Medi-Cal Fraud: Who Can Be Charged?

 “Medi-Cal fraud” is fraud that is committed in connection with California's Medi-Cal program.

Medi-Cal is a state program that provides free or low-cost health coverage to children and adults with limited income and assets.1 Medi-Cal fraud has elements of both health care fraud and California welfare fraud.

Acts by individuals that can lead to California Medi-Cal fraud charges include:

  • Receiving Medi-Cal benefits for which you are not eligible based on false declarations, or making false declarations about another person's eligibility for Medi-Cal;2
  • Knowingly making a false or fraudulent claim for payment of a Medi-Cal benefit; and
  • Knowingly submitting a claim for a Medi-Cal benefit that was not actually used by the claimant.3

And health care providers (usually doctors) may be charged with Medi-Cal fraud for doing any of the following:

  • Presenting any false or fraudulent claim to the Medi-Cal program for furnishing services or merchandise, with intent to defraud;
  • Knowingly submitting false information for the purpose of obtaining greater compensation than that to which they are entitled from the Medi-Cal program;
  • Knowingly submitting false information for the purpose of obtaining authorization to provide health care services to Medi-Cal patients;
  • Knowingly executing or attempting to execute a scheme to defraud the Medi-Cal program, or using fraud or false representations to obtain money or property from the Medi-Cal program;4 or
  • Soliciting, receiving, offering or giving any commercial bribe or kickback in return for referrals for services or purchasing of goods covered by Medi-Cal.5

Examples

Here are some examples of situations that could give rise to Medi-Cal fraud charges:

  • A man applies for Medi-Cal benefits. On the application he does not mention tens of thousands of dollars that he earns every year from doing handyman work under the table.
  • A dentist performs unnecessary tooth extractions on Medi-Cal patients and bills Medi-Cal for the cost.
  • A Medi-Cal recipient submits false receipts for reimbursement, for medicines s/he did not actually buy or use.
Medi_calfraud_dr-optimized
Both medical professionals (doctors) and Medi-Cal recipients may be accused of Medi-Cal fraud.

Penalties

Most forms of Medi-Cal fraud are California wobblers. This means that they may be charged as either misdemeanors or felonies in California law.6

The potential felony prison sentence for most forms of Medi-Cal fraud is anywhere from sixteen (16) months to five (5) years. Felony fines can go up to fifty thousand dollars ($50,000), or double or triple the amount of the fraud.7

In most cases, Medi-Cal fraud as a misdemeanor carries a potential county jail sentence of up to one (1) year.8

Legal defenses

If you are charged with Medi-Cal fraud in California, you may be able to get the charges reduced or dismissed by arguing one of the following common legal defenses:

  • You did not act knowingly or with fraudulent intent; and/or
  • There is insufficient evidence to support the charges.

In this article, our California insurance fraud defense attorneys9 explain the following:

1. Legal Definition of Medi-Cal Fraud in California

1.1. Welfare & Institutions Code 14014
1.2. Welfare & Institutions Code 14107
1.3. Welfare & Institutions Code 14107.2
1.4. Penal Code 550 PC

2. Penalties for Medi-Cal Fraud in California

2.1. Welfare & Institutions Code 14014 penalties
2.2. Welfare & Institutions Code 14107 penalties
2.3. Welfare & Institutions Code 14107.2 penalties
2.4. Penal Code 550 Penalties
2.5. Medi-Cal fraud and professional discipline in California

3. Legal Defenses to Medi-Cal Fraud Charges

4. Related Offenses to Medi-Cal Fraud

4.1. Elder abuse
4.2. Forgery
4.3. Perjury

If, after reading this article, you would like more information, we invite you to contact us at Shouse Law Group.

1. Legal Definition of Medi-Cal Fraud in California

Simply put, Medi-Cal fraud is any instance of California insurance fraud that has California's Medi-Cal program as a “victim.”

Medi_calfraud_medproceduresyringe-optimized
Medi-Cal fraud is a blanket term that refers to a variety of forms of fraud.

Medi-Cal is a program of free or low-cost health coverage for Californians. Groups that may receive Medi-Cal benefits include:

  • Low-income adults;
  • Families with children;
  • Seniors;
  • People with disabilities;
  • Children in foster care; and
  • Pregnant women.10

Medi-Cal fraud can be prosecuted under several different California statutes. These include:

1.1. Welfare & Institutions Code 14014

Welfare & Institutions Code 14014 prohibits the following forms of Medi-Cal fraud:

  1. Receiving Medi-Cal benefits for which you were not eligible based on false declarations about your eligibility; and
  2. Making false declarations as to the eligibility of any other person who receives Medi-Cal benefits for which s/he was not eligible.11

Example: Carla, a single mother, moves to California with her teenage son Jacob, who has autism.

Carla wants Jacob to receive Medi-Cal benefits to cover his extensive therapy. She applies for Medi-Cal for Jacob and reports only her own small income from her job as a waitress.

But Jacob actually is the beneficiary of a large trust fund that was left behind by his grandmother when she died. Jacob receives thousands of dollars a month from that fund—which Carla does not mention on the Medi-Cal application.

