healthcare fraud

April 19, 2024

When Medical Professionals are Accused of Healthcare Fraud

This country faces a serious problem in terms of healthcare fraud, and authorities have not hesitated to impose serious consequences. As the most expensive white-collar crime in the country—racking up nearly $100 billion in lost funds — the state of California is more than willing to prosecute fraudsters. Both state and federal prosecutors, in fact, are going after individuals and organized groups who engage in this type of fraud on a daily basis.

Examples of Fraud

Fraud might occur involving individuals who work in hospitals, nursing homes, dentist offices, and more. Professionals and staff who try to cheat health insurance companies are a serious concern because there are multiple ways to engage in a swindle, and a successful fraudster can essentially steal big dollars and impact patient outcomes. Deliberately providing incorrect or false information to an insurance company is the bottom line of many fraud cases.

Double billing insurance companies for a single procedure;
Coding procedures in a way that makes billing more expensive;
Charging for procedures and/or care to increase profits;
Prescribing unnecessary medications and/or procedures in order to get kickbacks from pharmaceutical companies.

Legal Penalties

When the fraud involves under $950, offenders in California may face misdemeanor charges with up to six months in jail and fines of $1,000. Felony health care fraud, however, could mean up to five years behind bars and as much as $50,000 in penalties, or double the amount of the fraud. In the case of medical professionals being convicted, they could lose their professional license. Federal penalties are dependent on the degree of injury that occurs to a patient. Even with no injuries, perpetrators could wind up serving 10 years behind bars. That doubles when serious injury results from the fraud and becomes a life sentence if the fraud results in a fatality.

Federal False Claims Act

Any person or entity who knowingly submits a sham claim for Medicare, Medicaid, or other federally funded programs or who intentionally retains an overpayment for 60+ days is in violation of the federal False Claims Act. In addition to having to pay triple the damages suffered by the Government, perpetrators may have to pay nearly $22,000 per falsified claim.

Defending Fraud Claims

One of the strongest defenses against claims of healthcare fraud is to demonstrate that any perceived billing irregularities were the result of misunderstandings and/or unintentional mistakes. Demonstrating that patients received legitimate care consistent with billing will be important, as will establishing a pattern of providing high-quality care aimed at patient well-being. Continue reading

June 27, 2019

Four Ways You are Committing Insurance Fraud

by David M. Boertje

According to the California Department of Insurance, insurance fraud occurs when someone knowingly lies to obtain a benefit or advantage to which they are not otherwise entitled. Insurance Fraud also occurs when an insurance company knowingly denies a benefit that is due and to which someone is entitled.

Other than tax evasion, the National Insurance Crime Bureau (NICB) identifies insurance fraud as the second most costly crime in the country. You may ask yourself, “Why would anyone want to commit insurance fraud?” The answer is simple – for financial gain. Two examples of insurance fraud include:

report of a San Diego dentist facing 75 felony counts of insurance fraud after allegedly collecting false claims for root canals she never performed.
An article about a Yorba Linda man being charged after using stolen identities to receive unemployment insurance benefits.

There are different laws that apply to insurance fraud in California. These laws state:

Anyone who willfully injures, destroys, abandons, or disposes of any insured property with intent to defraud the insurer can face jail time up to five years and fines of up to $50,000.

Anyone who solicits, accepts, or refers business with the intention of defrauding an insurance company can face up to three years in jail.

Anyone who commits any of the following act can be found guilty of either a misdemeanor or felony crime and face up to five years in prison:
- Makes or aids in making a false insurance claim;
- Makes several claims for the same injury or loss;
- Knowingly cause an auto accident with the intent to collect insurance money;
- Knowingly file a false or fraudulent medical insurance claim with the purpose of collecting money; and
- Submit information to support a false or fraudulent insurance claim.

As you can see, there are several categories of insurance fraud — auto, medical, and property. Today, we will focus on auto insurance fraud, which is the most common type of fraud in California.

Auto Insurance Fraud and California Law

Auto insurance fraud is defined as any criminal fraud that involves auto insurance. If you are intentionally performing the four acts below for personal and financial gain, you are committing auto insurance fraud in California.

Abandoning or Damaging Your Car: When you leave your car somewhere or use other methods to dispose of your vehicle, you are committing auto insurance fraud. The same goes if you are burning your car, dumping it in the river, or developing other ways to damage your property.

Providing Insurance Agency with False Information: If you’re giving the insurance company the wrong registration information, you are committing auto insurance fraud. Insurance companies base the price of premiums on location, and if you are scheming to avoid paying higher premiums for your own personal financial gain, you are defrauding your insurance company. In the end, you are cheating yourself and other members of the general public.

Filing Multiple Claims for the Same Car Accident: You are committing auto insurance fraud by making more than one claim to the same insurance agency or filing claims with different agencies with hopes of recovering financially.

Filing False Auto Insurance Claims: If you are faking auto accidents or even exaggerating an incident so you can file a false auto claim, you are defrauding an insurance company. As a result, you are committing auto insurance fraud and could face charges.

October 30, 2015

Fraud Case Alleges Hundreds of Surgeries By Non-Doctor

by David M. Boertje

An orthopedic surgeon, his lawyer, another doctor, and 12 other defendants (15 in total) have been charged in a California health-care fraud conspiracy in Los Angeles. This past Thursday, Los Angeles county prosecutors handed down indictments for Dr. Munir Uwaydah and the associates who helped cover his illicit activity. The conspiracy ring is alleged to have prescribed unnecessary expensive medications, billed two-minute doctor’s appointments as hour-long examinations, and doctored MRI results and medical records to justify unnecessary operations. It is also alleged that Dr. Uwaydah allowed his physician’s assistant, Peter Nelson, to perform surgeries at an Orange County hospital in 2005. Dr. Uwaydah’s medical license was revoked two years ago after several earlier allegations.

The conspiracy ring is estimated to have cheated insurance companies out of $150 million. It is described as one of the largest health-care schemes in state history. Uwaydah and Nelson are charged with 21 counts of aggravated mayhem — each for a different patient. The District Attorney stated that this is a vast underestimation of the hundreds of procedures that Nelson performed. Nelson is being held on a $21 million bail. The office manager, Kelly Soo Park, 49, is also being held on $18.5 million bail in the fraud case for her involvement in hiding Uwaydah’s money from investigators.

Health Care Fraud in California