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Healthcare Fraud and Abuse in California
Student’s Name
Institution
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Healthcare Fraud and Abuse in California
Healthcare fraud and abuse affect everyone, including both individuals and businesses.
They raise health insurance premiums exposing one to unnecessary medical procedures while
increasing taxes. Health fraud entails securing unfair/unlawful gain or depriving victims of legal
rights through intentional deception. On the other hand, abuse includes all practices inconsistent
with accepted sound fiscal, business, or medical practice and leads to unnecessary costs or
reimbursement for services that are not medically necessary or that fail to meet professionally
recognized standards for healthcare. Approximately 60 billion dollars are lost yearly because of
healthcare fraud and abuse in the US (Johns Hopkins, n.d).
The California Penal Code 550 (a) PC prohibits most healthcare and medical billing
fraud. In California, healthcare fraud includes insurance fraud and medical billing fraud, among
others. Common schemes violating Penal Code 550 (a) PC healthcare fraud laws include
submission of false healthcare claims, preparing a document to support false claims, submitting
several claims for the same procedure, billing services that were never offered to the patient, and
billing for more expensive services that patient did not get. Common instances of abuse include
misuse of codes on a claim, charging excess for services or supplies, and billing for services that
are considered not medically important. Healthcare fraud and abuse expose providers and
vendors to criminal and civil liability. The Department of Health Care Services (DHCS) lists
several ways through which one can report suspected healthcare fraud and abuse. One of the
ways is through calling the DHCS and Attorney General’s Bureau using a hotline; the call is free
while the caller remains anonymous. Furthermore, one can send a complaint through mail to the
DHCS or send an email.
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Several cases, including civil and criminal, have been successfully prosecuted in
California. In 2021, four defendants were charged with healthcare fraud that involved more than
$129 million intended in losses. Roselia Kubeck and Rosario Gonzalez pleaded guilty to
approaching residents of senior complexes in El Centro and Calexico, California, in 2021.
Ronald Charles Green Jr. and Melinda Elizabeth Green were charged with conspiring to defraud
Tricare and Medicare out of more than $129 million in the Southern District of California. In
2018, Daniel Capen of Manhattan Beach pleaded guilty to conspiracy and illegal kickback
charges that accounted for $142 million of Pacific Hospital’s claims, with the hospital receiving
$56 million. In 2020, three Healthcare providers, including Dignity Health, Twin Cities
Community Hospital, and Sierra Vista, agreed to pay $22.5 for false claims to California’s
Medicaid program (The United States Department of Justice, 2022). These are some of the
criminal and civil cases that have been successfully prosecuted in California.
California has been leading in trying to control healthcare fraud and abuse. According to
a report by Fierce Healthcare, in California, there were 151 Indicted/charged cases, 123
convictions, and 21 civil settlements judgments. The state managed to recover $388.26m. This is
significantly higher compared to Kentucky, which had indicted and charged 6 cases, 18
convictions, and 28 civil settlement judgments with a total of $81.44m. More effort is required to
cab healthcare fraud and effort.
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References
Fierce Healthcare. (2012). 5 states to Media fraud list, states recover $1.7B. Accessed from
https://www.fiercehealthcare.com/healthcare/5-states-top-medicaid-fraud-list-states-
recover-1-7b
Johns Hopkins. (n.d). Healthcare Fraud and Abuse. Accessed from
https://www.hopkinsmedicine.org/johns_hopkins_healthcare/providers_physicians/
health_care_fraud_and_abuse/
The United States Department of Justice. (2022). Three Healthcare Providers Agree to Pay $22.5
Million for Alleged False Claims to California’s Medicaid Program. Accessed
https://www.justice.gov/opa/pr/three-health-care-providers-agree-pay-225-million-
alleged-false-claims-california-s-medicaid