Jacob is approved as eligible for Medi-Cal. The program covers the cost of his therapy for several years.

Carla is guilty of Medi-Cal fraud for making false declarations, as a result of which Jacob received benefits he should not have received.

Medi_calfraud_medicaidapplication-optimized
It is a form of Medi-Cal fraud to lie on a Medi-Cal application--but only if you wrongfully receive benefits as a result.

It is important to note that you cannot be prosecuted under Welfare & Institutions Code 14014 merely for making false declarations on a Medi-Cal application. This Medi-Cal fraud law only applies if:

  1. You (or someone else) receive benefits as a result of the false declarations; and
  2. You (or the other person) actually were not eligible for those benefits.12

Example: Rose is not married, but she is living with her boyfriend, whose name is Joe. Rose and Joe have two children together, and they share a lease for an apartment.

Rose, who is unemployed, applies for Medi-Cal benefits, claiming she has no income and no assets. She does not mention Joe's income (he works part-time at a factory).

Rose has made false declarations on a Medi-Cal application. However, it turns out that Joe's income is low enough that she would have qualified for Medi-Cal anyway.

Therefore, she is not guilty under WIC 14014. (But she may be guilty of California perjury for lying on the application.)13

1.2. Welfare & Institutions Code 14107

Welfare & Institutions Code 14107 focuses on Medi-Cal fraud committed by medical practitioners (such as doctors, psychotherapists, physical therapists, pharmacists, etc.).

This Medi-Cal fraud statute makes it a crime to do any of the following:

  • Present for payment any false or fraudulent claim for furnishing services or merchandise covered by Medi-Cal, with intent to defraud;
  • Knowingly submit false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled under Medi-Cal;
  • Knowingly submit false information for the purpose of obtaining authorization to provide health care services or merchandise to Medi-Cal patients; or
  • Knowingly and willfully execute a scheme or artifice either to: 1) defraud the Medi-Cal program, or 2) use false or fraudulent pretenses to obtain money or property owned or controlled by the Medi-Cal program, in connection with the delivery of or payment for health care services or goods.14

Example: Samantha is a doctor who is authorized as a Medi-Cal provider. She employs Michael, an unlicensed medical assistant, to work in her office.

Samantha frequently lets Michael diagnose and treat patients when she is out of the office or on vacation. She leaves pre-signed prescription forms at the office, and Michael uses them to write prescriptions for patients.

Samantha then bills Medi-Cal for the cost of a visit with her (a physician) rather than for the cost of a visit with an assistant.

Samantha is guilty of Medi-Cal fraud, for submitting false information in order to get paid at a higher rate by Medi-Cal than she should.15

1.3. Welfare & Institutions Code 14107.2
Medi_calfraud_drprescription-optimized
Bribery and kickbacks by medical service providers can be a form of Medi-Cal fraud.

Welfare & Institutions Code 14107.2 Medi-Cal fraud is also usually charged against providers of medical services or supplies.

This law makes it a crime to offer, pay, solicit or receive any sort of renumeration (such as kickbacks, bribes or rebates) either:

  1. To refer a patient to a service provider for medical services covered under Medi-Cal; or
  2. To purchase, lease or order any goods, services or merchandise covered under Medi-Cal.16

Example: Isabel is a dentist. She treats a large number of patients who pay with Medi-Cal.

Isabel is friends with Martin, who distributes a special “extra-fluoride” toothpaste. Martin promises to pay Isabel 30% of the price of each tube of this toothpaste that she prescribes to her patients.

So Isabel prescribes this toothpaste to many of her patients, including those who have no particular need for it. Martin sells them the toothpaste, which is paid for by Medicare, and Martin and Isabel share the profits from the sales.

Both Martin and Isabel are guilt of Medi-Cal fraud under WIC 14107.2.

1.4. Penal Code 550 PC

Medi-Cal fraud could also be prosecuted under Penal Code 550 PC, a more general insurance fraud law. This statute makes it a crime to do any of the following:

  • Knowingly make or cause to be made any false or fraudulent claim for payment of a Medi-Cal benefit; or
  • Knowingly submit a claim for a Medi-Cal benefit that was not used by the claimant.17

This form of Medi-Cal fraud can be committed by either Medi-Cal recipients or Medi-Cal providers (doctors, etc.).

Example: Eli is a physical therapist who treats several Medi-Cal patients who suffer from chronic illness.

Eli works out a scheme with Rachel, one of his Medi-Cal patients whom he sees monthly. He and Rachel will claim to Medi-Cal that she actually visits him weekly. Eli will collect the extra payments from Medi-Cal and will give one-third of the money to Rachel, as long as she agrees to back up his story about the weekly visits.

Rachel and Eli could both be prosecuted under California Penal Code 550, for knowingly submitting claims for Medi-Cal benefits that were not used by the patient.

Medi_calfraud_medprocedureskinprick-optimized
Billing unnecessary medical procedures to Medi-Cal is one form of Medi-Cal fraud.

