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What to Do if You Are Facing Federal Charges for Healthcare Fraud
Facing federal charges for healthcare fraud is a serious situation that can result in long-term consequences, including prison time, fines, loss of licensure, and exclusion from federal healthcare programs. Federal prosecutors take these allegations seriously and dedicate extensive resources to investigating and pursuing cases. If you have learned you are under investigation or have already been charged, you need to act quickly and strategically with the help of a Wisconsin federal criminal defense lawyer.
This blog explains what healthcare fraud looks like under federal law, how investigations usually unfold, what penalties you may face, and what to do next if you are being targeted.
How Does Federal Law Define Healthcare Fraud?
Federal healthcare fraud laws prohibit knowingly submitting false information to obtain money or benefits through a healthcare program. Most charges involve claims submitted to Medicare, Medicaid, or private insurance companies. These cases often fall under one or more federal statutes, including:
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18 U.S. Code § 1347, which makes it a crime to knowingly defraud a healthcare benefit program or obtain funds through false statements.
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False Claims Act (31 U.S.C. §§ 3729–3733), which targets false or fraudulent billing to federal programs.
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Anti-Kickback Statute (42 U.S.C. § 1320a-7b), which bans financial arrangements tied to patient referrals.
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Stark Law (42 U.S.C. § 1395nn), which prohibits self-referrals by physicians for services covered by Medicare or Medicaid when there is a financial conflict of interest.
Violations can occur even when someone believes they are complying with the rules, especially given the complexity of billing regulations.
What Types of Conduct Can Lead to Charges?
Healthcare fraud can take many forms, ranging from honest mistakes to intentional schemes. Common allegations include billing for services that were never provided, misrepresenting the type of service or its necessity, and providing kickbacks to obtain patient referrals.
Federal authorities also investigate billing for unapproved treatments, manipulating patient records to justify higher charges, or using fabricated provider or patient identities. In some cases, prosecutors may charge people with submitting false information without proving they intended to break the law.
How Do Healthcare Fraud Investigations Begin?
Many people are unaware that they are under investigation until federal agents arrive at their home or office. These cases are typically led by the Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), or, in some cases, the Drug Enforcement Administration (DEA) or Internal Revenue Service (IRS).
Investigations may begin after a whistleblower reports misconduct, particularly through a "qui tam" lawsuit under the False Claims Act. Data analytics may also flag unusual billing patterns, which can prompt an audit or deeper inquiry. In other cases, patient complaints or tips from competitors trigger a review of a provider’s practices.
An investigation may include subpoenas for records, interviews with employees, or even the execution of search warrants. You may receive a letter from the U.S. Attorney’s Office informing you that you are a target. Even if you have not yet been charged, you should take any government contact seriously.
What Are the Possible Penalties of Federal Healthcare Fraud?
Under federal law, a person convicted may face up to 10 years in prison per offense. If the alleged fraud caused serious bodily harm, that sentence could rise to 20 years. In cases involving death, a life sentence is possible.
In addition to prison time, a person may be fined up to $250,000 per count. Organizations may face fines of up to $500,000 per offense. Courts may also require restitution, which involves repaying the government or private insurers for any payments received as a result of the fraud. Civil penalties can include triple the amount billed plus thousands of dollars in fines per false claim.
Other consequences include being banned from participating in Medicare or Medicaid, losing professional licenses, and suffering damage to professional reputation. These penalties make it critical to respond to charges with an informed and aggressive legal strategy.
What to Do First if You Are Being Investigated for Healthcare Fraud
Being investigated for healthcare fraud by the federal government can be terrifying. If you feel as though you have done nothing wrong, you may be tempted to speak openly with investigators, thinking this will help your case. Unfortunately, this is not often true. The steps you take after you find out you are being investigated can make an enormous difference in the outcome of your case.
Do Not Speak to Investigators Without Your Lawyer Present
If you are contacted by federal agents, remain calm and do not answer questions without legal counsel. Even if the agents say they are just trying to clear things up, anything you say can be used against you later. You have the right to remain silent and to request an attorney. Exercise both.
Speaking to investigators without a lawyer can not only damage your defense but may also lead to additional charges if the government believes you misled them. Politely tell the agents that your attorney will contact them, then follow through.
Hire an Attorney With Federal Criminal Defense Experience
Not all criminal defense attorneys are equipped to handle healthcare fraud cases. You need a lawyer with specific experience in federal court and white-collar crime. Federal charges are different from state cases in terms of procedures, rules of evidence, and potential sentencing.
Preserve Records and Avoid Any Attempt to Hide Evidence
You may be tempted to delete emails or discard documents that seem incriminating. This is a mistake. Destroying or altering records can lead to obstruction of justice charges, which carry additional prison time and may severely hurt your credibility.
Keep Quiet About the Investigation
Talking about the case — even with trusted coworkers, friends, or family — can backfire. Anything you say to others could be repeated under oath or come to light during the investigation. Prosecutors may subpoena witnesses to testify about conversations, especially if they believe you tried to influence them. Keep all discussions about the investigation between you and your lawyer.
Can You Be Prosecuted Without Intent to Commit Fraud?
In civil cases under the False Claims Act, yes. Liability does not always require intent. A provider can be held responsible for submitting false claims even if the error was unintentional. However, criminal charges usually require proof that you knowingly and willfully engaged in fraud.
This difference is critical. Your attorney may be able to demonstrate that any errors were honest mistakes or the result of poor internal controls — not criminal behavior. This can lead to reduced penalties or dismissal of criminal charges altogether.
Contact a Milwaukee, WI Federal Criminal Defense Attorney
If you are facing federal charges for healthcare fraud, your future and your professional livelihood are on the line. Take control of your situation by contacting a Wisconsin federal healthcare fraud defense attorney with Gimbel, Reilly, Guerin & Brown, LLP. We have experience defending clients against complex fraud allegations and our firm has the resources you need to fully tackle the allegations while still providing outstanding service.
Call 414-271-1440 to schedule a confidential consultation and begin building your defense.
