Criminal Defense for Medicare Fraud Charges | Protect Your Rights

Summary:

Criminal defense for Medicare fraud is a critical area of legal practice due to the severe consequences of conviction. Medicare fraud involves knowingly submitting false claims to obtain improper payments from government healthcare programs. Prosecutors aggressively pursue these cases, which often involve complex healthcare billing systems and federal laws. A strong criminal defense strategy is essential to protect rights, minimize penalties, and preserve professional licenses. The stakes are high—convictions can result in lengthy prison sentences, massive fines, and exclusion from federal healthcare programs.

What This Means for You:

• Immediate Action: If you’re under investigation or charged with Medicare fraud, immediately contact a specialized criminal defense attorney. Do not speak to investigators without legal counsel present, as anything you say can be used against you.
• Legal Risks: Convictions can lead to 10+ years in federal prison (depending on dollar amounts), fines up to $250,000 per count, mandatory restitution, and permanent exclusion from Medicare/Medicaid participation.
• Financial Impact: Beyond attorney fees, you may face asset forfeiture, civil false claims penalties (3x damages plus $11,000 per false claim), professional license revocation, and loss of business revenue from Medicare exclusion.
• Long-Term Strategy: Consider pre-indictment negotiations, compliance program implementation, and potential deferred prosecution agreements. If convicted, explore expungement options and reinstatement procedures for professional licenses.

Criminal Defense For Medicare Fraud Explained

Medicare fraud is prosecuted under various federal statutes, primarily 18 U.S.C. § 1347 (Healthcare Fraud) and 42 U.S.C. § 1320a-7b (Anti-Kickback Statute). To secure a conviction, prosecutors must prove: (1) the defendant knowingly and willfully executed a scheme to defraud a healthcare benefit program, (2) the scheme involved false representations or material omissions, and (3) the defendant acted with intent to obtain unauthorized payments. Medicare fraud cases are typically charged as felonies under federal law.

Types of Offenses

The most common Medicare fraud charges include:
Billing Fraud: Submitting claims for services not rendered, upcoding (billing for more expensive services than performed), or unbundling (billing separately for procedures normally billed together). These cases often involve millions in alleged losses, carrying sentences based on dollar amounts under federal sentencing guidelines.

Kickback Violations: Offering or receiving remuneration for patient referrals in federal healthcare programs, prohibited under the Anti-Kickback Statute (42 U.S.C. § 1320a-7b). Even if services were medically necessary, kickback arrangements violate the law and can result in 5-year prison terms per violation.

False Certifications: Knowingly certifying false statements in Medicare/Medicaid documentation. This includes falsifying patient records, treatment plans, or medical necessity determinations to justify claims.

Common Defenses

Effective Medicare fraud defenses focus on lack of criminal intent—the government must prove “knowing and willful” misconduct. Common strategies include demonstrating good faith billing errors, lack of provider control over billing processes, or insufficient evidence of intentional fraud. In kickback cases, attorneys may invoke statutory safe harbors or argue that payments were for legitimate services.

Procedural defenses challenging improper search warrants, statute of limitations violations, or selective prosecution can also succeed. Many cases turn on complex documentation—experienced attorneys scrutinize billing records and audit trails to identify reasonable doubt.

Penalties and Consequences

Medicare fraud penalties escalate based on dollar amounts and aggravating factors:

• Prison: 10 years per count (up to 20 years if patient harm occurred)
• Fines: $250,000+ per violation ($500,000 for organizations)
• Restitution: Mandatory repayment of fraudulent claims
• Exclusion: Minimum 5-year ban from federal healthcare programs (often permanent)
• Collateral Consequences: Medical license revocation, loss of hospital privileges, ineligibility for government contracts, and immigration consequences for non-citizens

Legal Process

1. Investigation: Usually conducted by HHS-OIG, FBI, or Medicare Fraud Strike Force (6-24 months)
2. Charging: Defendants receive target letters or face indictment
3. Arraignment: Formal reading of charges in federal court
4. Discovery: Government discloses evidence; defense files motions
5. Plea Negotiations: 90% of cases resolve pre-trial
6. Trial: If no plea, 6-12 month process with complex expert testimony
7. Sentencing: Federal guidelines calculation based on loss amounts
8. Appeal: Possible challenges to convictions or sentences

Choosing a Criminal Defense Attorney

Select an attorney with:

• Federal criminal trial experience
• Specific Medicare fraud case history
• Relationships with prosecutors and judges
• Forensic accounting resources
• Clear fee structures (flat fees for defined phases)

Medical professionals should prioritize attorneys who understand both legal and healthcare regulatory frameworks.

People Also Ask

What’s the difference between Medicare fraud and billing errors?

Medicare fraud requires proof of willful intent to deceive, while errors are unintentional mistakes. The government presumes fraud when patterns emerge, making documented compliance programs critical for defense. Even minor errors can trigger audits that escalate to criminal investigations.

Can Medicare fraud charges be dropped?

Yes—through pre-charge intervention demonstrating lack of intent, successful suppression of improperly obtained evidence, or proving insufficient evidence of wrongdoing. Early attorney involvement increases dismissal chances before indictment.

How long do Medicare fraud investigations take?

Federal investigations typically last 12-18 months before charges are filed. The statute of limitations is generally 5 years, but complex cases involving continuous schemes can extend this period. Parallel civil proceedings may continue for years after criminal resolution.

What should I do if approached by Medicare investigators?

Politely decline to answer questions without counsel present. Request business cards, note the date/time, and immediately contact a healthcare fraud defense attorney. Never destroy documents or discuss the case with colleagues.

Are whistleblowers involved in Medicare fraud cases?

Over 80% of cases originate from whistleblowers (often former employees) under the False Claims Act. These “qui tam” lawsuits allow whistleblowers to receive 15-30% of recovered funds, incentivizing detailed allegations.

Case Examples

• United States v. Salo (2023) – $64M home health fraud scheme
• United States v. Gonzalez (2022) – Compounding pharmacy fraud
• United States v. Thompson (2021) – Kickbacks for unnecessary testing

Extra Information

• HHS-OIG Enforcement Actions – Database of recent Medicare fraud cases
• 42 U.S.C. § 1320a-7b – Anti-Kickback Statute text
• ADA Fraud Prevention Guide – Compliance best practices for providers

Expert Opinion

Medicare fraud defenses require early, aggressive action—government investigations gain irreversible momentum without intervention. Specialized counsel can often mitigate outcomes before charges are filed, particularly by demonstrating good-faith compliance efforts and structuring favorable plea agreements when appropriate.

Key Terms

• Experienced Medicare fraud defense attorneys
• Federal healthcare fraud penalty mitigation
• Anti-kickback statute legal defenses
• Medicare exclusion defense strategies
• Healthcare provider criminal investigation representation

*featured image sourced by Pixabay.com

Featured image generated by Dall-E 3