| Code Section | Description | Penalty |
|---|---|---|
| WELFARE & INSTITUTIONS CODE § 14014 (False Declaration as to Eligibility) |
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| WELFARE & INSTITUTIONS CODE § 14107 (Fraudulent Claims) |
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| WELFARE & INSTITUTIONS CODE § 14107.2(a) (Kickbacks, Bribes or Rebates - Solicitation) |
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| WELFARE & INSTITUTIONS CODE § 14107.2(b) (Kickbacks, Bribes or Rebates - Offer) |
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| PENAL CODE § 487 (Grand Theft) |
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| PENAL CODE § 550(a)(5) (False Writing) |
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| PENAL CODE § 550(a)(6) (False Health Care Benefit Claim) |
| When claim or amount at issue is $950 or less:
When claim or amount at issue exceeds $950:
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| PENAL CODE § 550(a)(7) (Claim for Unused Health Care Benefit) |
| When claim or amount at issue is $950 or less:
When claim or amount at issue exceeds $950:
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FAQs
Medi-Cal Fraud Laws (Criminal)? ›
Health Care Claims Fraud
Can you go to jail for Medi-Cal fraud? ›Misdemeanor - one year county jail and/or $10,000 fine. Felony - 2, 3, or 5 years in county jail and/or $50,000 fine or double the amount of fraud, whichever is greater.
What are the two types of Medi-Cal fraud? ›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.
What are three examples of fraud in Medi-Cal practice? ›Common Types of Health Care Fraud
- Double billing: Submitting multiple claims for the same service.
- Phantom billing: Billing for a service visit or supplies the patient never received.
- Unbundling: Submitting multiple bills for the same service.
The AKS is a criminal law that prohibits the knowing and willful payment of "remuneration" to induce or reward patient referrals or the generation of business involving any item or service payable by the Federal health care programs (e.g., drugs, supplies, or health care services for Medicare or Medicaid patients).
Who investigates Medi-Cal fraud? ›Combating fraud and abuse of the state's Medi-Cal program is a team of dedicated prosecutors, special agents and investigative auditors in the Attorney General's Division of Medi-Cal Fraud and Elder Abuse.
What are the consequences of Medi-Cal billing fraud? ›Punishments for a Health Care Fraud Conviction
If you are convicted of felony health care fraud, the penalties include: two, three, or a five-year sentence in county jail; fines up to $50,000 or double the amount of fraud; probation that includes up to one year in county jail.
A caregiver cannot submit timesheets and accept payment for work that was not done or split the pay with the person being cared for or others. The caregiver and person being cared for can be taken to court for theft and submitting a false timesheet under Penal Code §487(a) or Penal Code §72.
What is the difference between medical abuse and fraud? ›Most TRICARE providers and beneficiaries are honest. Some are not. Fraud is when someone knowingly gives false information that allows someone to get a benefit that is not allowed. Abuse is when someone knowingly take actions that result in unnecessary cost or services.
How can you protect yourself from medical fraud? ›Scammers can also steal your medical identity, which can put you in harm's way. Protect yourself by guarding your health insurance ID card, which you will receive in the mail upon selecting the health insurance plan of your choice. Treat this card as you would a credit card or your driver's license.
What are the consequences of healthcare fraud and abuse? ›
Professionals or providers convicted of health care fraud may face incarceration, civil and criminal fines and exclusion from federal health care programs.
What is a false claim in medical billing? ›FALSE BILLING. Billing for services not rendered or products not delivered. Misrepresenting services rendered or products provided (inappropriate coding); misrepresenting the nature of a patient's condition (IPPS and OPPS fraud).
What is the penalty for phantom billing in healthcare? ›Punishments for Phantom Billing
Providers caught phantom billing face serious civil and criminal penalties. These may include: False Claims Act – Triple damages plus fines of $11,000 – $22,000 per false claim. Civil monetary penalties – Fines of $5,000 – $50,000 per fraudulent item or service billed.
The Division of Medi-Cal Fraud and Elder Abuse works to investigate and prosecute those who would defraud taxpayers of millions of dollars and divert scarce health care resources from the needy.
What can a healthcare professional be considered guilty of fraud if what can be shown? ›A health care professional could be considered guilty of fraud if the intent to deceive can be shown. Fraud in healthcare refers to the intentional misrepresentation of information or actions for personal gain, such as financial gain or professional advancement.
What is Title 18 health care fraud? ›In simple terms, Title 18 of the United States Code, Section 1347 makes it a federal crime to defraud any health care benefit program or obtain, by fraudulent means, any money from a health care benefit program. Like most fraud offenses, the key element of a charge of federal health care fraud is the intent to defraud.
What is the penalty for health care fraud in California? ›If convicted of felony health care fraud, the penalties include: two, three, or five year sentence in county jail, probation with up to one year in a county jail, up to $50,000 in fines or double the amount of the fraud itself.
Is it illegal to charge Medi-Cal patients? ›This means beneficiaries cannot be charged for co-pays, co-insurance, or deductibles. This applies to both Medicare and Medi-Cal providers.
What is the difference between Medi-Cal billing fraud and abuse? ›The main difference between fraud and abuse is intent – did they do it knowingly or not? Only the authorities may be able to answer that question. Whether it is fraud or abuse, it still wastes billions of dollars every year. It needs to be reported.
Is Medi-Cal identity theft an example of fraud? ›Medical identity theft happens when someone steals your personal information and uses it to receive medical care in your name. This type of fraud can be uniquely challenging for victims to spot, and it can take a long time — plus a lot of money — to resolve it.