2. Penalties for Medi-Cal Fraud in California

The penalties for Medi-Cal fraud depend on:

  1. The specific statute the defendant is alleged to have violated; and
  2. In many cases, the amount of money alleged to have been involved in the fraud.
2.1. Welfare & Institutions Code 14014 penalties

Medi-Cal fraud under Welfare & Institutions Code 14014 is punished in the same way as either petty theft or grand theft in California law.18

Fraud worth $950 or less

This means that, if the amount of benefits paid by Medi-Cal due to the defendant's fraud was nine hundred fifty dollars ($950) or less, the defendant will be charged with WIC 14014 Medi-Cal fraud as a misdemeanor.19

The potential penalties in this case will be;

Fraud worth more than $950

But if the amount of benefits fraudulently obtained is alleged to be more than nine hundred fifty dollars ($950), then this form of Medi-Cal fraud becomes a wobbler. This means it is a crime that may be charged as either a misdemeanor or a felony, depending on:

  • The circumstances of the charges; and
  • The defendant's criminal history.21
Gavel_money_bail-optimized
The penalties for some forms of Medi-Cal fraud depend on the amount of money involved.

Charged as a misdemeanor, wobbler Medi-Cal fraud under WIC 14014 carries the same penalties just described—except the maximum jail sentence rises to one (1) year.22

But when it is charged as a felony, the potential penalties are:

  • Felony (formal) probation;
  • Sixteen (16) months, two (2) years or three (3) years served in county jail under California's realignment program;
  • A fine of up to ten thousand dollars ($10,00); and/or
  • Repayment of any fraudulently-received benefits to the California Department of Health Care Services.23
2.2. Welfare & Institutions Code 14107 penalties

Medi-Cal fraud by medical providers under Welfare & Institutions Code 14107 is also a California wobbler.24

When it is charged as a misdemeanor, the potential penalties are:

  • Misdemeanor probation;
  • Up to one (1) year in county jail; and/or
  • A fine of up to three (3) times the amount of the fraud or improper reimbursement.25

When WIC 14107 Medi-Cal fraud is charged as a felony, the penalties are:

  • Felony probation;
  • Two (2), three (3) or five (5) years in California state prison; and/or
  • A fine of up to three (3) times the amount of the fraud or improper reimbursement.26

Sentence enhancements

The sentence for WIC 14107 Medi-Cal fraud increases under certain circumstances.

Medi_calfraud_gbiwheelchair-optimized
WIC 14107 Medi-Cal fraud is punished more harshly if it causes great or serious bodily injury.

If you are charged with this crime for participating in a scheme to defraud Medi-Cal, and that scheme is committed under circumstances likely to cause or that do cause great bodily injury or serious bodily injury to two (2) or more people—then you will face an additional four (4) years in prison for every person who suffers great bodily injury or serious bodily injury as a result.27

Example : Let's return to Samantha, the doctor from our example above. Samantha regularly lets her unlicensed assistant Michael treat her Medi-Cal patients, and then bills Medi-Cal for the amount it would have cost for a visit with her personally.

One of Samantha's patients, Juan, comes to her office with a broken ankle. Michael incorrectly diagnoses it as a sprain and sends Juan home with painkillers and instructions to rest.

Because the broken ankle is not re-set, it heals improperly—and Juan is left with permanent limitations on his ability to engage in certain physical activities.

Samantha is charged with Medi-Cal fraud under WIC 14107 as a felony. She receives a base sentence of 5 years in prison.

But Samantha's scheme to defraud Medi-Cal left Juan with a serious bodily injury—and was likely to cause serious bodily injury to at least 2 people, given the dangers of allowing an unlicensed assistant to treat patients.

So she receives an additional sentence of 4 years. This brings her total sentence to 9 years in prison.

Medi-Cal fraud and the felony-murder rule

In some cases, Medi-Cal fraud defendants who are medical providers can even be charged with California murder.28

Specifically, if you accidentally kill someone while committing WIC 14107 Medi-Cal fraud in an inherently dangerous way, you could be guilty of second-degree murder under California's “felony-murder rule."29

Second-degree murder is punishable by fifteen (15) years to life in state prison.30

2.3. Welfare & Institutions Code 14107.2 penalties

WIC 14017.2 (bribes or kickbacks for referrals of Medi-Cal business) is a wobbler for a first offense. But if you have a prior conviction for this form of Medi-Cal fraud, then it will always be a felony.31

It carries a potential county jail sentence of one (1) year if charged as a misdemeanor, and a potential county jail sentence of sixteen (16) months, two (2) years or three (3) years if charged as a felony.32

2.4. Penal Code 550 Penalties

Medi-Cal fraud under Penal Code 550 is also a wobbler. The potential misdemeanor penalties under this law are:

  • Misdemeanor probation;
  • Up to one (1) year in county jail; and/or
  • A fine of up to ten thousand dollars ($10,000).33
Medi_calfraud_dentistexam-optimized
Dentists are one of the groups of medical professionals who are regularly charged with Medi-Cal fraud.

