Twenty one doctors, pharmacists and business owners were charged in an alleged $40 million medical insurance scam in Orange County and elsewhere. According to a news report in The Orange County Register, the accused masterminds of this alleged operation – a Beverly Hills couple — own medical-billing and medical management companies. Officials say those individuals carried out a complex insurance fraud for which they recruited doctors and pharmacists to prescribe unnecessary treatments for patients on workers’ compensation.
The couple along with 21 doctors, one physician assistant and two pharmacists, face a string of felony charges including insurance fraud, filing false and fraudulent claims and conspiracy to commit medical-insurance fraud. Prosecutors alleged that the couple, from 2011 to 2015, billed for unnecessary creams, tests and treatments with a view of gaining profits. They said the alleged scam victimized more than 13,000 patients and at least 27 insurance carriers.
How Officials Say the Scam Worked
Prosecutors say the couple made oral and written agreements with physicians throughout California including five in Orange County to pay them each time they prescribed a cream or medication that was not a necessary part of the treatment plan. The doctors apparently labeled the payment kickbacks as “marketing expenses.” The couple is accused of working with two pharmacists in Costa Mesa to manufacture creams that did nothing and were not approved by the U.S. Food and Drug Administration (FDA). They were accused of paying $15 to $40 per tube of the cream and then billing insurance companies $250 to $700 per tube.
Officials say the couple also purchased repackaged oral pain medications from Orange County outfits and then sent the medications directly to the doctors. When those drugs were prescribed, the couple allegedly billed workers’ compensation carriers without showing the wholesale costs. They later split the profits with the doctors, officials alleged. In addition, prosecutors said the couple provided technical staff to participating doctors’ offices for unnecessary urine tests. The tests were then referred to a lab for additional testing regardless of what the results were. They then billed insurance carriers for hundreds of dollars for these tests even if each test only cost $60.
Health Care Fraud Cases
Prosecuting health care fraud cases has become a top priority for law enforcement officials over the past few years. Law enforcement agencies receive grants from the state of California to help with identifying and apprehending those who commit these types of fraudulent activities. Many times, such investigations might be triggered with a call to the tip line. As we saw in this most recent case featured in The Orange County Register, local law enforcement officials scrutinize not only primary care physicians, but also medical testing labs, equipment suppliers, pharmacies, residential care facilities, group homes, hospitals and medical transport companies. Basically, any person or entity that bills for healthcare services may be subject to healthcare fraud investigations and prosecutions.
It is a fact of life that insurance companies no longer pay doctors as much for their services as they did years ago. There has been an increase in the number of doctors referred for criminal prosecution for health care fraud in their billing. Insurance companies pay investigators to review medical claims and determine if there is any fraudulent activity. When such fraud is detected or suspected, the cases are referred to law enforcement for prosecution.
A majority of these cases are for billing fraud, which may occur when a doctor bills for more procedures than were performed. In these instances, if convicted, physicians could face significant prison sentences as a well as loss of their license from the California Medical Board. If you are a doctor, pharmacist or any other type of medical professional, and have a search warrant executed in which prosecutors or other state investigators have seized your patient records, it is critical that you contact an experienced Orange County health insurance fraud attorney who can help protect your rights.
Examples of Health Care Fraud
Health care fraud and insurance fraud may include a variety of suspected activity including:
- Over billing insurance companies for work that was performed or billing them for work that was not performed.
- Falsifying medical records for the sake of profit.
- Ordering unnecessary medications, procedures or tests for patients.
- Double billing for work performed.
- Prescribing unnecessary medicines or medical equipment.
- Billing for emergency services that were not provided.
- Billing for physical therapy that was not provided.
Consequences of a Conviction
If you are convicted of health care fraud charges, you could be looking at a number of consequences including imprisonment in state prison or a county jail; loss of professional license; parole or probation; substantial fines and court costs; and restitution that may include money collected from insurance agencies. Those convicted will also be barred from being Medicare or Medi-Cal providers in the future. In many of these cases, law enforcement agencies work hand in hand with local prosecutors to compile evidence and put together a substantial case against health care providers.
If You Are Under Investigation
You are very likely to know if you are under investigation because of search warrants that might be issued. As soon as you learn that you are under investigation, it is crucial that you seek the counsel of an experienced Orange County health care fraud attorney, who will look out for your best interests and protect your rights every step of the way. Do not talk to investigators or agree to interviews without first speaking with your criminal defense lawyer. Anything you say or do during an investigation could be held against you.
The experienced white collar crime defense attorneys at the Law Offices of Randy Collins have a long and successful track record of obtaining the best possible outcomes for our clients. We will strive to get you an acquittal or get your charges reduced. The stakes are extremely high in health care fraud cases where individuals stand to face lengthy prison sentences and lose their professional licenses, thereby losing their ability to earn a livelihood. Don’t take a chance with your future. Call us at (888) 250-2865 for a no-cost, no-obligation consultation and case evaluation.