People v. Guzman

201 Cal. App. 4th 1090, 134 Cal. Rptr. 3d 66, 2011 Cal. App. LEXIS 1548
California Court of Appeal·Decided December 12, 2011·No. No. B232299·Published·Cited by 7 cases

Opinion

Opinion

YEGAN, J.

A physician, like any other person, knows that he cannot lawfully obtain money based upon a fraudulent representation. This is theft by false pretenses. (People v. Shirley (1978) 78 Cal.App.3d 424, 436 [144 Cal.Rptr. 282].) A physician should also know that he cannot lawfully submit a Medi-Cal claim representing that he is supplying an expensive FDA-approved intrauterine device when, in fact, he is supplying a cheaper non-FDA-approved intrauterine device.1

Eduardo Jose Guzman, a licensed obstetrician-gynecologist, appeals from the judgment entered after his conviction by a jury of Medi-Cal fraud in violation of Welfare and Institutions Code section 14107, subdivision (b)(1). The jury returned a guilty verdict on a single count alleging that he had submitted a fraudulent Medi-Cal claim for the insertion of an intrauterine device (IUD) into patient Blanca G. The court suspended the imposition of sentence and placed appellant on formal probation for 36 months. As a condition of probation, appellant was ordered to perform 90 days of community service.

[1093] Appellant contends (1) the trial court erroneously upheld the validity of a search and seizure that he had challenged through a Penal Code section 995 motion,2 (2) the trial court erroneously admitted evidence “concerning the purported illegality of [appellant’s insertion of] non-FDA approved IUDs in his patients,” (3) the evidence is insufficient to show that appellant intended to defraud Medi-Cal, and (4) the Medi-Cal claim for Blanca G. “is not false or fraudulent as a matter of law.” We affirm.

Facts

Prosecution Evidence

The Medi-Cal program supplies a “provider manual” (manual) to physicians who provide services under the program. The manual informs physicians how to submit claims and specifies a unique procedure code for each allowed service.

Since November 2001 the manual has specified a procedure code of X1522 for the insertion of a ParaGard IUD. In the wake of the “Daikon shield debacle,” the FDA has focused on the safety of the IUD. The ParaGard, engineered and built to rigorous specifications, is the only “Copper T” type IUD approved by the FDA. Medi-Cal will pay only for FDA-approved IUD’s. A physician cannot lawfully insert a non-FDA-approved IUD into a patient. ParaGard IUD’s are manufactured in New York by Teva Pharmaceuticals. Until April 2006 Medi-Cal paid $261.80 for each insertion of a ParaGard IUD. In April 2006 the payment increased to $374.16 per IUD. At the time of trial in August 2010, a single ParaGard IUD cost $392.

From 2004 through February 2006, appellant’s office billed Medi-Cal for the insertion of 176 IUD’s under procedure code XI522. For these IUD’s, Medi-Cal paid appellant $45,919.72. During this period, appellant did not use the ParaGard IUD. Instead, he used a cheaper Copper T type IUD manufactured in Mexico by Dentilab.

The actual Medi-Cal billing was done by appellant’s employees (billers). Appellant did not mention the name “ParaGard” to the billers, nor did he tell them to use procedure code X1522. The billers knew to use code X1522 for the insertion of an IUD because the code was “in the computer.”

On February 16, 2006, Medi-Cal fraud investigators went to appellant’s office and asked him to provide copies of invoices for ParaGard IUD’s billed to Medi-Cal in 2005. He was expressly told that he could be reimbursed only [1094] for this specific IUD. Appellant “said he couldn’t find the invoices right now but would send them in.” On February 23, 2006, the investigators received in the mail three invoices from appellant. The invoices were from Alpine Oxygen Home Care (Alpine Oxygen) and were dated in 2005. The invoices showed that Alpine Oxygen had sold 45 Copper T IUD’s to appellant at $378 each. The invoices did not specify the brand of the IUD’s.

The invoices were forgeries. Alpine Oxygen never sold IUD’s. The owner of Alpine Oxygen never had any contact with appellant, and he did not recognize the handwriting on the invoices.

On February 21, 2006, after appellant had received actual notice of the requirement of “ParaGard IUD only reimbursement,” someone in appellant’s office signed a Medi-Cal claim form showing that, seven days earlier, an IUD had been inserted into patient Blanca G. The claim form billed Medi-Cal under procedure code X1522, the code for a ParaGard IUD. Appellant concedes that “[t]he copper T [IUD] used ... for this patient [Blanca G.] had been manufactured in Mexico and was not a ParaGard brand of copper T.”

Defense Evidence

Ruben Arlidyd Sanchez worked for appellant for more than six years and did his billing from 2004 until December 2005, when her employment ended. On appellant’s behalf, Sanchez bought IUD’s for about $100 each from a vendor named Pablo. When Sanchez billed Medi-Cal for an IUD, appellant did not tell her what procedure code to put on the claim form. For each IUD, Sanchez used procedure code X1522 and billed Medi-Cal $300. She believed that procedure code X1522 applied to any IUD, not just the ParaGard brand.

Appellant testified as follows: The Dentilab IUD’s were “very safe and . . . effective.” Appellant purchased them because they cost less than ParaGard IUD’s. Each Dentilab IUD cost about $150, while each Paragard IUD cost between $200 and $300.

Until early 2006, appellant did not know that the FDA regulated Copper T IUD’s. It was not until February 16, 2006, when the investigators came to his office, that he learned that Medi-Cal would pay only for ParaGard IUD’s. At that time, he directed his staff to dispose of the Dentilab IUD’s.

Appellant’s staff found the Alpine Oxygen IUD invoices that he sent to the investigators. He believed that they were genuine invoices.

When appellant inserted an IUD into a patient, he would write on a form the type of IUD (e.g., Copper T) that he had inserted. He would then give the [1095] form to a biller in his office, who would complete the claim form to be sent to Medi-Cal. Appellant did not “understand the biffing” process. He never intended to deceive Medi-Cal.

Jury Verdict

The jury was unable to reach unanimous verdicts on 20 counts alleging that appellant had submitted fraudulent Medi-Cal claims for the insertion of Dentilab IUD’s into patients other than Blanca G. According to appellant’s counsel, the only difference between these 20 counts and the Blanca G. count is that the claim for services provided to Blanca G. was signed after Medi-Cal investigators informed appellant that Medi-Cal would pay only for the insertion of ParaGard IUD’s. The claims for the Dentilab IUD’s inserted into the other patients were signed before the investigators so informed appellant. The People note, “It appears that the timing of [the Blanca G.j false claim, postdating the Medi-Cal investigators’ visit, may have been a factor distinguishing it from other false claims charged.” The trial court dismissed the counts on which the jury had deadlocked.3

Search and Seizure

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People v. Guzman, 201 Cal. App. 4th 1090, 134 Cal. Rptr. 3d 66, 2011 Cal. App. LEXIS 1548 (Cal. Ct. App. 2011).

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