The healthcare system provides financial assistance to persons who would otherwise struggle to afford health care services in the country. Therefore, the available funds for distribution attract multiple applicants per year looking to benefit. Health care fraud is also quite common during the distribution of the funds, as some parties seek to gain wrongfully for the welfare system. As a result, committing healthcare fraud is an offense attracting criminal penalties for persons found guilty. Thus, if you are facing healthcare fraud charges, you want to partner with an experienced criminal defense attorney to help you present solid defenses and increase your chances of a favorable case outcome. At Riverside Criminal Defense Attorney Law Firm, we work hard to provide quality legal assistance to clients facing healthcare fraud charges in California.

Understanding What Healthcare Fraud Is

Healthcare fraud falls within the category of the fraudulent offense with relevant provisions that prohibit it under section 550(a) of the California Penal Code. The provision makes it an offense to commit healthcare fraud by knowingly presenting false information to obtain money or other benefits from the healthcare system.

Based on this, the offense highly revolves around fraudulent actions and benefiting from them. The main elements of fraud include providing false information, presenting yourself under false pretenses, or manipulating data to suit your needs.

Since arrested persons may think of different ways to defraud the healthcare system, multiple offenses could result in your arrest. Understanding the different types of fraud is essential to help you prepare for your case or avoid dealing with possible punishment altogether by avoiding these actions. They include:

Presenting Multiple Claims for Healthcare Funding Assistance

The funds available to help parties in need access healthcare services affordably are only available in limited amounts to each individual. These limits exist to promote fairness in their distribution, as some parties may otherwise miss out on receiving the benefits.

You may face charges for presenting claims for assistance more than once, even after receiving information about the limits during the application.  Your case may involve creating false identities, each with a valid social security number and a different application. You will face criminal charges if the system detects fraud and links them to you.

Alternatively, some parties may force their loved ones or third parties to present claims on their behalf, but with them as the sole beneficiaries. This also amounts to a criminal offense because you will have used multiple claims to benefit alone.

Supporting an Unlawful Claim in Writing

Parties in a position to provide recommendations or support for a party seeking healthcare benefits may be answerable to the offense. This happens if they provided their recommendation knowing that the claim before them was fraudulent.

For example, patients may ask their doctor to write them multiple drug prescriptions they intend to sell, as they will have obtained the drugs cheaply through healthcare funding. If the doctor knows the person’s intentions and signs off on the documents, they are answerable to healthcare fraud charges.

Presenting Claims on Undelivered Benefits

On top of this, you risk facing criminal charges for presenting claims about undelivered benefits, meaning that you fault the healthcare benefits system for not providing you with the benefits. While many persons presenting these claims may be genuine, investigation officers can depict fraud and decide to arrest you.

Therefore, you should ensure that your claims are well-founded and accurate before presenting them to the relevant body. Doing so will help you avoid unnecessary scrutiny and possible arrest for fraud.

Investigation Officers Involved in Health Care Fraud Cases

Most criminal cases involve a limited number of investigation officers, as the case facts are fairly straightforward, and a single department can handle the investigation process. However, most healthcare fraud cases involve sophisticated schemes that run for months or years undetected. Subsequently, you should be aware of the possible investigation bodies deployed in healthcare fraud cases to help you prepare for questioning and other procedures.

Some commonly deployed investigation bodies include:

The Drug Enforcement Administration (DEA)

Common healthcare fraud practices share a link to illegal drug distribution after the offenders fraudulently obtain them. Therefore, the DEA can step in to trace drug distribution by checking medical container labels, transportation details, and stock records. They will then arrest the suspected parties involved in healthcare fraud based on their information.

The Federal Bureau of Investigations (FBI)

Additionally, the FBI may involve itself in your case if the suspected healthcare fraud extends to a countrywide syndicate. Since the bureau has multiple officers throughout the country, they will aid in faster investigations to determine whether to arrest you.

Other bodies include:

  • The state Medicaid fraud control department.
  • The Local medicare and Medicaid service offices.
  • Healthcare fraud prevention officers are in charge of the state.

Elements of Crime Related to Healthcare Fraud

Once the presiding prosecutor takes on your case, they are in charge of proving that you are guilty of the alleged accusations beyond a reasonable doubt. To do this, they must establish that you participated in the fraudulent activities by showing that your case met all elements of the crime.

You should note that the prosecutor must satisfy all case elements for the jury or judge to find you guilty. Therefore, you want to listen carefully to the prosecutor’s presentations and pick out any inconsistencies that may help you raise defenses.

The two main elements of the crime to prove in your area are:

You Knowingly Made a Fraudulent Healthcare Application

Firstly, the prosecutor must prove that you were aware of your actions, meaning that you contemplated or planned to file an application that would help you benefit unlawfully. Different offenders can commit the crime in various ways, so the prosecutor will be specific to your actions that amounted to an offense.

