Healthcare Fraud Charges in Federal Court: What Providers Need to Know

Healthcare professionals—doctors, pharmacists, billing coordinators, clinic managers, and administrators—are increasingly finding themselves under the scrutiny of federal agencies. What may begin as a routine audit or billing inquiry can quickly escalate into a criminal investigation for healthcare fraud, exposing providers to felony charges, financial penalties, asset seizures, and even prison time.

Healthcare fraud is one of the most aggressively prosecuted white-collar crimes in the federal system. It draws the attention of multiple government agencies, often through automated billing analysis, whistleblower reports, or data-sharing between insurers and law enforcement. For professionals working in healthcare, it’s critical to understand what these charges involve, how investigations begin, and what to do if you’re being targeted.

At Perlman Defense Federal Criminal Lawyers, we represent licensed providers and healthcare businesses facing federal healthcare fraud allegations. We understand the intricacies of Medicare billing, provider compliance, and federal criminal statutes. This guide breaks down what healthcare fraud looks like under federal law, how prosecutors build these cases, and what defense strategies can protect your career and freedom.

What Is Healthcare Fraud?

Healthcare fraud is defined as any act of deception or misrepresentation intended to obtain unauthorized benefits or payments from a healthcare program. When the fraud affects federal programs—such as Medicare, Medicaid, Tricare, or the VA—it becomes a federal offense.

Common statutes used to prosecute healthcare fraud include:

• 18 U.S.C. § 1347 – Health Care Fraud
  
• 42 U.S.C. § 1320a-7b – Anti-Kickback Statute
  
• 18 U.S.C. § 1035 – False Statements in Healthcare Matters
  
• 18 U.S.C. § 1349 – Conspiracy to Commit Fraud
  
• 18 U.S.C. § 1956 – Money Laundering (in fraud proceeds)
  

In many cases, these are paired with wire fraud, mail fraud, false claims, or conspiracy charges, increasing exposure and sentencing severity.

Common Types of Federal Healthcare Fraud Allegations

Federal prosecutors often focus on patterns of behavior that suggest a scheme to defraud government health programs. These may include:

1. Billing for Services Not Rendered
Submitting claims for office visits, procedures, or diagnostic tests that never took place.

2. Upcoding
Billing for more complex or expensive services than those actually provided (e.g., using CPT codes that exaggerate the service level).

3. Unbundling
Separating services normally billed together to increase reimbursement.

4. Kickbacks and Illegal Referrals
Paying or receiving anything of value in exchange for patient referrals or use of particular drugs, devices, or services (a violation of the Anti-Kickback Statute).

5. Ghost Patients or Phantom Billing
Submitting claims for non-existent patients or services provided to deceased individuals.

6. Prescription Fraud or Overprescribing
Issuing medically unnecessary prescriptions—particularly opioids—or submitting false pharmacy claims.

7. DME or Home Health Fraud
Billing for durable medical equipment (DME) or home health services not actually delivered or not medically necessary.

8. Provider Enrollment Fraud
Misrepresenting ownership, licensure status, or provider history when enrolling in Medicare or Medicaid.

Even honest mistakes in billing or coding can raise red flags. If the government believes those mistakes were part of a broader scheme, the case may shift from a civil audit to a criminal investigation.

Agencies Involved in Investigating Healthcare Fraud

Federal healthcare fraud investigations are rarely limited to one agency. These cases are often led by:

• Health and Human Services – Office of Inspector General (HHS-OIG)
  
• Federal Bureau of Investigation (FBI)
  
• Department of Justice (DOJ)
  
• Medicare Fraud Strike Force
  
• Centers for Medicare & Medicaid Services (CMS)
  
• Drug Enforcement Administration (DEA)
  
• Internal Revenue Service – Criminal Investigation (IRS-CI)
  

They often collaborate through data-sharing initiatives and coordinated enforcement programs. One example is the Healthcare Fraud Prevention Partnership (HFPP), a public-private collaboration designed to detect fraud across multiple payers.

Red Flags That May Trigger a Federal Investigation

Healthcare professionals are often caught off guard when they find themselves under federal investigation. Watch for these signs:

• Your practice is audited by Medicare or Medicaid contractors
  
• You receive a subpoena for billing records or patient files
  
• Other providers or staff members are questioned by agents
  
• A search warrant is executed at your office or home
  
• You receive a letter from HHS-OIG, DOJ, or the U.S. Attorney’s Office
  
• You’re asked to participate in an interview without a warrant
  

These events may signal that your practice, or your billing patterns, have been flagged by automated systems or through whistleblower complaints.

Penalties for Federal Healthcare Fraud

Healthcare fraud charges can result in severe criminal, civil, and administrative penalties, including:

• Up to 10 years in prison per count under 18 U.S.C. § 1347
  
• Up to 20 years if the fraud results in serious bodily injury
  
• Up to life in prison if the fraud results in death
  
• Fines up to $250,000 per offense (or more for organizations)
  
• Restitution to the government or affected programs
  
• Asset forfeiture of income or property related to the fraud
  
• Mandatory exclusion from Medicare/Medicaid participation
  
• Loss of DEA registration (for prescribers)
  
• Revocation of medical licenses or credentials
  

Many healthcare fraud cases also involve enhanced sentencing based on:

• Amount of financial loss
  
• Number of victims
  
• Role in the offense (organizer vs. participant)
  
• Abuse of position of trust
  
• Use of sophisticated means or shell companies
  

How Perlman Defense Fights Federal Healthcare Fraud Charges

At Perlman Defense Federal Criminal Lawyers, we know that a healthcare fraud charge doesn’t just threaten your freedom—it threatens your license, your livelihood, and your legacy. Our defense strategies are tailored to the specific facts, agency involvement, and goals of each client.

1. Challenging the Intent Element
Fraud requires intent. We show that errors in coding, billing, or documentation were accidental, due to third-party contractors, or part of systemic confusion—not criminal behavior.

2. Expert Review of Claims Data
We work with billing and coding experts to review claims data, showing compliance or inconsistencies in the government’s interpretation.

3. Suppressing Illegally Obtained Evidence
We challenge the validity of search warrants, subpoenas, and agent conduct—particularly when the Fourth or Fifth Amendments are at issue.

4. Disputing “Scheme” Theories
We contest claims that our client participated in a coordinated or ongoing scheme. Even when irregularities exist, they may not rise to the level of criminal conspiracy.

5. Negotiating Administrative or Civil Resolutions
In some cases, we resolve matters before indictment by working with DOJ or OIG to address compliance concerns without criminal charges.

6. Licensing and Collateral Consequences
We help healthcare professionals defend their licenses, credentials, and DEA numbers in parallel administrative proceedings.

What to Do If You’re Facing a Healthcare Fraud Investigation

If you’ve been contacted by HHS, served with a subpoena, or told you’re under investigation, take the following steps:

• Do not speak to federal agents without legal representation
  
• Do not alter or destroy records—this can lead to obstruction charges
  
• Do not contact witnesses or co-workers about the case
  
• Preserve all relevant documents, billing logs, and communications
  
• Hire a federal defense attorney experienced in healthcare fraud
  

Time is critical. Early legal intervention may prevent formal charges, limit exposure, or open the door to civil or administrative resolution.

Call Perlman Defense Federal Criminal Lawyers Today

If you're a doctor, pharmacist, clinic manager, or healthcare business owner under investigation for healthcare fraud, you're not alone—and you're not defenseless. At Perlman Defense Federal Criminal Lawyers, we have the skill, discretion, and deep federal experience to challenge fraud charges and protect your professional future.

Your license, your freedom, and your reputation are worth fighting for. Let’s begin your defense today.