At Varghese & Associates, we understand that healthcare professionals facing fraud allegations need strong legal representation to protect their reputation, livelihood, and freedom. Our team of dedicated healthcare fraud defense lawyers has a proven track record of successfully navigating the complexities of healthcare fraud cases throughout New York.

Contact Varghese & Associates today for a confidential consultation with a healthcare fraud defense lawyer who understands the complexities of these cases and will vigorously defend your rights at every stage of the process.

How a Healthcare Fraud Defense Lawyer Can Defend Your Rights

At Varghese & Associates, our healthcare fraud defense lawyers provide strategic legal representation to protect healthcare professionals facing serious allegations. When federal or state authorities target you or your practice, we implement comprehensive defense strategies to safeguard your rights, reputation, and career.

• Early Intervention Strategies: Our healthcare fraud defense lawyer team can engage with investigators before formal charges are filed, potentially preventing charges or limiting their scope while protecting your constitutional rights throughout the process.
• Thorough Evidence Analysis: We meticulously review all documentation, including patient records, billing procedures, compliance protocols, and electronic health records to identify weaknesses in the prosecution's case.
• Regulatory Knowledge Application: Our NYC criminal defense lawyer team leverages deep understanding of healthcare regulations to challenge misinterpretations of complex billing rules and demonstrate good faith compliance efforts.
• Expert Witness Coordination: We collaborate with medical coding specialists, healthcare administrators, and other professionals who can testify about industry standards and explain why your actions were reasonable and appropriate.
• Strategic Negotiation Approach: When beneficial, our healthcare fraud defense lawyer can negotiate with prosecutors for reduced charges, alternative resolutions, or civil settlements that minimize potential consequences.
• Investigation Procedural Challenges: We scrutinize how evidence was gathered, identifying any procedural violations that could lead to suppression of key evidence or dismissal of charges.
• Intent Requirement Defense: Our team works to demonstrate lack of fraudulent intent by presenting evidence of good faith efforts to comply with regulations and highlighting administrative errors rather than deliberate misconduct.
• Parallel Proceedings Management: We coordinate defense strategies across simultaneous criminal, civil, administrative, and licensing board actions to ensure consistent and effective representation across all forums.
• Medicare/Medicaid Audit Defense: Our healthcare fraud defense lawyer team responds to program audits with comprehensive documentation supporting the medical necessity and appropriateness of services billed.
• Documentation Substantiation: We gather and present evidence supporting the medical necessity of services provided, proper documentation practices, and adherence to coding requirements.
• Digital Evidence Analysis: Our NYC criminal defense lawyer professionals thoroughly examine electronic health records, billing software data, and other digital evidence to identify exculpatory information and technical defenses.
• Trial Representation Excellence: When cases proceed to trial, we provide compelling courtroom advocacy including strategic jury selection, effective witness cross-examination, and clear explanation of complex healthcare regulations.
• Reputation Protection Strategies: Throughout the process, we implement approaches designed to minimize reputational damage and protect your ability to practice in the future.
• Administrative Resolution Development: We craft compliance plans and corrective action proposals that can serve as alternatives to prosecution or mitigate penalties.

Penalties for Healthcare Fraud in NYC

At Varghese & Associates, our healthcare fraud defense lawyers understand that penalties for healthcare fraud in New York City can be severe and life-altering. Federal and state authorities impose multi-layered consequences that can impact your professional practice, personal freedom, and financial stability.

• Federal Criminal Penalties: Healthcare fraud prosecuted under 18 U.S.C. § 1347 carries potential imprisonment of up to 10 years per count, which can increase to 20 years if the fraud results in serious bodily injury and life imprisonment if it results in death.
• State Criminal Sanctions: New York State prosecutes healthcare fraud under multiple statutes with penalties ranging from misdemeanor charges for smaller frauds to Class B felonies carrying up to 25 years imprisonment for schemes exceeding $1 million.
• Substantial Financial Fines: Our healthcare fraud defense lawyer team has seen federal cases resulting in fines of up to $250,000 per individual count or $500,000 per organization, while New York State imposes additional fines based on the fraud amount.
• False Claims Act Liability: Violations can trigger treble damages (three times the amount of the fraud) plus penalties of $11,803 to $23,607 per false claim submitted after June 19, 2020.
• Mandatory Restitution Orders: Courts typically order full repayment of all fraudulently obtained funds to government programs or private insurers, often amounting to millions of dollars in large cases.
• Program Exclusion Consequences: The Office of Inspector General can exclude individuals and entities from participation in Medicare, Medicaid, and all federal healthcare programs for minimum periods of 5 years and potentially permanently.
• Asset Forfeiture Actions: Our NYC criminal defense lawyer professionals regularly defend against government seizure of personal and business assets believed to be connected to fraudulent activities or purchased with proceeds of fraud.
• Civil Monetary Penalties: Administrative penalties can reach $100,000 per violation for various healthcare fraud schemes, particularly those involving kickbacks or patient inducements.
• Professional License Revocation: The New York State Office of Professional Medical Conduct and other licensing boards typically initiate proceedings that can result in license suspension, restriction, or permanent revocation.
• Insurance Network Termination: Private insurers almost invariably terminate provider contracts following fraud allegations, resulting in immediate loss of patient base and revenue streams.
• Corporate Integrity Agreements: To avoid exclusion, providers may be required to enter costly 5-year compliance programs with independent monitors, regular reporting, and strict oversight requirements.
• Reputation Damage Consequences: Beyond formal penalties, public reporting of allegations causes irreparable damage to professional standing in the community and can permanently affect career opportunities.
• Personal Financial Collapse: Our healthcare fraud defense lawyer team has witnessed how legal defense costs, coupled with inability to practice and substantial financial penalties, often lead to bankruptcy and personal financial devastation.
• Collateral Professional Impacts: Medical societies and professional organizations typically revoke memberships and certifications, further limiting future practice opportunities and professional advancement.

