Criminal Defense Lawyers

My Brighton Beach Medical Clinic is Under Federal Investigation

The FBI showed up at your clinic. Or maybe it was OIG investigators. Or maybe you received a subpoena for patient records going back years. However it happened, you’re now realizing that your Brighton Beach medical practice – the one you built from nothing, the one that supports your family – is under federal investigation for healthcare fraud. And you’re terrified.

You should be. Not because you’re guilty, but because Brighton Beach has become one of the most heavily targeted areas in America for healthcare fraud prosecutions. The Medicare Fraud Strike Force has operated in Brooklyn since 2007, and they’ve charged over 3,000 individuals in that time. Your ZIP code has more healthcare providers barred from Medicare than almost any other in the country.

But here’s what nobody tells you: by the time investigators show up at your door, the investigation is almost over. CMS algorithms flagged your billing patterns months or years ago. And there may be someone inside your own clinic who’s been collecting evidence against you – someone who gets paid a percentage of whatever the government recovers. Understanding what you’re actually facing is the first step toward defending yourself.

How CMS Algorithms Already Flagged Your Clinic

Heres something most medical clinic owners dont understand. The government dosent need a tip or a complaint to start investigating you. They have computers doing it automaticaly.

Since 2011, the Centers for Medicare and Medicaid Services has run something called the Fraud Prevention System. Its basicly the same technology credit card companies use to detect fraud – predictive analytics that scan every single Medicare claim before payment. The system compares your billing patterns to national averages. If your looking like an outlier, you get flagged.

Think about what that means. Every claim you’ve ever submitted is in a database. Your procedure codes, your diagnosis codes, your patient volume, your geographic location, your referral patterns – all of it is being compared to thousands of other providers. And the algorithms are looking for anomalies.

Are you billing more 99215 evaluation codes than the average provider in your specialty? Flag. Are your patients receiving more expensive procedures than similar demographics elsewhere? Flag. Are you ordering unusual combinations of tests? Flag.

And heres the kicker. CMS actualy publishes this data. The Medicare Provider Utilization and Payment Data is public. Anyone – including investigators – can look at exactly what you’ve billed and compare it to everyone else. The evidence they’ll use against you is sitting in a public database.

By the time a human being actualy looks at your file, the computer has already decided your suspicious.

The Whistleblower Who May Be Inside Your Office

OK so heres the part that keeps clinic owners up at night. There might be someone in your own office who’s been documenting everything you do – and there getting paid for it.

The False Claims Act allows private citizens to file lawsuits on behalf of the government. These are called “qui tam” cases, and the person filing is called a “relator.” If the government recovers money based on that lawsuit, the relator gets between 15% and 30% of the recovery.

Read that again. Your billing specialist, your office manager, your nurse – any of them could be collecting evidence right now, knowing that if your clinic gets hit with a $2 million settlement, there looking at $300,000 to $600,000 personally.

And heres what makes it worse. These cases are filed under seal. That means the lawsuit exists, investigators are using it to build there criminal case, and you have absolutly no idea. The case stays sealed while the government decides wheather to intervene. That can take years. The whole time, your being investigated based on information from someone who works for you.

The whistleblower is protected from retaliation by federal law. You cant fire them for cooperating with the government. If you do, thats another lawsuit.

Since 1986, qui tam relators have received rewards totaling more than $8 billion. In fiscal year 2022 alone, over $1.7 billion in False Claims Act settlements came from healthcare cases. This isnt rare. Its a business.

The biggest threat to your clinic isnt the FBI agent at your door. Its the employee whos been documenting everything for years.

Why Brighton Beach Is Ground Zero

Lets talk about were you are. Because geography matters in healthcare fraud prosecutions.

Brighton Beach has one of the highest rates of healthcare fraud prosecution in the nation. This isnt stereotype or bias – its statistical fact. An analysis of CMS data shows that more healthcare providers in the Brighton Beach ZIP code are currently barred from Medicare than almost any other ZIP code in America.

The Medicare Fraud Strike Force has operated in Brooklyn since March 2007. They specificaly target “emerging or migrating fraud schemes” in high-fraud areas. Brighton Beach is always on there radar.

You’ve heard of some of the cases. The $250 million no-fault insurance fraud ring busted in 2012 – the largest in the nations history at the time. The ringleaders, Mikhail Zemlyansky (“Russian Mike”) and Michael Danilovich (“Fat Mike”), ran 10 clinics and 105 corporations. Irina Shelikhova, who masterminded a $77 million Medicare fraud scheme, fled to Ukraine, lived as a fugitive for two years, and got arrested at JFK when she tried to return. She got 15 years.

In 2023, Dr. Alexander Ivanov and office manager Svetlana Kozlovskaya were indicted for a $700,000 Medicaid fraud at there Brighton Beach clinic. They allegedly billed for services never provided and sold prescriptions for controlled substances.

