1. Billing Evidence Must Be Reconciled Claim by Claim
A claim can identify the correct patient and date yet describe a service the records do not support. The disputed line item, not the practice's general billing habits, is the starting point.
Match Procedure Codes to the Services Delivered
Match CPT or HCPCS codes, modifiers, and units to treatment notes and the payer's rules. Upcoding may describe a higher-level service than the records support. Unbundling may involve separately billing procedures that should be grouped.
A useful comparison identifies the discrepancy:
| Claim Entry | Supporting Record | Issue to Resolve |
|---|---|---|
| Procedure code and units | Treatment note and procedure report | Service and quantity billed |
| Diagnosis and authorization | Physician order and clinical findings | Coverage and necessity |
| Submission or adjustment date | Billing log and remittance advice | Original claim versus correction |
Procedure code and units
- Supporting RecordTreatment note and procedure report
- Issue to ResolveService and quantity billed
Diagnosis and authorization
- Supporting RecordPhysician order and clinical findings
- Issue to ResolveCoverage and necessity
Submission or adjustment date
- Supporting RecordBilling log and remittance advice
- Issue to ResolveOriginal claim versus correction
An incorrect code may justify repayment without proving deception. Medicare billing fraud disputes also require the rules effective on the service date.
Test Medical Necessity against the Record
Actual treatment may still fall outside the payer's coverage criteria. Compare the applicable policy, diagnostic findings, orders, and authorization with the submitted claim.
Preserve electronic health record timestamps and amendment histories. A late entry is not necessarily fabricated, but contemporaneous records may clarify its significance.
2. Criminal Liability Depends on More Than a Billing Difference
The alleged misstatement, the defendant's knowledge, and their conduct must meet the elements of the charged offense. A rejected code alone cannot do that work.
Distinguish Federal and California Fraud Elements
Under 18 U.S.C. §1347, prosecutors must prove knowing and willful execution or attempted execution of a scheme to defraud a healthcare benefit program or obtain its money through fraudulent representations. Knowledge of §1347 itself is not required.
California Penal Code §550(a)(6)-(8) addresses knowingly false healthcare benefit claims, claims for benefits not used by a claimant, and duplicate claims submitted with intent to defraud. Welfare and Institutions Code §14107 covers specified fraudulent Medi-Cal claims and reimbursement information.
A separate wire fraud evidence review addresses §1343, which has different elements from §1347.
Identify the Person Behind Each Submission
A physician, coder, manager, and contractor may touch the same claim. Access logs, approvals, code changes, and messages can show who did what.
A warning received before later submissions may bear on knowledge. A finding issued only afterward is different. A name or job title on a claim does not, by itself, prove personal knowledge.
3. Audit Findings and Fraud Investigations Follow Different Procedures
A repayment demand, payment suspension, and criminal subpoena call for different responses. The notice determines which procedure and deadline apply.
Calculate Deadlines from the Actual Notice
For an eligible party appealing an initial Medicare Fee-for-Service claim determination, CMS generally allows 120 days after receipt to request redetermination. That deadline does not cover every audit or overpayment notice.
Under 22 CCR §51022, a Medi-Cal provider challenging covered audit findings files a Statement of Disputed Issues with DHCS. Institutional providers have 60 calendar days after receipt of findings, while non-institutional providers have 30. Under 22 CCR §51024, institutional providers may also have 30 days after a later Report of Findings to request a formal hearing. Non-institutional providers ordinarily need no separate formal-hearing request.
Check the notice date and any subpoena return date. A criminal investigation does not automatically extend an administrative deadline.
Separate Civil Knowledge Standards from Criminal Intent
The federal False Claims Act, 31 U.S.C. §3729, covers specified false claims and material false records. Knowledge includes actual knowledge, deliberate ignorance, and reckless disregard, without requiring specific intent to defraud.
A healthcare False Claims Act review therefore considers falsity, materiality where required, and knowledge separately from criminal intent.
Under Welfare and Institutions Code §14107.11, a credible fraud allegation under investigation generally triggers temporary Medi-Cal payment suspension unless a statutory exception applies. A refund or suspension does not decide criminal guilt.
4. Los Angeles County Cases May Involve Different Authorities
Los Angeles County has no separate elements for federal healthcare fraud. Which agency is involved determines the local case path.
Federal Healthcare Fraud Cases in the Central District
The FBI, HHS Office of Inspector General, and Department of Justice handle federal healthcare fraud matters. Federal charges arising in Los Angeles County may proceed in the Central District of California.
The Los Angeles Strike Force works with the U.S. Attorney's Office for the Central District. Local cases have involved alleged hospice and unnecessary-procedure schemes. Those allegations do not establish another provider's liability.
Medi-Cal Reviews and State Insurance Fraud Cases
DHCS investigates suspected Medi-Cal provider fraud and refers qualifying matters to California DOJ's Division of Medi-Cal Fraud and Elder Abuse.
The Los Angeles County District Attorney handles healthcare-related workers' compensation fraud. That is distinct from a Medicare contractor's claim review. The agency on the notice identifies the relevant process.
11 Nov, 2026
