments and raise them when presenting the defenses.

The following are the main elements of crime associated with healthcare fraud:

You Knowingly Undertook or  Tried to Undertake a Healthcare Scheme

Firstly, the prosecutor must demonstrate that you are knowingly or intentionally involved in a scheme. Their line of argument may also focus on showing that you attempted to involve yourself in a scheme, depending on the case circumstances.

To do this, the prosecution team should consolidate the evidentiary findings they receive from the investigation officers they partner with. Examples of evidential sources include any paperwork that shows preparations to file claims or representations to the healthcare department.

The documents may include letters of claim, spreadsheets detailing health care financial aid received, or medical receipts you obtained after receiving medical practices. Focusing on the documents to present is essential for the prosecutor, as it helps them demonstrate that you had created a scheme targeting the healthcare system.

Additionally, the prosecutor should prove that you were involved in preparing the healthcare scheme and that you acted intentionally. Doing so is critical to showing your criminal culpability, so the prosecution team should work on their evidence to ensure it is compelling.

The Scheme Involved Fraud or False Pretenses

Secondly, the prosecutor must prove that the scheme you involve yourself in is aimed at defrauding the healthcare system. The most likely way for the prosecutor to build their argument is by showing that you participated in fraud or used pretenses.

Fraud involves presenting untruthful information or making false promises to trick an unsuspecting party into agreeing with your requests. For example, you will be answerable to fraud charges for deceiving a healthcare worker about your earning bracket for inclusion into the subsidized healthcare payment system.

Alternatively, the prosecutor can prove this element by showing that you used pretenses to defraud the healthcare system. Usually, pretenses involve any untruthful facts that you present as a justification or excuse to obtain benefits you would otherwise not be entitled to.

For example, if you lie that you suffer from a terminal disease and forge doctor reports to support your claims, you will be answerable for using pretenses to commit fraud. You may have relied on lies to trick a healthcare system worker into providing healthcare benefits that you do not qualify for.

You Intended to Defraud the Healthcare Program to Obtain Benefits

Finally, the prosecutor must point to specific expected outcomes from your fraudulent operations. Showing this element of the crime is important because it frames the reason for your actions to the specific loss you caused or attempted to cause to the aggrieved party.

Examples of benefits that accused parties seek to receive through fraud include access to money, services, exemptions, and goods available under the healthcare system. Thus, the prosecutor must provide sufficient evidence detailing the benefit you received, amounting to subsequent loss on the system.

For example, if you received money through fraud, the prosecutor's presentation should demonstrate whether you came into contact with the funds. They can obtain information about your bank account through financial statements.

Additionally, any information regarding goods you received after deceiving the system may lead to the investigation officers retrieving them from your residence or person. For example, if you obtained medication in high quantities, the DEA can retrieve it, and the prosecutor can use the drugs as exhibits in court to further prove your guilt.

Types of Actions Amounting to Healthcare Fraud

Although the prosecutor confines themselves to the three main elements of a crime when handling your case, they are conscious of the possibility of different forms of the offense. If you are unsure of the classifications of different actions under healthcare fraud charges, your defense lawyer will help you establish which category your case facts fall in. They include:

Submitting Multiple Healthcare Benefit Claims

Usually, the healthcare system only allows individuals to submit claims to receive healthcare benefits under one account. Thus, an individual can only receive healthcare benefits in the form of money, services, or medication once after approval of their submissions.

Therefore, making and submitting multiple healthcare benefit claims is fraud because these benefits will only help one individual. The offense often occurs when an accused commits identity theft and uses multiple people’s identities to obtain benefits more than once.

Alternatively, you may face a charge under this category for recruiting third parties to create false online profiles to receive multiple benefits on your behalf. If so, the prosecutor obtains all relevant evidence to show that you planned and orchestrated the multiple requests for healthcare benefits.

Presenting Healthcare Claims for Unwarranted Benefits

You may also face healthcare fraud for submitting claims where no benefits were delivered. Case facts surrounding this accusation will likely arise upon collaboration with a healthcare system worker to target innocent parties eligible for healthcare benefits. Thus, fraud occurs because you take away their eligibility for the claims and receive them as your own.

The fraud also manifests by directly requesting healthcare claims even when you know you do not qualify. You are likely to have used false information or bribed someone to include you in the list of eligible beneficiaries, hence denying a genuinely qualified party from benefiting.

Writing a Supporting Document to Help a Fraudulent Claim Succeed

Healthcare system workers may also face fraud charges if they assist in actualizing a fraudulent scheme. The offense often occurs when a healthcare worker agrees to create a supporting document promoting healthcare fraud.

For example, if a doctor helps you by writing a false report about a severe condition that you face, they make you eligible to receive healthcare services available to patients suffering from the condition. However, since you do not genuinely suffer from the disease, you will have defrauded the system, resulting in inefficiency in service delivery.

Consequently, writing the support document also amounts to fraud, and the responsible party is also answerable in court for the offense. However, the prosecutor can only successfully show that the party is guilty if they were aware of the fraud they were participating in. The prosecutor also bears the burden of proving that the party knew about their wrongdoings.

Presenting a Fraudulent or False Healthcare Claim

The most common form of healthcare fraud charges involves preparing and presenting a false healthcare claim. As an accused, you will likely obtain the healthcare forms unlawfully and present them under pretenses to obtain the benefits set aside for eligible parties.

