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What is Medical Fraud both Federal and State?


What is Medical Fraud under both Federal and California Law?

 Medical fraud is a term used to describe the act of making false claims or misrepresenting information. The target is a healthcare provider, insurance company, or a payer like the State or Federal Government.

Medical fraud can involve a wide range of activities, including billing for services that were never provided, providing unnecessary medical treatments, or using false information to obtain prescription drugs.  DME fraud, telemedicine fraud and pharmacy or provider drug compounding is also a focus of fraud investigations.

The Health Care Fraud Statute makes it illegal to intentionally deceive a health care benefit program. Violation of this medical fraud statute is punishable by imprisonment for up to 10 years and criminal fines of up to $250,000.  

Other federal medical fraud statutes include 18 U.S. Code § 1035 (False statements relating to health care matters) and 42 U.S. Code § 1320a-7b (Criminal penalties for acts involving Federal health care programs).

In California the Health Care Fraud Statute under Welfare and Institutions Code § 14107 makes it a criminal offense to present a false claim for payment for goods or services with intent to defraud, or knowingly engage in a scheme to defraud the Medi-Cal program.

A violation of this healthcare fraud statute is punishable by imprisonment for up to 5 years and criminal fines not exceeding three times the amount of fraud or improper reimbursement or value of scheme. 

Other statutes that may apply to medical fraud include Welfare and Institutions Code § 14014 (False Declaration as to Eligibility) and Penal Code § 550 (False Health Care Benefit Claim)

State prosecutors frequently charge Penal Code section 550 violations as a catch-all for any and all conduct that they contend led to an insurance payment that was not justified.

Our office has handled many medical fraud cases. It requires expertise and specialized knowledge. Call our healthcare fraud attorneys at the first sign of an investigation.