The California Medicaid program is called Medi-Cal. This program involves public health insurance coverage for low income adults and children. Instituted in 1966, this system accounts for one fourth of the state budget of California, covering one of every six Californians. The coverage has now been expanded to include persons with disabilities, pregnant women and those suffering from diseases such as tuberculosis, breast cancer and HIV/AIDS.

To be eligible for coverage under Medi-Cal, there are very strict guidelines to be followed. The benefits of Medi-Cal include preventive and primary health care for those individuals that fall within its eligibility requirements.

The law defines Medi-Cal fraud as the intentional attempt or commission of act/s to receive unauthorized benefits and/or payments from the Medi-Cal program. These acts include health care providers billing for unauthorized or unnecessary services or supplies, falsification of information to obtain payments or double billing for benefits already received.

Specifically, the California Welfare and Institutions Code Sec 14014 imposes penalties on those individuals who make false claims of eligibility for the Medi-Cal program. Sec 14107 of the same code penalizes health care providers who make fraudulent claims for reimbursement or who solicits or receives bribes or “kickbacks” for referrals for services or merchandise under the Medi-Cal program. Another law, Sec 550 of the California Penal Code prohibits the knowledgeable preparation, making or submission of fraudulent health insurance claims.

For the crime of Medi-Cal fraud, the imposable penalty depends upon the circumstances of the offense committed and the accused’s criminal history. These two facts determine whether to prosecute the crime as either a misdemeanor or as a felony crime. If the value of the fraud amounts to below $950, then the crime would be prosecuted under Sec 484 of the California Penal Code or petty theft but if it is above $950, then the crime is prosecuted under Sec 487 of the California Penal Code or grand theft.

For misdemeanor Medi-Cal fraud, the imposable penalties include summary probation, up to twelve (12) months imprisonment in county jail, payment of fines of up to $10,000 or three times the amount fraudulently obtained and forfeiture of any fraudulently obtained assets. For felony Medi-Cal fraud, the imposable penalties are formal probation, between sixteen (16) to sixty (60) months in state prison with an additional and consecutive four (4) years in prison of as a result of or because of the fraud serious bodily injury is sustained or twenty five (25) years to life imprisonment if the victim dies, payment of up to $50,000 in fines or double of the amount of fraud, whichever is greater and the forfeiture of proceeds and assets obtained due to the fraud.

The crime of medi-cal fraud is a serious matter in California. Should you be or know anyone facing any of these charges, do reach out to the lawyers at the Law Offices of Ramiro J. Lluis for a free consultation today.