For example, the prosecution team may have to prove that you submitted a false unused healthcare benefit, intending to obtain the financial benefits yourself. In doing so, the prosecutor should ensure that the element of knowledge is present, as it forms the basis for the accusations.

Thus, the prosecutor may rely on the false paperwork you presented or call on a witness to demonstrate the unlawful tactics you applied. In scrutinizing the documents, the prosecution team can detect a deliberate alteration or falsification of records, resulting in a strong case against you.

Alternatively, the prosecutor can prove that you knew what you were doing by showing your involvement in making multiple claims. If the team can link you to two or more applications through your handwriting, bank details, or even the application wording, they may succeed in their case.

You Intended to Defraud the Healthcare System or Program Using the Application

Secondly, the prosecutor should prove that you had the intention to defraud the targeted healthcare program. Proving criminal intent is essential to establishing guilt, as it ties up with your reason for acting wrongfully. In this case, your intention to defraud is depictable by assessing whether you obtained money, drugs, or services and whether they benefited you. At the same time, the prosecutor will determine the losses or negative impact of your fraud on the targeted program to establish that your actions were fraudulent.

In court, you can expect the prosecution team to present your bank statements after the alleged fraudulent transaction and documents and witness statements that prove you provided false information for wrongful gains.

Defenses for Healthcare Fraud Charges

After the prosecutor finalizes their case presentation against you, your attorney will have the chance to present defenses on your behalf. This part of the case trial is crucial to the verdict, as it may cast reasonable doubt on the prosecutor’s case. As a result, you want to take your time and prepare solid defenses with your criminal defense attorney’s help. Some applicable defenses include:

You Did Not Intend to Defraud the Healthcare System

Since the element of criminal intent is central to the case, you can argue that you lacked any intent to defraud the healthcare system. In doing so, you will not necessarily deny your actions but rather the existence of an unlawful motive behind them.

For example, if you filed multiple claims for previous overcharges, you can argue that the claims went unanswered, leading you to repeat the application process. This does not indicate any intention to defraud but rather a persistence in seeking assistance.

In different circumstances, your case facts may point to you issuing false statements to a healthcare representative to avoid making payments. However, providing proof of genuine mistake in providing the information is acceptable, provided your attorney indicates the relevance of the details to the matter.

Furthermore, explaining the reasons for the potential mistakes misinterpreted as an intention to defraud can increase your credibility and cast reasonable doubt on the prosecutor’s case. While you will likely rely on circumstantial evidence, it can still prove useful in driving your point further.

If the defense proves successful, the judge may request you to refund any monetary benefits or evasions you obtained. Doing so will prove that you lacked the intent to defraud and are willing to cooperate to restore the healthcare funds. On the other hand, the judge may strike out the defense if your arguments are incoherent and lack sufficient proof.

You Lacked Knowledge of the Impact of Your Actions

Furthermore, you could argue that you did not know what you were doing amounted to health care fraud. While ignorance is generally unacceptable as a defense, you can argue through different case facts to establish your non-involvement in the fraud crime. This defense goes well with your claim of lack of intent to defraud.

When presenting your case, your criminal defense attorney will delve into the specific case factors that the judge should consider to show your lack of knowledge. For example, if you filled out health care benefit forms on behalf of somebody else as an assistant or secretary, you may have been unaware of the criminal purpose they were used for.

Similarly, if you worked within the healthcare system and followed orders that aimed at promoting healthcare fraud, you may argue that you were simply doing your job and did not know of any underlying criminal elements. This is useful if you face arrest and prosecution as an inexperienced employee.

While your counter argument may be believable, you will still need to justify it by ensuring you provide evidence of your claims. For example, you may call on a witness who can help corroborate your claims of lack of knowledge. Moreover, your attorney can help show that some details that could have helped you detect healthcare fraud were undisclosed to you.

In doing so, you will have increased your credibility and further showed that the prosecutor’s presentation against you did not prove your guilt. However, you should remember that the prosecution team will contradict your defenses during cross-examination, so you should have an accurate record of events beforehand.

You Acted Under Duress

Moreover, you may have been a victim of duress, whereby a person used undue pressure to force you into the healthcare fraud scheme. Most cases involve the oppressive third-party making you act on their behalf because they do not want any attention to themselves. Consequently, you will face the repercussions they should have taken on, including your arrest and trial.

It is, therefore, in your best interests to reveal that you acted under duress when committing the healthcare fraud, as it may alleviate the consequences. When building on this defense, you want to ensure that your narration is accurate and that you can provide strong evidence to support your case.

For example, your criminal defense attorney can help you expose the malicious third party by presenting evidence of the type of duress you faced from them. This may include showing text messages, emails, or recorded phone calls where the third party forced you to perform the fraudulent activities on their behalf.

