Healthcare fraud involves knowingly and willfully submitting false claims or misrepresenting services to get payments from federal programs like Medicare or Medicaid. It’s a federal crime that can lead to prison, fines, and exclusion from government healthcare programs.

Healthcare fraud is investigated by multiple federal and state agencies. The most active federal agencies include:

• The Department of Health and Human Services, Office of Inspector General (HHS-OIG)

• The Federal Bureau of Investigation (FBI)

• The U.S. Department of Justice (DOJ), including the Criminal Division and U.S. Attorney’s Offices

• Medicaid Fraud Control Units (MFCUs)

• Centers for Medicare & Medicaid Services (CMS), which conducts audits and refers suspicious activity to law enforcement.

• These agencies often collaborate through task forces and use data analytics to detect suspicious billing patterns.

• If you are contacted by any of these agencies, you should consult a healthcare fraud defense attorney before responding.

Common Medicare fraud schemes include:

• Phantom billing: Charging for services never provided

• Upcoding: Billing for a more expensive service than was performed

• Unbundling: Charging separately for services that should be billed as one

• Billing for medically unnecessary services

• Kickbacks for patient referrals:  These schemes often trigger investigations by the DOJ, HHS, or the Medicare Fraud Strike Force.

Medical equipment fraud is a major focus of Medicare enforcement. It often involves:

• Billing for durable medical equipment (DME) never delivered

• Using stolen patient IDs to file false DME claims

• Providing kickbacks to doctors for equipment prescriptions

• Enrolling fake companies to submit fraudulent claims

Agencies like the FBI, HHS, and Medicaid Fraud Control Units investigate fraud through audits, subpoenas, and data analytics. These investigations review billing records, compliance practices, and communications to build a case. A skilled lawyer can help you respond strategically and avoid escalation.

Yes. A civil investigative demand is a federal notice that you're under investigation. It’s not a routine request.  It often signals the start of a healthcare fraud case. An experienced CID defense lawyer can help you respond carefully, protect your rights, and prevent criminal charges.

Yes, especially if they are repeated or appear intentional. Even honest billing errors can trigger fraud investigations if they’re widespread. If your practice is under audit or investigation, consult a healthcare fraud defense lawyer immediately.

The False Claims Act allows the federal government—or whistleblowers—to sue providers who knowingly submit false claims. Penalties include fines over $20,000 per claim and triple damages. If you’ve been named in a qui tam lawsuit, consult a False Claims Act defense attorney immediately.

The Anti-Kickback Statute (AKS) is a federal law that makes it illegal to offer, pay, solicit, or receive anything of value in exchange for referrals for services covered by Medicare, Medicaid, or other federal healthcare programs. This includes cash, gifts, rent deals, or bonuses. Violations can lead to criminal prosecution, civil penalties, and exclusion from federal programs.

Examples of AKS violations include:

• Paying physicians for patient referrals

• Offering free medical equipment in exchange for exclusive contracts

• Waiving co-pays to attract more patients

• Providing financial incentives to marketers for bringing in federally insured patients

• Even well-intentioned arrangements can trigger liability if they involve patient referrals for medical services involving federal programs.

The AKS (42 U.S.C. § 1320a-7b) is a federal law that makes it a felony for anyone to “knowingly and willfully” pay or receive any kickback, bribe, or rebate in exchange for referrals of services reimbursed by Medicare, Medicaid or other federal health programs. To convict someone under the AKS, the government must prove both the act (giving or receiving remuneration for referrals) and the required mens rea: that the defendant acted knowingly and willfully. In plain terms, the person must have intentionally engaged in the transaction and understood (or was reckless about) the fact that it was wrongful. This mens rea requirement ensures that only deliberate pay-for-referral schemes are punished under the statute.

The government builds healthcare fraud cases using a wide range of evidence, including:

• Billing and claims data submitted to Medicare or Medicaid

• Medical records and documentation of services provided

• Emails, text messages, or internal communications suggesting intent or knowledge

• Testimony from whistleblowers, former employees or co-conspirators who have pled guilty and are cooperating with the government for leniency at sentencing

• Data analytics to identify abnormal billing patterns or statistical outliers

• Subpoenaed documents and interview transcripts This evidence is often used to show a pattern of fraud or to prove intent.

Healthcare fraud charges can lead to suspension or revocation of a medical license, even before conviction. Licensing boards often act based on allegations alone, for example an indictment. A lawyer can help protect your professional license and advise you on how to respond during investigations.