And the felony penalties for this form of Medi-Cal fraud include:

  • Felony probation;
  • Two (2), three (3) or five (5) years in county jail; and/or
  • A fine of up to fifty thousand dollars ($50,000) or double the amount of the fraud, whichever is greater.34

The exception is if the total amount of the fraud is nine hundred fifty dollars ($950) or less (this includes the aggregate of multiple claims over a period of twelve (12) consecutive months).

In that case, PC 550 Medi-Cal fraud is always a misdemeanor. The potential penalties are up to six (6) months in county jail, and/or a fine of up to one thousand dollars ($1,000).35

2.5. Medi-Cal fraud and professional discipline in California

California doctors, nurses and pharmacists who are accused of being involved in Medi-Cal fraud also need to be concerned about professional discipline.

For California doctors, any criminal conviction for an offense that is “substantially related” to the qualifications, functions, or duties of a physician can trigger doctor discipline, including potentially the loss of their medical license.36 Medi-Cal fraud certainly can be deemed to fall into this category.

Nurses can also face nurse discipline and license revocation (in some cases) as a result of a Medi-Cal fraud conviction.37

Pharmacists are yet another group of medical professionals that need to worry about the effect of a Medi-Cal fraud conviction on their professional license.38

3. Legal Defenses to Medi-Cal Fraud Charges

Medi-Cal is a taxpayer-funded program that consumes a large share of the California state budget. And, nationally, between 3% and 10% of state-funded health care programs' budgets are lost to fraud.39

This explains why the California Office of the Attorney General is very motivated to investigate and prosecute Medi-Cal fraud cases. In fact, the Attorney General has established a specialized Bureau of Medi-Cal Fraud and Elder Abuse.

But as San Bernardino criminal defense attorney Michael Scafiddi40 puts it:

“Of course, this kind of vigilant—and often politically-motivated—law enforcement has an unfortunate side effect: it can lead to innocent people being wrongfully accused.”

If you are charged with California Medi-Cal fraud, you and your criminal defense attorney may want to consider the following legal defenses:

Medi_calfraud_benefitfraud-optimized
Concern about potential losses to taxpayers makes Medi-Cal fraud prosecutions a hot political issue.

You did not act with knowledge or fraudulent intent

You are not guilty of Medi-Cal fraud unless you acted with either:

  • Knowledge that a particular statement or behavior was false or fraudulent; or
  • Fraudulent intent.41

Many times a careless mistake on your part will be flagged as potential fraud by someone involved in California Medi-Cal fraud enforcement.

But the burden is on the prosecution to prove, beyond a reasonable doubt, that you knew you were submitting a false or fraudulent statement, and did not simply make a mistake.

A skilled criminal defense attorney may be able to cast enough doubt on this assertion to lead to charges being dropped—or a not-guilty verdict in a jury trial.

There is insufficient evidence that you committed Medi-Cal fraud

It is not uncommon for Medi-Cal fraud cases to revolve around a highly complex set of facts, which could include:

  • Arcane details of a defendant's personal finances;
  • Highly technical and sometimes conflicting medical diagnoses; and/or
  • Scientific evidence about various medical conditions and the treatments for them.

Prosecutors may try to take advantage of this complexity and ambiguity to convict someone unjustly. So you need a good criminal defense attorney on your side—someone who understands the technicalities involved and can help present them clearly to a jury.

4. Related Offenses to Medi-Cal Fraud

Other California offenses that may be charged along with or instead of Medi-Cal fraud include:

4.1. Elder abuse

Penal Code 368 PC, California's elder abuse law, makes it a crime to willfully or negligently impose unjustifiable physical pain and/or mental suffering on a person who is 65 or older.42

This offense is a wobbler, carrying a potential state prison sentence of two (2), three (3) or (4) years, and a fine of up to six thousand dollars ($6,000), if it is charged as a felony.43

Img-elder-abuse-wheelchair-optimized
Medi-Cal prosecutions sometimes involve allegations of elder abuse as well.

It is common for Medi-Cal fraud cases to involve nursing homes, or agencies providing in-home care for the elderly, which serve a large number of Medi-Cal recipients.

If a nursing home bills Medi-Cal for care by doctors or licensed nurses, while instead providing care by unlicensed assistants, and an elderly patient is injured while under their care—then the prosecutor may build a case against the home's owners or managers for both Medi-Cal fraud and elder abuse.

4.2. Forgery

Penal Code 470 PC California forgery is the act of doing any of the following with intent to commit a fraud:

  • Signing someone else's name;
  • Faking a seal or someone else's handwriting;
  • Changing or falsifying a legal document; or
  • Faking, altering or presenting as genuine a false financial document.44

So, for example, if you fake a doctor's signature on a report about an injury and use that report to obtain Medi-Cal reimbursement, you may be charged with both Medi-Cal fraud and forgery.

Forgery is a wobbler and carries the same potential sentence as grand theft.45

4.3. Perjury

You commit Penal Code 118 PC perjury when you deliberately give false information while under oath.46

You could be charged with both perjury and Medi-Cal fraud in a variety of situations—for example, if you deliberately misstate your income or assets on a Medi-Cal application.

