As a health care professional in California, you may be prepared for a medical malpractice or other type of civil claim by purchasing various types of insurance. However, you may have no fallback prepared to deal with a criminal charge.

California state statutes spell out exactly what activities constitute health care fraud, as well as the penalties that may result from a conviction.

The definition

There are four basic activities listed in California Penal Code 550(a) that refer to health care fraud:

  • Intentionally making or having someone else make a false claim in order to receive payment for a health care benefit
  • Intentionally submitting a claim for a benefit that the claimant did not use
  • Intentionally presenting more than one claim in order to receive multiple payments for the same benefit
  • Intentionally presenting for payment undercharges for benefits for a specific claimant with the exception of situations where you know that you are submitting overcharges for benefits for that same claimant at the same time

Not only is it illegal for you to do any of things yourself, it is also illegal for you to help someone else through aiding, abetting or conspiracy. The law also considers paying someone else to perform one of these activities to be health care fraud.

The penalties

Violating one of these prohibited activities is a public offense which could lead to a conviction. The penalties vary based on the amount of the fraudulent claim.

If the claim is for more than $950, then you could face two to five years in prison, and/or a fine of up to $50,000 or twice the amount of the claim, whichever is more. Alternately, a conviction could result in a one-year jail sentence and/or a fine of up to $10,000.

If the claim is for less than $950, you could spend up to six months in jail and/or pay a fine of up to $1,000. However, if there is more than one claim over the course of 12 months, and these total more than $950, then you would face the penalties for a claim over $950 instead.