Home-care fraud & the law

What the law forbids

A handful of federal and California laws govern how care paid for by Medicare and Medi-Cal may be referred and billed. The most important:

• Federal Anti-Kickback Statute (42 U.S.C. § 1320a-7b). It is a felony to knowingly pay OR receive anything of value to induce referrals of services covered by a federal health program. Both sides — the payer and the receiver — can be prosecuted, and that includes paying a patient to enroll.
• False Claims Act (31 U.S.C. §§ 3729–3733). Billing Medicare or Medi-Cal for services that were not provided, not medically necessary, or for patients who did not qualify creates civil liability for up to three times the loss plus penalties. Whistleblowers can sue on the government's behalf.
• Physician Self-Referral “Stark” Law (42 U.S.C. § 1395nn) and EKRA (18 U.S.C. § 220). Additional federal limits on referrals tied to a financial relationship, extending in some cases to privately-insured patients.
• California law (Welfare & Institutions Code § 14107.2; Business & Professions Code § 650). State crimes mirror the federal kickback and referral-fee prohibitions for Medi-Cal and for licensed professionals.
• Program exclusion. Beyond prison, fines, restitution, and forfeiture, the HHS Office of Inspector General can bar an individual or company from ever billing Medicare or Medicaid again — often ending a career or a business.

This is not theoretical — real Southern California cases

These are matters of public record, reported by the U.S. Department of Justice and the HHS Office of Inspector General. They involve home health and Medicare fraud prosecuted right here in the Los Angeles area.

These are illustrative public examples, not an exhaustive list. The full record of enforcement actions is published by the agencies below.

Verify a provider & report fraud

• Check whether a person or company has been barred from Medicare/Medicaid in the HHS-OIG List of Excluded Individuals/Entities (LEIE).
• Report suspected fraud to the HHS-OIG Hotline, to Medicare at 1-800-MEDICARE, or to the California DHCS Medi-Cal fraud line.
• Never accept money, gifts, or free services in exchange for your Medicare or Medi-Cal number, or for becoming a patient — and never give your number to someone who offers it. If it feels off, it probably is.