Perjury is always a felony and carries a potential sentence of two (2), three (3) or four (4) years.47

Call us for help…

Help-support-call-us

For questions about California's Medi-Cal fraud laws, or to discuss your case confidentially with one of our California criminal defense attorneys, do not hesitate to contact us at Shouse Law Group.

We have local criminal law offices in and around Los Angeles, San Diego, Orange County, Riverside, San Bernardino, Ventura, San Jose, Oakland, the San Francisco Bay area, and several nearby cities.

For more information on Nevada “health care fraud” laws, please see our page on Nevada “health care fraud” laws.

Additional Resources:

California Office of the Attorney General: Medi-Cal Fraud Complaint Form

California Department of Health Care Services: Medi-Cal Eligibility and Enrollment

Legal References:


1 See Medi-Cal Overview, Covered California website.

2 Welfare & Institutions Code 14014 – False declarations as to eligibility; willful and knowing encouragement to make false declarations; penalties; implementation [form of Medi-Cal fraud]. (“(a) Any person receiving health care for which he or she was not eligible on the basis of false declarations as to his or her eligibility or any person making false declarations as to eligibility on behalf of any other person receiving health care for which that other person was not eligible shall be liable for repayment and shall be guilty of a misdemeanor or felony depending on the amount paid on his or her behalf for which he or she was not eligible, as specified in Section 487 of the Penal Code.”)

See also Penal Code 487 PC – “Grand theft” defined [relevant to penalties for Medi-Cal fraud]. (“Grand theft is theft committed in any of the following cases: (a) When the money, labor, or real or personal property taken is of a value exceeding nine hundred fifty dollars ($950), except as provided in subdivision (b).”)

See also Penal Code 489 PC – Grand theft; punishment [applies to penalties for Medi-Cal fraud]. (“Grand theft is punishable as follows: . . . (c) In all other cases, by imprisonment in a county jail not exceeding one year or pursuant to subdivision (h) of Section 1170.”)

See also Penal Code 490 PC— Petty theft; punishment [applies to penalties for Medi-Cal fraud]. (“Petty theft is punishable by fine not exceeding one thousand dollars ($1,000), or by imprisonment in the county jail not exceeding six months, or both.”)

3 Penal Code 550 PC – False or fraudulent claims or statements [including in connection with Medi-Cal]; prohibited acts. (“(a) It is unlawful to do any of the following, or to aid, abet, solicit, or conspire with any person to do any of the following: . . . (6) Knowingly make or cause to be made any false or fraudulent claim for payment of a health care benefit. (7) Knowingly submit a claim for a health care benefit that was not used by, or on behalf of, the claimant. (8) Knowingly present multiple claims for payment of the same health care benefit with an intent to defraud. (9) Knowingly present for payment any undercharges for health care benefits on behalf of a specific claimant unless any known overcharges for health care benefits for that claimant are presented for reconciliation at that same time. . . . (c) . . . (2) Every person who violates paragraph (6), (7), (8), or (9) of subdivision (a) is guilty of a public offense. (A) When the claim or amount at issue exceeds nine hundred fifty dollars ($950), the offense is punishable by imprisonment pursuant to subdivision (h) of Section 1170 for two, three, or five years, or by a fine not exceeding fifty thousand dollars ($50,000) or double the amount of the fraud, whichever is greater, or by both that imprisonment and fine, or by imprisonment in a county jail not to exceed one year, by a fine of not more than ten thousand dollars ($10,000), or by both that imprisonment and fine. (B) When the claim or amount at issue is nine hundred fifty dollars ($950) or less, the offense is punishable by imprisonment in a county jail not to exceed six months, or by a fine of not more than one thousand dollars ($1,000), or by both that imprisonment and fine, unless the aggregate amount of the claims or amount at issue exceeds nine hundred fifty dollars ($950) in any 12-consecutive-month period, in which case the claims or amounts may be charged as in subparagraph (A). . . . (4) Restitution shall be ordered for a person convicted of violating this section, including restitution for any medical evaluation or treatment services obtained or provided. The court shall determine the amount of restitution and the person or persons to whom the restitution shall be paid. (d) Notwithstanding any other provision of law, probation shall not be granted to, nor shall the execution or imposition of a sentence be suspended for, any adult person convicted of felony violations of this section who previously has been convicted of felony violations of this section or Section 548, or of Section 1871.4 of the Insurance Code, or former Section 556 of the Insurance Code, or former Section 1871.1 of the Insurance Code as an adult under charges separately brought and tried two or more times. The existence of any fact that would make a person ineligible for probation under this subdivision shall be alleged in the information or indictment, and either admitted by the defendant in an open court, or found to be true by the jury trying the issue of guilt or by the court where guilt is established by plea of guilty or nolo contendere or by trial by the court sitting without a jury. Except when the existence of the fact was not admitted or found to be true or the court finds that a prior felony conviction was invalid, the court shall not strike or dismiss any prior felony convictions alleged in the information or indictment. This subdivision does not prohibit the adjournment of criminal proceedings pursuant to Division 3 (commencing with Section 3000) or Division 6 (commencing with Section 6000) of the Welfare and Institutions Code. (e) Except as otherwise provided in subdivision (f), any person who violates subdivision (a) or (b) and who has a prior felony conviction of an offense set forth in either subdivision (a) or (b), in Section 548, in Section 1871.4 of the Insurance Code, in former Section 556 of the Insurance Code, or in former Section 1871.1 of the Insurance Code shall receive a two-year enhancement for each prior felony conviction in addition to the sentence provided in subdivision (c). The existence of any fact that would subject a person to a penalty enhancement shall be alleged in the information or indictment and either admitted by the defendant in open court, or found to be true by the jury trying the issue of guilt or by the court where guilt is established by plea of guilty or nolo contendere or by trial by the court sitting without a jury. Any person who violates this section shall be subject to appropriate orders of restitution pursuant to Section 13967 of the Government Code.”)

