Disability/Healthcare Insurance Fraud Unit

Print

Disability and healthcare insurance fraud is a prevalent and prolific enterprise.  The National Heath Care Anti-Fraud Association estimates conservatively that health care fraud costs the nation about $68 billion annually — about 3 percent of the nation's $2.26 trillion in health care spending.  Other estimates range as high as 10 percent of annual health care expenditure, or $230 billion.  This results in higher premiums and higher costs for goods and services for the residents of Monterey County. 

The Monterey County District Attorney’s Disability and Healthcare Insurance Fraud Unit is comprised of an experienced attorney and an investigator who are not only committed to diligently investigating and prosecuting insurance fraud, but are also dedicated to taking a proactive approach to prevent fraud by offering training and conducting outreach in the community.   

HEALTHCARE FRAUD IS A CRIME and includes: 

Billing fraud – Occurs when bills are inflated by a healthcare provider or when an insurance company is billed for a good or service that was not given. 

Identity theft – Using someone else’s identity to secure or pay for a healthcare benefit. 

False disability claims – False claims submitted against a private disability insurance policy or a claimant performing activities exceeding alleged physical limitations. 

Prescription fraud – A pharmacist inflates bills or falsifies billing to an insurance company or a person illegally obtains medical prescriptions. 

Dental fraud – Dentist inflates bills or performs unauthorized services for profit. 

Cappers and kickbacks – Cases where patients are recruited and paid to undergo medical treatment, when the procedures are performed or not. 

Surgery center fraud – Any alleged fraudulent activity relating to a surgery center.

Long term care fraud – Fraudulent billing submitted regarding the type or amount of care provided. 

The Monterey County District Attorney’s Disability and Healthcare Insurance Fraud Unit is a vertical prosecution team specifically directed at this very specialized and complicated area of criminal law.  Additionally, the unit works closely with investigators from the California Department of Insurance and California Department of Consumer Affairs.

Healthcare Fraud is a felony, punishable by up to five years in prison and fines up to $150,000.  Restitution is generally ordered in all cases during the sentencing process.

Healthcare fraud and abuse is a serious problem, and your assistance is vital in helping us to prevent the problem.  Simple tips that may help you prevent fraud and abuse include:

  • Review your explanation of benefits to ensure accurate dates of service, name of providers, and types of services reported
  • Protect your insurance card and personal information at all times
  • Count your pills each time that you pick up a prescription
  • Research your providers with your state’s medical boards
  • Report suspected fraud and abuse as soon as possible

Our unit also provides outreach to the community to educate and raise awareness on topics of healthcare/disability fraud, including, but not limited to: 

  • How to Avoid being a Victim of Healthcare Fraud
  • Prescription Drug Abuse
  • Private Long Term Disability Fraud to Protect our Seniors and Disabled
  • Protecting Your Healthcare Identity

If your group is interested in receiving a presentation or training, please contact DDA Amy Patterson at (831) 755-5070.

If you would like to report suspected disability and healthcare fraud in Monterey County, please call the District Attorney’s Office Fraud Hotline at (831) 755-3224.   The more information you provide allows our unit to follow-up on these reported suspected activities.

Related Links:

California Department of Insurance
http://www.insurance.ca.gov/

Medical Board of California
http://www.mbc.ca.gov/

California Board of Chiropractic Examiners
http://www.chiro.ca.gov/


California Board of Pharmacy
http://www.pharmacy.ca.gov/

California Department of Consumer Affairs
http://www.dca.ca.gov/