For example, you may have worked with an insider to obtain a healthcare claim form and received information on specific details to qualify you for benefits. Alternatively, you may have assumed the identity of an unsuspecting victim and received their benefits before they uncovered your scheme.

False claims entail using fabricated or untrue statements to access benefits. The situation often involves obtaining a false supporting document, as discussed above, to justify your claims to the healthcare system wrongfully.

Generally, you should remember that the prosecutor analyzes your case facts and categorizes them under any discussed classes when presenting a case against you. They will also streamline the elements of the crime to cover the circumstances surrounding your case, so you want to follow their lines of argument closely to ensure they do not raise false claims against you.

Defenses Applicable in a Healthcare Fraud Charge

After the prosecution team concludes its case, the defense hearing will begin, giving you a chance to raise your counterarguments. Having worked on your defenses in advance with your criminal defense team gives you an advantage, so you want to engage them at the earliest opportunity.

Notably, the defense hearing may occur in one court session or extend to multiple sessions, depending on the number of defenses you intend to raise. Despite this, you are better off focusing on one or two primary defenses to avoid the possibility of contradicting yourself. Thus, your defense lawyer will help you establish the best defense strategy based on your case facts.

Some applicable defenses to consider include the following:

You Did Not Intend to Defraud the Healthcare System

Intention to defraud is a primary element of the crime, without which the prosecutor’s case is less likely to succeed. Subsequently, adopting a strategy to show that you lacked the intent to defraud is an excellent option that may increase your chances of a favorable outcome.

Lack of intention means that you were unaware that your actions were wrong, either because they remained unknown to you or because your instructors were truthful. The defense works best if you can provide evidence to show that the operations resulting in fraud were genuine mistakes or out of ignorance.

For example, if you are unfamiliar with the healthcare benefits claim online system, you may have submitted your claim more than once by accident. If so, you can point out your prior unfamiliarity with the online system, which resulted in the possible fraud accusation.

Further, you may have requested someone else make applications to help navigate the unfamiliar online systems. The party may have engaged in fraudulent activity, which you were unaware of until you received information on your criminal charges. Thus, you want to provide evidence on these possibilities to build your case and persuade the judge of your innocence.

You Did Not Know the Operations You Undertook Were Fraudulent

Alternatively, you can rely on the defense of lack of knowledge. If successful, the counterargument can help you avoid legal responsibility, meaning you are more likely to receive an acquittal.

Lack of knowledge means that you did not play an active role in the healthcare fraud scheme, despite your possible assistance towards the scheme. Employees or freelancers who undertake various roles in preparing healthcare documents are likely to face accusations and can rely on the defense.

For example, if your role is to key in figures in spreadsheets without additional information on what the details are for, you can avoid criminal culpability. However, your defense must show that you were not privy to any information surrounding the healthcare fraud scheme.

Thus, you need to prepare adequate evidential sources that dissociate you from the offense and instead portray you as an innocent bystander. To achieve this, your defense attorney will guide you on the documents, witnesses, and statements to present in court.

You Suffered a Violation of Constitutional Rights

Sometimes, your case facts may be direct in demonstrating that you acted unlawfully. Nevertheless, you can still raise a defense on any mistreatment from law enforcement officers, particularly any treatment violating your constitutional rights.

For example, if the investigating officers force you to provide self-incriminating evidence before trial or confess to the crime, you can raise these issues during the defense hearing.

Although the defense may not entirely absolve you of facing penalties, they may persuade the judge to be more lenient with their punishment based on constitutional violations and malpractice from the officers. The defense is suitable where the prosecutor has an overwhelming evidence against you, but they obtained it unlawfully.

You Acted Under Duress

Lastly, you can also defend your actions by stating that you faced coercion or duress by committing healthcare fraud on behalf of a third party. For example, your employer may have forced you to present fraudulent information to the healthcare system or risk losing your job, so they can avoid paying worker’s compensation.

Depending on your case circumstances, you can alter the defense to fit the facts and persuade the court that you did not act voluntarily. If your evidence is compelling, you will likely receive an acquittal or a significant sentence reduction.

Penalties for Committing Health Care Fraud

After the prosecution and defense argue their cases, the judge will issue the final verdict. If the judge finds you guilty, you will face the penalties stipulated in the Penal Code.

Healthcare fraud is a wobbler offense that can attract misdemeanor or felony penalties. The difference in charges and subsequent penalties depends on the degree of loss you caused to the aggrieved party.

A misdemeanor offense and penalty is available when you defraud the healthcare system of any amount below $950. If so, you may face up to six months in county jail. Alternatively, the court may fine you a maximum of $1000 for the offense.

Conversely, a felony offense is applicable if you defrauded the aggrieved parties with amounts above $950. The punishment for felony offenders is a five-year maximum jail sentence or a court fine of up to $50,000 or twice the amount you defrauded the healthcare system. Usually, the presiding judge decides on the higher amount between the two options.

Contact a Defense Attorney Near Me

When you or a loved one faces healthcare fraud charges, you face serious repercussions, depending on your case outcome. Therefore, partnering with a reputable criminal defense team is a great way to improve your chances of a fair outcome and secure your liberty. The best legal defense team provides enough time and attention to your case, undertaking all the necessary research to aid your defense strategy.

At Los Angeles Criminal Attorney, you can expect the best legal services geared towards helping you receive the best possible case outcome. Our attorneys will provide customized services to suit your case needs while engaging you at every stage for consistent updates. With our team, you can look forward to a fair trial process. For more information on how to fight healthcare fraud accusations, call us today at 424-333-0943.