This is the environment your operating in. Investigators know this area. Prosecutors have experience with these cases. Juries in Brooklyn have heard testimony about Brighton Beach healthcare fraud for almost two decades.

Being in this ZIP code dosent mean your guilty. But it does mean your under more scrutiny than a clinic in Kansas.

How “Billing Errors” Become “Criminal Schemes”

Heres were most clinic owners get confused. You might look at your billing and think “sure, maybe there are some errors, but errors arent crimes.” And your right – in theory. But prosecutors dont see isolated errors. They see patterns.

Under 18 USC 1347, healthcare fraud requires that you “knowingly and willfully” executed a scheme to defraud. The key words are “knowingly” and “scheme.” A single billing mistake isnt a scheme. But if prosecutors can show the same “mistake” happening over and over, across multiple patients, over months or years – now its a pattern. And patterns suggest intent.

Lets say you regularly bill 99215 (high-complexity office visit) when the documentation might only support 99213 (moderate-complexity). One time? Thats an error. Your billing staff misread the chart. Fifty times? Thats harder to explain. Two hundred times across two years? Prosecutors will argue thats not error – thats a scheme.

And once its a scheme, everyones potentially liable. Under conspiracy law, if your part of an agreement to commit healthcare fraud, your responsible for everything your co-conspirators do. That means your responsible for the billing specialists clicks, the office managers approvals, the referring physicians referrals.

One pattern. Dozens of patients. Hundreds of claims. Thats how “billing errors” become “conspiracy to commit healthcare fraud.”

The Investigation Timeline Nobody Explains

Most clinic owners think the investigation starts when they first hear about it. The subpoena shows up, or the FBI visits, and they think “OK, now there investigating me.”

Wrong. By the time you hear about it, the investigation is often nearly complete.

Heres the typical timeline. Your billing patterns get flagged by CMS algorithms. The Strike Force reviews the data. Maybe a qui tam case gets filed under seal. Investigators start pulling records – bank statements, billing data, patient files. They interview former employees. They build a case. All of this happens without you knowing.

Then – maybe years later – they execute a search warrant or issue subpoenas. You think this is the beginning. Its actualy close to the end.

The statute of limitations for healthcare fraud is generally five years. But investigations can run for two, three, even four years before charges are filed. That means there looking at billing from seven or eight years ago. Can you explain every coding decision from 2018?

And heres another timing issue. The qui tam case stays sealed while the government investigates. During that time, the whistleblower is cooperating, investigators are gathering evidence, and you have no idea any of this is happening. When the case finally unseals, your facing evidence that was collected over years.

The audit isnt the start of the investigation. Its the confirmation that there ready to move.

If you just received a subpoena or had a visit from investigators, assume they already have most of what they need.

What Happens to Your Medical License

Heres an uncomfortable truth. Even if your aquitted of criminal charges, you can still lose your medical license.

In New York, the Office of Professional Medical Conduct (OPMC) handles medical license discipline. OPMC operates seperately from the criminal justice system. They have different standards of proof. Criminal cases require proof “beyond a reasonable doubt.” OPMC only requires “preponderance of the evidence” – meaning more likely than not.

So you can beat the criminal case – convince twelve jurors that the government didnt prove its case – and still lose your license because OPMC decides it was “more likely than not” that you committed misconduct.

And if your convicted of a felony related to healthcare, the consequences are severe. New York mandates license revocation for felonies involving healthcare fraud or moral turpitude. After revocation, theres a minimum five-year bar before your even eligible to reapply.

Federal exclusion is even worse. If your convicted of Medicare or Medicaid fraud, OIG is legally required to exclude you from all federal healthcare programs. Not “may exclude” – must exclude. That means no Medicare, no Medicaid, no TRICARE, no VA. For many practices, thats a death sentence even without prison.

The criminal case and the license case happen in paralell. You need attorneys handling both, because a statement you make in one proceeding can be used against you in the other.

The Penalties Your Actually Facing

Lets be specific about what your looking at.

Under 18 USC 1347, basic healthcare fraud carries a maximum sentence of 10 years in federal prison. If the fraud resulted in serious bodily injury to any patient, that goes up to 20 years. If someone died as a result of the fraud – even indirectly – you could face life imprisonment.

Thats in addition to fines up to $250,000 and mandatory restitution. The government will calculate how much Medicare or Medicaid paid on your fraudulent claims, and youll have to pay it back. Plus interest. Plus penalties under the False Claims Act, which can be treble damages – three times the fraud amount.

The 2025 National Healthcare Fraud Takedown charged 324 defendants in connection with $14.6 billion in alleged fraud. Thats the largest takedown in DOJ history, double the previous record. Healthcare fraud prosecution isnt slowing down – its accelerating.