4 Welfare & Institutions Code 14107 – Fraudulent claims; intent; punishment; other enforcement remedies [Medi-Cal fraud by health care providers]. (“(a) Any person, including any applicant or provider as defined in Section 14043.1, or billing agent, as defined in Section 14040.1, who engages in any of the activities identified in subdivision (b) is punishable by imprisonment as set forth in subdivisions (c), (d), and (e), by a fine not exceeding three times the amount of the fraud or improper reimbursement or value of the scheme or artifice, or by both this fine and imprisonment. (b) The following activities are subject to subdivision (a): (1) A person, with intent to defraud, presents for allowance or payment any false or fraudulent claim for furnishing services or merchandise under this chapter or Chapter 8 (commencing with Section 14200). (2) A person knowingly submits false information for the purpose of obtaining greater compensation than that to which he or she is legally entitled for furnishing services or merchandise under this chapter or Chapter 8 (commencing with Section 14200). (3) A person knowingly submits false information for the purpose of obtaining authorization for furnishing services or merchandise under this chapter or Chapter 8 (commencing with Section 14200). (4) A person knowingly and willfully executes, or attempts to execute, a scheme or artifice to do either of the following: (A) Defraud the Medi-Cal program or any other health care program administered by the department or its agents or contractors. (B) Obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, the Medi-Cal program or any other health care program administered by the department or its agents or contractors, in connection with the delivery of or payment for health care benefits, services, goods, supplies, or merchandise. (c) A violation of subdivision (a) is punishable by imprisonment in a county jail, or in the state prison for two, three, or five years. (d) If the execution of a scheme or artifice to defraud as defined in paragraph (4) of subdivision (b) is committed under circumstances likely to cause or that do cause two or more persons great bodily injury, as defined in Section 12022.7 of the Penal Code, or serious bodily injury, as defined in paragraph (4) of subdivision (f) of Section 243 of the Penal Code, a term of four years, in addition and consecutive to the term of imprisonment imposed in subdivision (c), shall be imposed for each person who suffers great bodily injury or serious bodily injury. The additional terms provided in this subdivision shall not be imposed unless the facts showing the circumstances that were likely to cause or that did cause great bodily injury or serious bodily injury to two or more persons are charged in the accusatory pleading and admitted or found to be true by the trier of fact. (e) If the execution of a scheme or artifice to defraud, as defined in paragraph (4) of subdivision (b) results in a death which constitutes a second degree murder, as defined in Section 189 of the Penal Code, the offense shall be punishable, upon conviction, pursuant to subdivision (a) of Section 190 of the Penal Code. (f) Any person, including an applicant or provider as defined in Section 14043.1, or billing agent, as defined in Section 14040.1, who has engaged in any of the activities subject to fine or imprisonment under this section, shall be subject to the asset forfeiture provisions for criminal profiteering. (g) Pursuant to Section 923 of the Penal Code, the Attorney General may convene a grand jury to investigate and indict for any of the activities subject to fine, imprisonment, or asset forfeiture under this section. (h) The enforcement remedies provided under this section are not exclusive and shall not preclude the use of any other criminal or civil remedy. However, an act or omission punishable in different ways by this section and other provisions of law shall not be punished under more than one provision, but the penalty to be imposed shall be determined as set forth in Section 654 of the Penal Code.”)

5 Welfare & Institutions Code 14107.2 – Kickbacks, bribes or rebates; punishment [form of Medi-Cal fraud]. (“(a) Any person who solicits or receives any remuneration, including, but not restricted to, any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in valuable consideration of any kind, either: (1) In return for the referral, or promised referral, of any individual to a person for the furnishing or arranging for the furnishing of any service or merchandise for which payment may be made, in whole or in part, under this chapter or Chapter 8 (commencing with Section 14200); or (2) In return for the purchasing, leasing, ordering, or arranging for or recommending the purchasing, leasing, or ordering of any goods, facility, service or merchandise for which payment may be made, in whole or in part, under this chapter or Chapter 8 (commencing with Section 14200), is punishable upon a first conviction by imprisonment in a county jail for not longer than one year or imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code, or by a fine not exceeding ten thousand dollars ($10,000), or by both that imprisonment and fine. A second or subsequent conviction shall be punishable by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code. (b) Any person who offers or pays any remuneration, including, but not restricted to, any kickback, bribe, or rebate, directly or indirectly, overtly or covertly, in cash or in valuable consideration of any kind, either: (1) To refer any individual to a person for the furnishing or arranging for furnishing of any service or merchandise for which payment may be made, in whole or in part, under this chapter or Chapter 8 (commencing with Section 14200); or (2) To purchase, lease, order, or arrange for or recommend the purchasing, leasing, or ordering of any goods, facility, service, or merchandise for which payment may be made, in whole or in part, under this chapter or Chapter 8 (commencing with Section 14200), is punishable upon a first conviction by imprisonment in a county jail for not longer than one year or pursuant to subdivision (h) of Section 1170 of the Penal Code, or by a fine not exceeding ten thousand dollars ($10,000), or by both that imprisonment and fine. A second or subsequent conviction shall be punishable by imprisonment pursuant to subdivision (h) of Section 1170 of the Penal Code.”)

