Attorney For Federal Healthcare Fraud | Expert Defense Against Medicare & Medicaid Fraud Charges

Summary:

Federal healthcare fraud is among the most aggressively prosecuted white-collar crimes, carrying severe penalties including long prison sentences and million-dollar fines. An experienced Attorney For Federal Healthcare Fraud is essential because these cases involve complex billing schemes, voluminous records, and federal agencies with immense resources. These specialists understand how to challenge the government’s evidence, negotiate favorable plea deals, or build winning trial defenses by attacking prosecutorial theories of intent and knowledge. Without a skilled federal healthcare fraud defense lawyer, you risk devastating financial consequences and potential loss of professional licenses.

What This Means for You:

• Immediate Action: If under investigation, immediately cease all communication about the case and contact a federal healthcare fraud attorney. Preserve all relevant documents and digital records, but do not share them with investigators without counsel present.
• Legal Risks: Federal sentencing guidelines for healthcare fraud often recommend 24+ months imprisonment even for first offenses, with mandatory enhancements for losses exceeding $1.5M or targeting vulnerable populations.
• Financial Impact: Beyond six-figure legal fees, expect mandatory restitution payments, potential False Claims Act liabilities (treble damages + penalties up to $23,331 per false claim), and exclusion from Medicare/Medicaid programs.
• Long-Term Strategy: Early cooperation credit may be available if properly negotiated. Post-conviction, explore options for sentence reductions, professional license reinstatement, and sealing certain records where possible.

Federal Healthcare Fraud Attorney | Expert Defense Against Fraud Charges

“Federal Healthcare Fraud” Explained

Federal healthcare fraud primarily falls under 18 U.S.C. §1347, which prohibits knowingly executing schemes to defraud healthcare benefit programs. The prosecution must prove: (1) defendant devised or participated in a scheme to defraud a healthcare benefit program; (2) acted with intent to defraud; (3) the scheme involved material misrepresentations; and 4) the program was a federal healthcare program like Medicare/Medicaid. Most charges are felonies, with 10-year maximum sentences extending to 20 years if patient harm results.

Common charging documents include indictments under: 18 U.S.C. §1347 (healthcare fraud), §1349 (fraud conspiracy), §287 (false claims), and the Anti-Kickback Statute (42 U.S.C. §1320a-7b). Parallel civil actions often accompany criminal cases under the False Claims Act (31 U.S.C. §§3729-3733).

Types of Offenses

Billing Fraud: Upcoding (billing for more expensive services than performed), unbundling (billing separately for services normally bundled), or billing for services never rendered. Example: A physical therapy clinic billing for 60-minute sessions when only providing 15-minute treatments. First-time offenders typically face 18-24 months under sentencing guidelines.

Prescription Fraud: Illegal kickbacks between pharmaceutical reps and prescribers, medically unnecessary prescriptions, or “pill mill” operations. Recent cases involving opioid manufacturers show sentences reaching 5-7 years for high-dollar schemes.

Diagnostic Fraud: Performing unnecessary tests or falsifying diagnoses to justify treatments. A Florida lab owner received 15 years after billing $187M for unnecessary cancer genomic tests.

Stark Law Violations: Physician self-referral prohibitions (42 U.S.C. §1395nn) often overlap with fraud charges when doctors refer Medicare patients to entities they financially benefit from without proper exemptions.

Common Defenses

Lack of Intent: Successful when billing errors resulted from complex regulations rather than fraudulent intent. A Texas dentist avoided conviction by showing confusing Medicaid billing policies caused accidental overbilling.

Good Faith Reliance: Following professional advice or industry standards can negate willfulness. A medical equipment supplier successfully argued they relied on consultant-provided coding guidance.

Statute of Limitations: Federally, charges must generally be brought within 5 years (18 U.S.C. §3282). Cases involving concealment may extend this period.

Penalties and Consequences

Beyond statutory maximums, sentencing considers the “loss amount” (actual or intended) with enhancements at $1.5M, $3.5M, and $9.5M thresholds. Additional consequences include:

• Mandatory exclusion from federal healthcare programs (minimum 5 years)
• State medical license revocation or suspension
• Reputational damage leading to practice closures
• Debarment from government contracts
• Forfeiture of assets connected to fraudulent proceeds

Legal Process

1. Investigation: Whistleblower complaints or data analytics often trigger multi-agency investigations (FBI, HHS-OIG, CMS, DCIS)
2. Charging: Prosecutors may seek indictment or offer pre-trial diversion for smaller cases
3. Arraignment: Initial plea entered (typically “not guilty” to preserve options)
4. Discovery: Review millions of pages of billing records, emails, and audit reports
5. Pre-Trial Motions: Challenge evidence collection methods (e.g., defective search warrants)
6. Resolution: 90%+ cases settle via plea agreement; trials focus on intent elements

Choosing a Criminal Defense Attorney

Select counsel with:

• Federal court trial experience (most cases prosecuted in U.S. District Courts)
• Understanding of CPT/HCPCS coding systems and healthcare reimbursement rules
• Relationships with forensic accountants to challenge loss calculations
• Track record negotiating with DOJ’s Healthcare Fraud Strike Forces

People Also Ask

What’s considered federal healthcare fraud?
Federal healthcare fraud involves knowingly submitting false claims to government programs like Medicare or receiving kickbacks for referrals. This includes billing for services not rendered, falsifying diagnoses, or paying/receiving illegal remuneration under the Anti-Kickback Statute.

What’s the difference between healthcare fraud and abuse?
Fraud requires intent to deceive (e.g., knowingly billing for fictitious services), while abuse involves improper practices that don’t meet fraud’s intent requirements (e.g., excessive testing without medical necessity). Abuse often leads to civil monetary penalties rather than criminal charges.

How long do healthcare fraud investigations take?
Federal probes typically run 18-36 months before charges emerge. Qui tam lawsuits under the False Claims Act remain sealed for 60+ days while the government investigates whistleblower allegations.

Case Examples

• U.S. v. Wonderyear ($205M fraud – 20-year sentence)
• U.S. v. Spicer ($16M unnecessary procedures)
• U.S. v. Thabet (Pharmacy kickback scheme)

Extra Information

• HHS-OIG Fraud Risk Indicator – Self-assessment tool for healthcare compliance
• DOJ False Claims Act Overview – Explains qui tam whistleblower provisions

Expert Opinion

“Early intervention by experienced federal healthcare defense counsel can mean the difference between probation and prison. These cases turn on intent evidence – we immediately work to demonstrate legitimate interpretations of ambiguous billing situations before prosecutors cement their theories.” – Michael Cohen, Former Assistant U.S. Attorney (Healthcare Fraud Unit)

Key Terms

• Federal healthcare fraud defense attorney
• Medicare fraud criminal lawyer
• Anti-Kickback Statute violation defense
• False Claims Act qui tam lawsuit defense
• Healthcare billing fraud sentencing mitigation

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