Irina Shelikhova got 15 years for her $77 million scheme. She was 50 years old when she was sentenced. Shell be 65 when she gets out, assuming no early release. Her career, her reputation, her freedom – all gone.

These arent scare tactics. These are the actual penalties that federal judges impose on Brighton Beach clinic owners who are convicted of healthcare fraud.

What To Do When FBI Shows Up At Your Clinic

So the agents are at your door. Now what?

Step 1: Do not speak without an attorney.
The agents will seem friendly. They might say there just trying to understand your billing practices. They might suggest that cooperation will help you. Dont believe it. Every word you say becomes evidence. Memory errors become false statements. Explanations become admissions. Say nothing substantive until you have legal representation.

Step 2: Ask if they have a warrant.
If they have a search warrant, ask to see it. Read it carefully. The warrant specifies what they can search and what they can seize. They must stay within those bounds. If they dont have a warrant, you dont have to let them in. Tell them your attorney will be in touch.

Step 3: Dont destroy anything.
The moment you learn about an investigation, every document in your office becomes potential evidence. Destroying records – even records you think are irrelevant – can be charged as obstruction of justice. Thats a seperate federal crime that can add years to your sentence.

Step 4: Secure your electronic records.
They will want your computers, your billing software, your EHR system. Work with your attorney to understand what they can access and what protections might apply.

Step 5: Contact a federal healthcare fraud attorney immedietly.
Not your business lawyer. Not your malpractice attorney. Someone who specializes in federal healthcare fraud defense. This is a highly technical area of law and you need someone who knows the Strike Force, knows the prosecutors, knows how these cases work.

Defense Strategies That Work In Healthcare Cases

Healthcare fraud cases are defensible. People do win them. But the defenses that work are specific to this kind of prosecution.

Lack of Intent: The government must prove you knowingly and willfully participated in a scheme to defraud. If your billing errors were genuine mistakes – if you relied on staff or consultants or industry standard practices – thats not fraud. Intent is the hardest element for prosecutors to prove.

Reliance on Professionals: If you had a billing company, a compliance program, or professional coders handling your claims, you may have a defense based on reasonable reliance. You cant be expected to personally verify every code.

Industry Standard Practices: Sometimes what prosecutors call “fraud” is actualy common practice across the industry. If your billing looks like everyone elses billing, thats evidence against specific intent to defraud.

Constitutional Challenges: How did investigators get there evidence? Was the search warrant properly issued? Were subpoenas proper? Evidence obtained improperly can be suppressed.

Negotiated Resolution: Many healthcare fraud cases end in civil settlements rather than criminal convictions. You pay restitution, agree to compliance monitoring, maybe face exclusion – but you avoid prison. This is often the best realistic outcome.

The key is getting an attorney involved early, before you make statements, before you produce documents, before you damage your own defense.

The Immigration Consequences Nobody Mentions

If your not a US citizen, the stakes are even higher. Healthcare fraud is an “aggravated felony” under immigration law. That means mandatory deportation for non-citizens, even green card holders who’ve lived here for decades.

A conviction for healthcare fraud over a certain threshold makes you deportable. It also makes you permanantly inadmissable – meaning even if you leave volunterily, you can never come back. All those years building your practice, building your life in America – gone.

And the immigration consequences dont require a conviction. USCIS can use evidence from a criminal investigation – even one that dosent result in charges – as grounds for denying naturalization or green card renewal. The fact that you were under investigation can follow you forever.

If your facing a healthcare fraud investigation and your not a citizen, you need an attorney who understands both federal criminal defense AND immigration law. The decisions you make in the criminal case can have devastating immigration consequences that your criminal lawyer might not even think about.

For immigrant clinic owners, this isnt just about prison and fines. Its about wheather you can stay in the country you’ve called home.

What This Means For Your Clinic

If your a Brighton Beach clinic owner reading this because you just learned your under investigation, understand what your facing. This isnt a billing audit. This is a federal criminal investigation that has probly been running for months or years. The algorithms flagged you. There may be a whistleblower inside your practice. The prosecutors have experience with clinics exactly like yours.

But understanding the threat is the first step toward defending against it. Get an attorney who knows federal healthcare fraud. Understand your exposure. Develop a strategy.

Your clinic may survive this. Your license may survive this. You may avoid prison. But only if you take it seriously from the beginning, and only if you have experienced legal representation guiding every decision.

The worst thing you can do is assume you can explain your way out of it. The second worst thing is waiting to see what happens. The time to act is now.

Every day you wait is a day the government uses to strengthen there case. Every conversation you have without legal counsel is a potential source of evidence against you. Every document you handle without proper guidance could become a problem later.

Your clinic represents years of hard work, sacrifice, and service to your community. Dont let a federal investigation destroy everything youve built. Fight back – but fight smart, with the right legal team at your side.

The stakes are too high for anything less.