You should also present the type of coercion you faced. This is because the court will only accept the defense if it convinces the jury and judge that you reasonably believed to be in danger if you did not comply with the third party. It is noteworthy that the threats you receive will only support your defense if they pose a risk to you.

Thus, alleged threats to other people that forced you to comply are not always persuasive to the court as a reason for your participation in the fraud. If the defense is successful, you may receive a full acquittal, meaning that you are not liable for penalties.

However, the judge may still issue punishment if a party had a chance to disregard the duress but failed to do so. This will commonly happen if the prosecutor can prove that although you acted under pressure, you also benefited from the fraud operations.

You Faced False Accusations

Some defendants may also fall victim to false accusations based on different circumstances. Notably, many cases involving false accusations occur in workplace settings, as one party tries to sabotage another.

For example, if you worked in a healthcare financial service, your colleague may set you up, resulting in arrest and charges. However, you will only face the consequences if the judge finds all the crime elements are present.

Hence, raising this defense is useful where you were genuinely involved in the healthcare fraud but faced criminal accusations. Providing an alibi that can prove your non-involvement is a strategic approach when presenting this defense, as it will cast reasonable doubt on the prosecutor’s case.

Also, naming the parties you firmly believe have raised false accusations against you is advisable, as it will also introduce scrutiny on them. This way, you build your credibility to the jury and have the malicious parties answerable to the judge. You can also raise the issue of false accusations in the preliminary case stages if the judge allows it, as you will save on time and resources otherwise spent during the trial.

You Suffered From Police Misconduct

Police misconduct during investigations, arrests, and trials can also cause a pivotal change in your case if you show that it caused bias and disadvantage to you. Usually, police misconduct encompasses actions like planting evidence, fabricating reports and witness statements, and forced confessions while in custody. Sometimes, the officers in question may forcefully collaborate with malicious third parties to hold you liable for their offenses. Therefore, this defense ties in with the previously discussed point on false accusations.

Although exposing police misconduct is a justifiable defense, you want to be careful when presenting your case. This is because your strategy involves challenging the law enforcement integrity and causing potential problems for the named officers. Additionally, the jury may view your defense as clutching at straws because it reflects your involvement in the crime and shifts blame to others.

Nevertheless, you can overcome the prejudice and possible adverse effects of using this defense by providing solid and verified evidence to support it. For example, if your attorney has access to the unaltered witness statements, they can present them in court as a comparison for the fabricated copies presented by the officers in charge to wrongfully incriminate you. If the judge and jury side with you, you can expect to receive a full acquittal for the charges.

Your Case Involves Mistaken Identity

Lastly, mistaken identity may be the cause of your arrest for healthcare fraud, especially if you share your full name with the actual offender. While proving mistaken identity should be straightforward, you may face several challenges in contradicting the prosecutor’s case without sufficient evidence.

Therefore, you want to work with your criminal defense attorney to track the actual suspect or request law enforcement officers to help. You should also work on presenting a foolproof alibi for the case facts that the prosecutor presents, as proving you were in a different location and setting when the alleged fraud occurred will eliminate you from the list of potential offenders.

Penalties for Committing Healthcare Fraud

If the jury or judge finds you guilty of healthcare fraud, you will receive penalties for the crime, depending on whether your case included aggravating factors. Healthcare fraud is a wobbler offense, meaning the prosecutor may charge you with a felony or misdemeanor.

Misdemeanor Penalties

You would face a misdemeanor charge if your fraud amounted to a loss of $950 or less from any department in the healthcare fraud. The amount is equivalent to petty theft when compared to theft crime charges.

Subsequently, misdemeanor charges attract a sentence in the county jail of up to six months or a fine of up to $1000.

Felony Penalties

On the other hand, you may receive a felony charge, resulting in felony penalties when the judge finds you guilty. This would be the case if you defrauded the healthcare system of any amount above $950. By exceeding the $950 limit, your actions are the equivalent of grand theft, which attracts more serious penalties.

As a result, you can expect to face a sentence of up to five years in prison. Alternatively, you may have to pay a fine of up to $50,000 or double the amount you defrauded the healthcare system. The presiding judge will determine the more suitable fine penalty to issue by choosing the more expensive option.

Find a Criminal Defense Attorney Near Me

Dealing with healthcare fraud charges requires you to prepare adequately for the oncoming court trial, as you risk facing severe penalties. Moreover, a favorable case outcome that has you acquitted or receive a reduced sentence is highly beneficial, so you want to partner with the necessary parties to help you attain it. Working with an experienced attorney improves your chances of beating the prosecutor’s case and avoiding the sentences that the judge may otherwise issue. With Riverside Criminal Defense Attorney Law Firm, you can look forward to excellent services that help you develop convincing counterarguments for your case. Over the years, our legal team has handled multiple health care fraud cases successfully, making us your best option in handling your case. If you or a loved one requires criminal defense services in Riverside, California, call us today at 951-946-6366.