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Healthcare Fraud Defense

At Elliott Sauter, our defense attorneys have years of experience as federal prosecutors working on healthcare matters. This experience gives us a unique and valuable perspective on how to analyze, deconstruct and defend against allegations of fraud. As trial lawyers, we understand how the government conducts its investigation and the tactics it employs at trial. There is no substitute for trial experience.

Healthcare fraud covers a broad scope of activities, but is generally defined as the intentional filing of false claims for medical services in order to obtain money from healthcare programs. The claims at issue are normally related to services either not being rendered or services that are deemed to be medically unnecessary.

Forms of health care fraud include, but are not limited to:

  • Billing for care that was never given
  • Billing for services that are ineligible for reimbursement
  • Intentionally dispensing less or more medication than prescribed
  • Filling duplicate claims
  • Intentionally reporting a diagnosis, procedure, and/or services incorrectly
  • Employing unlicensed and unqualified staff
  • Prescribing unnecessary treatment and/or prescriptions
  • Offering or accepting improper payment in return for referrals

Criminal prosecutions are initiated and pursued against targets that the government believes intentionally defrauded health insurance programs. This includes private insurance programs as well as federally funded programs such as Medicare, Tricare, Medicaid and DOL (federal workers compensation insurance) to name a few.

Healthcare fraud enforcement is a priority for the federal government as it involves millions of citizens compiled in thousands of insurance pools, billions of dollars, and in some instances may involve conduct that potentially places patients in harm’s way. The adverse effects of healthcare fraud can be long lasting and negatively impact a large number of people and companies, even those not directly involved.

Successful prosecution may result in incarceration, fines, loss of professional license, and exclusion from federal programs.

Cases of this nature are quickly becoming more commonplace. In fact, fraud, extortion, and bribery offenses account for 6.4% of federal prisoners alone.

When prosecuting these cases, the government’s goals are first and foremost, the incarceration of the convicted individual(s) and secondly, locating and recovering the assets to satisfy restitution and penalties.


Criminal healthcare charges carry significant penalties with up to ten years imprisonment and fines of up to $250,000 per count. In addition to this, federal wire and mail fraud statutes may increase penalties to up to twenty years imprisonment.

Recent Department of Justice initiatives to thwart healthcare fraud has brought on increased attention to medical practices, hospitals, labs, pharmacies, surgery centers, and MSO’s (management services organizations) among others. With this increased attention comes more audits and investigations.

It’s worth noting that many states have their own individual laws regarding complimentary insurance fraud statutes that ensure further compliance. Also, healthcare fraud may affect professional licensing. Again, this depends on your specific circumstances, area of practice and state. You may need to protect your license with state and association licensing.

Three Steps To Protecting Your Practice Or Company


Secure A Criminal Healthcare Attorney

If you suspect you are the target of a criminal healthcare investigation, you need to act quickly to retain competent counsel. The sooner you take the steps necessary to prepare, the more efficient your defense will be.


Gather Documentation

Collect all relevant documents related to the case to the best of your ability. Documentation will be used to show how your practice has acted ethically and legally.


Understand The Law

It is vital to understand the laws and regulations that affect your practice or area of employment. Many organizations have a compliance officer who does this. If you do not have a compliance officer, identify a person at your practice or company who will act in that capacity and seek guidance from a trained legal professional who can get them started in their new role.

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