A chiropractor, clinic owner, biller, marketer, or treating provider may face allegations that care was unnecessary, visits were repeated or never performed, records were copied, codes overstated the service, referrals were purchased, or treatment was connected to staged accidents or workers’ compensation claims. Investigators may compare clinical files, claims, remittances, patient histories, referral sources, financial records, EHR logs, and communications.
Clinical disagreement, utilization review, a denied authorization, documentation weakness, or an ordinary coding error is not automatically fraud. Criminal and civil theories require proof under the law actually charged. Medical necessity is also fact-, payer-, source-, and time-specific. Our California healthcare fraud guide explains the broader framework; this page focuses on chiropractic care and associated claims.
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Do not backdate a note, recreate an examination, change a code without preserving the original, merge user accounts, delete messages, coach patients or staff, or silently continue routine destruction. Counsel can coordinate a lawful hold and preserve native metadata while keeping necessary patient care operating.
A voluntary interview, administrative request, subpoena, and search warrant create different duties. Preserve the document and determine its scope before responding. Our healthcare investigation and subpoena defense guide addresses early-response issues.
A necessity review should identify the payer and plan terms, the benefit at issue, the diagnosis and symptoms, objective and subjective findings, treatment goals, frequency and duration, documented response, reassessment, alternative care, discharge criteria, and the clinical sources applicable at that time. An investigator’s retrospective opinion does not replace the charged statute’s mental-state requirement.
Repeated care can be clinically defensible, unnecessary, noncovered, poorly documented, or fraudulent depending on the evidence. Those are not synonyms. Utilization review may apply contractual or administrative criteria that differ from criminal proof. A denial, overpayment, extrapolation, or repayment demand does not by itself establish a knowingly false representation.
The defense should compare complete charts rather than isolated phrases, examine whether templates captured individualized findings, test sampling methods, identify changes in condition or goals, and determine whether the accused person—not merely a billing system or another employee—made or caused the challenged representation.
Authorities may allege billing for a visit, modality, exam, or supply that was not provided; duplicating a service; recording a different date; or billing while the patient or provider was elsewhere. Appointment and EHR data should be reconciled with staff schedules, patient communications, device logs, claims, and payment history. A missing check-in record or inconsistent recollection is evidence to investigate, not automatic proof of a false claim.
A code dispute may concern service intensity, separate versus bundled procedures, timed units, modifiers, provider identity, place of service, or the documentation needed by a particular payer. The medical billing fraud guide explains why a coding error, ambiguous rule, software mapping, or corrected claim should be separated from knowing falsity.
Templates and repeated language may prompt scrutiny, especially when notes do not reflect changing findings or response. The analysis should preserve version history and determine who created, edited, signed, or imported each entry. Sloppy documentation can create licensing, repayment, or credibility problems without proving intentional fabrication.
Investigators may trace advertising, lead purchases, transportation, gifts, percentages, ownership, leases, or other value. A marketing or service contract is neither automatically lawful nor automatically a kickback. The payment, work performed, compensation method, referrals, program, disclosure, and intent matter. See our kickback and patient-referral defense guide.
A clinic may be accused of treating recruited patients after staged collisions, exaggerating injury, generating predetermined treatment plans, or submitting workplace-treatment claims supported by false reports. The government must prove the accused person’s own knowing participation. Treatment linked to a disputed accident or work injury is not automatically fraudulent. See our workers’ compensation fraud defense page.
Penal Code section 550 contains several separate insurance-fraud offenses. Its healthcare-benefit provisions address knowingly false or fraudulent claims, claims for benefits not used by or for the claimant, duplicate claims presented with intent to defraud, and a specified reconciliation rule for undercharges and known overcharges. Section 550(a)(10) brings qualifying workers’ compensation health-benefit claims within those provisions.
Section 550 applies only when the facts fit the selected subdivision and its required knowledge or intent. It should not be invoked as a generic label for a medical-necessity disagreement, denied claim, documentation deficiency, or billing correction. The defense should identify the exact claim, payer, service, representation, submitter, edit history, payment, and accused person’s role.
Private-payer allegations may also overlap with our California insurance fraud defense page.
Insurance Code section 1871.4 applies to workers’ compensation facts. It addresses knowingly false or fraudulent material statements or representations made to obtain or deny compensation, presenting statements supporting or opposing a claim with knowledge of falsity or fraud, and specified assistance, conspiracy, or solicitation. The statute states that a “statement” includes a bill, medical record, doctor report, x-ray, test result, or other evidence of loss, injury, or expense.
A treatment dispute does not become an Insurance Code case merely because workers’ compensation paid the bill. The prosecution must connect the accused person to a materially false statement and the required mental state. The timing, audience, complete report, underlying examination, billing workflow, and who controlled the record are central.
Business and Professions Code section 650 makes specified remuneration or other consideration for patient referrals unlawful for licensees under its scope, including licensees under the Chiropractic Initiative Act. It also contains fact-specific provisions for services, ownership, advertising, and other arrangements. The text—not a generic “fee splitting” label—must be applied to the actual relationship.
Labor Code section 139.32 separately governs specified workers’ compensation referral and financial-interest arrangements. The current text requires written disclosure to a third-party payer or other entity receiving a payment claim when an interested party has a financial interest in the service entity, and contains prohibitions, exceptions, and remedies. AB 1398 was chaptered in 2025 and the official code states the amendment became effective January 1, 2026. It is current law, not a pending proposal.