6 See endnotes 2-5, above.

7 Same.

8 Same.

9 Our California insurance fraud defense attorneys have local Los Angeles law offices in Beverly Hills, Burbank, Glendale, Lancaster, Long Beach, Los Angeles, Pasadena, Pomona, Torrance, Van Nuys, West Covina, and Whittier. We have additional law offices conveniently located throughout the state in Orange County, San Diego, Riverside, San Bernardino, Ventura, San Jose, Oakland, the San Francisco Bay area, and several nearby cities.

10 See Medi-Cal Overview, Covered California website.

11 Welfare & Institutions Code 14014 – False declarations as to eligibility; willful and knowing encouragement to make false declarations; penalties; implementation [form of Medi-Cal fraud], endnote 2, above.

12 People v. Dixon (1975) 46 Cal.App.3d 431, 434. (“Expressed another way, proof of two factors is requisite to establish the offense [Medi-Cal fraud under Welfare & Institutions Code 14014]: (1) the false declarations, and (2) the receipt of ineligible health care. At bench, only the first of these factors was proved, for it was never shown that Dixon received health care for which she was not eligible.”)

13 Based on the facts of the same.

14 Welfare & Institutions Code 14107 – Fraudulent claims; intent; punishment; other enforcement remedies [Medi-Cal fraud by health care providers], endnote 4, above.

15 Based on the facts of People v. Drake (1996) 42 Cal.App.4th 592.

16 Welfare & Institutions Code 14107.2 – Kickbacks, bribes or rebates; punishment [form of Medi-Cal fraud], endnote 5, above.

17 Penal Code 550 PC – False or fraudulent claims or statements [including in connection with Medi-Cal]; prohibited acts, endnote 3, above.

18 Welfare & Institutions Code 14014 – False declarations as to eligibility; willful and knowing encouragement to make false declarations; penalties; implementation [form of Medi-Cal fraud], endnote 2, above.

19 Same.

See also Penal Code 487 PC – “Grand theft” defined [relevant to penalties for Medi-Cal fraud], endnote 2, above.

See also Penal Code 488 PC – Petty theft defined. (“Theft in other cases is petty theft.”)

20 Same.

See also Penal Code 490 PC— Petty theft; punishment [applies to penalties for Medi-Cal fraud], endnote 2, above.

21 Welfare & Institutions Code 14014 – False declarations as to eligibility; willful and knowing encouragement to make false declarations; penalties; implementation [form of Medi-Cal fraud], endnote 2, above.

See also Penal Code 489 PC – Grand theft; punishment [applies to penalties for Medi-Cal fraud], endnote , above.

22 Same.

23 Same.

See also Penal Code 672 PC – Offenses for which no fine prescribed; fine authorized in addition to imprisonment. (“Upon a conviction for any crime punishable by imprisonment in any jail or prison, in relation to which no fine is herein prescribed, the court may impose a fine on the offender not exceeding one thousand dollars ($1,000) in cases of misdemeanors or ten thousand dollars ($10,000) in cases of felonies [such as felony Medi-Cal fraud] in addition to the imprisonment prescribed.”)

24 Welfare & Institutions Code 14107 – Fraudulent claims; intent; punishment; other enforcement remedies [Medi-Cal fraud by health care providers], endnote 4, above.

25 Same.

26 Same.

27 Same.

28 Welfare & Institutions Code 14107 – Fraudulent claims; intent; punishment; other enforcement remedies [Medi-Cal fraud by health care providers]. (“(e) If the execution of a scheme or artifice to defraud, as defined in paragraph (4) of subdivision (b) results in a death which constitutes a second degree murder, as defined in Section 189 of the Penal Code, the offense shall be punishable, upon conviction, pursuant to subdivision (a) of Section 190 of the Penal Code.”)

See also Penal Code 189 PC – Murder; degrees.

29 CALCRIM 541A – Felony Murder: Second Degree—Defendant Allegedly Committed Fatal Act. (“The defendant is charged [in Count ] with murder, under a theory of felony murder. To prove that the defendant is guilty of second degree murder under this theory, the People must prove that: 1 The defendant committed [or attempted to commit] <insert inherently dangerous felony or felonies> [including forms of Medi-Cal fraud]; 2 The defendant intended to commit <insert inherently dangerous felony or felonies>; AND 3 The defendant did an act that caused the death of another person.”)

