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Federal Healthcare Fraud
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Federal Healthcare Fraud: Medicare and Medicaid Fraud Defense
Healthcare fraud is the DOJ’s white-collar crime priority. Were talking billions of dollars in alleged fraud every year, dedicated strike force teams in major cities, and sentences that rival drug trafficking. Under 18 USC 1347, healthcare fraud carrys up to 10 years in federal prison—or 20 years if patients were seriously injured, and life imprisonment if someone died.
If your a doctor, clinic owner, pharmacy operator, DME supplier, or anyone in the healthcare industry facing federal investigation, you need to understand what healthcare fraud really means and how to defend yourself.
What Is Healthcare Fraud?
Healthcare fraud under 18 USC 1347 is executing a scheme to defraud any healthcare benefit program—Medicare, Medicaid, private insurance, TRICARE, VA benefits. Common allegations include:
False billing – Billing for services not rendered, upcoding, unbundling
Kickbacks – Paying for patient referrals (Anti-Kickback Statute)
Unnecessary services – Ordering medically unnecessary treatments
Identity theft billing – Using stolen patient information
Telemedicine fraud – Prescribing without proper examinations
Related Statutes
Anti-Kickback Statute (42 USC 1320a-7b) – Prohibits paying for referrals in federal healthcare programs. Up to 10 years.
Stark Law – Prohibits physician self-referrals
False Claims Act (31 USC 3729) – Civil and criminal liability for false claims to government
Penalties
Healthcare fraud penalties are severe:
18 USC 1347: 10 years (20 if serious injury, life if death)
Anti-Kickback: 10 years per count
Plus wire fraud, mail fraud, money laundering charges typically added
Beyond prison: mandatory exclusion from Medicare/Medicaid (career-ending for healthcare providers), civil monetary penalties up to $100,000 per false claim, treble damages under False Claims Act.
Healthcare Fraud Strike Forces
DOJ has Healthcare Fraud Strike Force teams in major cities—Miami, Los Angeles, Detroit, Houston, Brooklyn, and others. These specialized units do nothing but healthcare fraud prosecution. They’re experienced, resourced, and effective.
Defense Strategies
Medical Necessity
Were the services medically necessary? This is often the central dispute. Defense involves expert medical testimony supporting the clinical decisions.
Lack of Intent
Healthcare billing is complex. Mistakes happen. Coding errors occur. If you lacked intent to defraud—if billing issues were errors, not schemes—thats a defense.
Safe Harbors
The Anti-Kickback Statute has “safe harbor” exceptions. If your arrangement fits a safe harbor, its not illegal regardless of referral patterns.
Compliance Programs
Having robust compliance programs can negate intent and provide mitigating factors at sentencing.
Act Now
Healthcare fraud investigations often start with data analysis—billing patterns that look suspicious to computers. By the time agents show up, the case may be largely built. Early intervention—ideally during the investigation phase—is critical.
Contact a federal healthcare fraud defense attorney immediately. Your medical license, your practice, and your freedom are all at stake.