Whether section 650 or section 139.32 applies depends on the license, interested parties, referral, payer, financial interest, compensation, services, exceptions, disclosures, and dates. A referral relationship should not be characterized before those facts are traced.
Welfare and Institutions Code section 14107 addresses specified false Medi-Cal claims, knowingly false information, and schemes to defraud Medi-Cal or another health program administered by DHCS. Section 14107.2 separately addresses specified remuneration connected to referrals, purchasing, leasing, or ordering for Medi-Cal-covered goods or services. Program scope and each statute’s mental state must be analyzed separately.
18 U.S.C. section 1347 addresses knowingly and willfully executing or attempting a scheme to defraud a healthcare benefit program or obtain its money or property by false pretenses connected with healthcare benefits, items, or services. 18 U.S.C. section 1035 addresses specified knowingly and willfully made materially false statements or writings in matters involving a healthcare benefit program.
The federal False Claims Act is a separate civil statute. Its knowledge, falsity, materiality, causation, procedure, damages, and penalty issues should not be collapsed into a criminal charge. Medicare and Medi-Cal questions are discussed further in our Medicare and Medi-Cal fraud defense guide.
The Board of Chiropractic Examiners investigates licensed and unlicensed people and identifies fraud and other criminal activity among its complex matters. The Chiropractic Initiative Act, Board regulations, and the law applicable during the alleged period should be reviewed before predicting any licensing consequence.
The Board publishes final disciplinary actions and pending accusations. A final action is case-specific; a pending accusation is an allegation and may be withdrawn, dismissed, settled, or adjudicated. Neither proves what occurred in another matter. Criminal, payer, civil, workers’ compensation, enrollment, and licensing tracks have different authorities and standards.
As of August 16, 2026, the Board’s proposed-regulations page lists no current proposed regulations. It also identifies a new inactive-license regulation filed June 26, 2026 with an October 1, 2026 effective date. That future-effective rule is not treated here as an operative August 2026 requirement and is not a substitute for current law.
Chiropractors, owners, administrators, and other licensees may need coordinated professional criminal and licensing defense. An audit, complaint, accusation, payment suspension, or criminal charge does not automatically revoke a license or establish exclusion.
The California Department of Insurance Fraud Division investigates insurance-fraud crimes, including Penal Code section 550 and related offenses. Its workers’ compensation program describes investigations involving false or exaggerated claims, overtreatment, and related schemes. Agency descriptions identify enforcement risk; they do not reduce the prosecution’s burden in a particular case.
DHCS Investigations investigates suspected Medi-Cal provider fraud, waste, and abuse and uses data analytics, audits, payment controls, and referrals. DHCS gives examples including double billing, services not rendered, unbundling, kickbacks, and unnecessary services. The California Attorney General’s Division of Medi-Cal Fraud and Elder Abuse is the state Medicaid Fraud Control Unit. Federal matters may also involve DOJ, HHS-OIG, FBI, CMS, contractors, or other agencies.
No defense applies automatically. A refund, repayment, disclosure, self-report, contract change, patient contact, interview, or cooperation decision may affect several proceedings and should be evaluated before action. No criminal, civil, payer, licensing, or sentencing result can be promised.
No. It may support an audit, denial, overpayment, or expert dispute, but fraud requires proof under the selected statute, including its conduct and mental-state elements. The clinical basis, payer rules, source materials, and contemporaneous records matter.
Yes. Frequency and duration depend on the patient, diagnosis, goals, response, evidence, benefit terms, and documentation. Repetition may also be questioned or noncovered. The issue cannot be decided from visit count alone.
Not automatically. Section 550 requires conduct and knowledge or intent specified by the charged subdivision. The code, documentation, rule clarity, workflow, correction history, and person responsible should be examined.
Yes. Insurance Code section 1871.4 expressly includes bills, medical records, doctor reports, x-rays, tests, and related claim evidence within its definition of a statement. The state must still prove a materially false statement and the required mental state.
No. AB 1398 was chaptered in 2025, and the official Labor Code section 139.32 states that its amendment became effective January 1, 2026. Its financial-interest disclosure rule must be applied to the actual parties and referral facts.
The Board has separate administrative authority and procedures. A complaint or accusation is not a conviction, and its result cannot be assumed. Deadlines and collateral effects may still require immediate attention.
Preserve the request and relevant evidence, determine whether it is voluntary or compulsory, avoid altering records or guessing, and obtain advice about scope, privilege, status, and a coordinated response.
This page provides general information, not legal advice. Reading it, calling the firm, or submitting information does not by itself create an attorney-client relationship. Laws and procedures can change, and every matter depends on its facts, evidence, jurisdiction, and timing. Past results do not guarantee a future outcome.
Call 888-702-8882 to discuss a chiropractic treatment, billing, referral, or insurance-fraud investigation with My Rights Law.
This page was written by the My Rights Law Editorial Team and reviewed for legal accuracy by Bobby Shamuilian.
Attorney Shamuilian is the founder and managing partner of My Rights Law and is widely recognized as a legal authority, frequently appearing as a legal analyst and TV pundit on national news outlets.
He has earned a perfect “10.0 – Top Attorney” rating on AVVO and a “10.0” rating on Justia, and has been named among the “Top 40 Under 40” and the “Top 100 Trial Lawyers” by The National Trial Lawyers.
With his proven expertise and dedication, Mr. Shamuilian is committed to protecting your rights and achieving the best possible outcome for your case.
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