30 Penal Code 190 PC -- Punishment for violating California's murder laws [including by accidentally killing someone while committing Medi-Cal fraud]. ("(a) Except as provided in subdivision (b), (c), or (d), every person guilty of murder in the second degree shall be punished by imprisonment in the state prison for a term of 15 years to life.")

31 Welfare & Institutions Code 14107.2 – Kickbacks, bribes or rebates; punishment [form of Medi-Cal fraud], endnote 5, above.

32 Same.

33 Penal Code 550 PC – False or fraudulent claims or statements [including in connection with Medi-Cal]; prohibited acts, endnote 3, above.

34 Same.

35 Same.

36 See Business & Professions Code 2236 – Criminal convictions and doctor discipline [may apply to doctors convicted of Medi-Cal fraud].

37 See Business & Professions Code 2761 – Criminal convictions and nurse discipline [may apply to nurses convicted of Medi-Cal fraud].

38 See Business & Professions Code 4301 – Criminal convictions and pharmacist discipline [may apply to pharmacists convicted of Medi-Cal fraud].

39 See Medi-Cal Fraud, California Department of Justice, Office of the Attorney General, Bureau of Medi-Cal Fraud and Elder Abuse website.

40 San Bernardino criminal defense attorney Michael Scafiddi is a former police officer who now uses that inside knowledge to help defend clients accused of violating California criminal fraud laws. He practices criminal defense primarily in San Bernardino and Riverside Counties, and makes appearances at the Murrieta Southwest Justice Center and in Banning, Fontana, Joshua Tree, Barstow, and Victorville.

41 See Welfare & Institutions Code 14014 – False declarations as to eligibility; willful and knowing encouragement to make false declarations; penalties; implementation [form of Medi-Cal fraud], endnote 2, above; Welfare & Institutions Code 14107 – Fraudulent claims; intent; punishment; other enforcement remedies [Medi-Cal fraud by health care providers], endnote 4, above; Penal Code 550 PC – False or fraudulent claims or statements [including in connection with Medi-Cal]; prohibited acts, endnote 3, above.

See also Judicial Council of California Criminal Jury Instructions (“CALCRIM”) 2000 – Insurance Fraud [including Medi-Cal fraud]: Fraudulent Claims (Pen. Code, § 550(a)(1), (4)-(7) & (9)) (specifying intent to defraud as an element of insurance fraud under Penal Code 550).

42 Penal Code 368 PC – Elder abuse [may be charged along with Medi-Cal fraud]. (“(b)(1) Any person who knows or reasonably should know that a person is an elder or dependent adult and who, under circumstances or conditions likely to produce great bodily harm or death, willfully causes or permits any elder or dependent adult to suffer, or inflicts thereon unjustifiable physical pain or mental suffering, or having the care or custody of any elder or dependent adult, willfully causes or permits the person or health of the elder or dependent adult to be injured, or willfully causes or permits the elder or dependent adult to be placed in a situation in which his or her person or health is endangered, is punishable by imprisonment in a county jail not exceeding one year, or by a fine not to exceed six thousand dollars ($6,000), or by both that fine and imprisonment, or by imprisonment in the state prison for two, three, or four years.”)

43 See same.

44 Penal Code 470 PC – Forgery; signatures or seals; corruption of records [may be charged along with Medi-Cal fraud].

45 Penal Code 473 PC – Forgery; punishment. (“(a) Forgery is punishable by imprisonment in a county jail for not more than one year, or by imprisonment pursuant to subdivision (h) of Section 1170.”)

46 Penal Code 118 PC – “Perjury” defined; evidence necessary to support conviction [may be charged along with Medi-Cal fraud]. (“(a) Every person who, having taken an oath that he or she will testify, declare, depose, or certify truly before any competent tribunal, officer, or person, in any of the cases in which the oath may by law of the State of California be administered, willfully and contrary to the oath, states as true any material matter which he or she knows to be false, and every person who testifies, declares, deposes, or certifies under penalty of perjury in any of the cases in which the testimony, declarations, depositions, or certification is permitted by law of the State of California under penalty of perjury and willfully states as true any material matter which he or she knows to be false, is guilty of perjury.”)

47 Penal Code 126 PC – Punishment. (“Perjury is punishable by imprisonment pursuant to subdivision (h) of Section 1170 for two, three or four years.”)

Save

Free attorney consultations...

Our attorneys want to hear your side of the story. Contact us 24/7 to schedule a FREE consultation with a criminal defense lawyer. We may be able to get your charges reduced or even dismissed altogether. And if necessary, we will champion your case all the way to trial.

Regain peace of mind...

Our defense attorneys understand that being accused of a crime is one of the most difficult times of your life. Rely on us to zealously and discreetly protect your rights and to fight for the most favorable resolution possible.

Office Locations

Shouse Law Group has multiple locations all across California and Nevada. Click Office Locations to find out which office is right for you.

To contact us, please select your state:

Call us 24/7 (855) 396-0370