If you are facing healthcare fraud allegations in NYC, immediate consultation with an experienced healthcare fraud defense lawyer is critical to potentially mitigate these severe penalties. Contact Varghese & Associates today to discuss strategic defense options and protection of your rights throughout the investigation and prosecution process.

Healthcare Fraud Defense Cases We Take

At Varghese & Associates, our healthcare fraud defense lawyers represent clients across the full spectrum of healthcare fraud allegations in New York and federal courts. We provide strategic defense for healthcare professionals and organizations facing investigations or charges from government agencies and private insurers.

• Medicare Fraud Allegations: Our healthcare fraud defense lawyer team defends against accusations of improper Medicare billing, including upcoding, phantom billing, and services not medically necessary while navigating the complex Medicare regulatory landscape.
• Medicaid Fraud Investigations: We represent healthcare providers facing state Medicaid Fraud Control Unit investigations, addressing allegations ranging from billing irregularities to quality of care issues with thorough documentation review and strategic defense planning.
• Anti-Kickback Violations: Our team defends clients against accusations of receiving or providing illegal remuneration for patient referrals, developing defenses based on safe harbor provisions and legitimate business arrangements.
• Stark Law Self-Referral Cases: Our criminal defense attorneys handle cases involving alleged improper financial relationships between physicians and designated health service providers, analyzing complex exceptions and demonstrating compliance with regulatory requirements.
• False Claims Act Allegations: Our healthcare fraud defense lawyer professionals defend against whistleblower (qui tam) lawsuits and government prosecutions alleging submission of false claims to federal healthcare programs, focusing on documentation integrity and compliance efforts.
• Private Insurance Fraud: Our criminal defense lawyers represent healthcare professionals facing accusations from commercial insurers regarding billing practices, medical necessity determinations, and contractual compliance issues.
• Electronic Health Record Misuse: Our NYC criminal defense lawyer team addresses allegations regarding improper documentation, cloning of records, or manipulation of EHR systems to support fraudulent billing claims.
• Controlled Substance Prescribing Issues: Our healthcare fraud defense attorneys defend healthcare providers against allegations of improper prescribing practices, pill mill operations, or diversion of controlled substances through thorough analysis of prescription patterns and patient records.
• Billing Company/Consultant Liability: We represent medical billing companies and consultants facing derivative liability for healthcare providers' alleged fraudulent billing, establishing appropriate standards of care and documentation.
• Multi-Agency Investigations: Our healthcare fraud defense lawyer team coordinates responses to complex investigations involving multiple federal and state agencies, including DOJ, HHS-OIG, FBI, and state licensing boards.
• Corporate Integrity Agreement Violations: Our healthcare fraud attorneys defend healthcare entities accused of violating the terms of Corporate Integrity Agreements, demonstrating good faith compliance efforts and addressing alleged reporting failures.
• Healthcare Fraud Conspiracy Charges: Our NYC criminal defense lawyer professionals defend clients against allegations of conspiracy to commit healthcare fraud, working to distinguish legitimate business practices from fraudulent schemes.
• Mail and Wire Fraud in Healthcare: We handle healthcare fraud cases where electronic transmissions or mailings form the basis of fraud charges, challenging the government's evidence regarding intent and interstate commerce requirements.
• Grand Jury Subpoena Responses: Our healthcare fraud lawyer team guides healthcare professionals through grand jury proceedings, managing document production and witness testimony while protecting constitutional rights.

What Constitutes Healthcare Fraud?

Healthcare fraud occurs when an individual or entity knowingly and willfully executes or attempts to execute a scheme to defraud any healthcare benefit program or to obtain money or property from a healthcare benefit program through false representations.

• Billing for Services Not Rendered: The submission of claims for medical services, procedures, or supplies that were never actually provided to patients. Under 18 U.S.C. § 1347, this constitutes healthcare fraud when done "knowingly and willfully" as part of a "scheme or artifice to defraud any healthcare benefit program."
• Upcoding Services: Reporting CPT or HCPCS codes that reflect higher-paying services than those actually performed. The Centers for Medicare & Medicaid Services (CMS) explicitly prohibits this practice, defining it as "reporting a higher level of service than was actually provided."
• Unbundling Charges: Billing separately for procedures that should be billed under a single code. Medicare regulations at 42 C.F.R. § 424.5(a)(6) require that claims be filed "in accordance with CMS instructions," which explicitly prohibit this practice.
• Medically Unnecessary Services: Providing and billing for services that do not meet the Medicare standard of being "reasonable and necessary for the diagnosis or treatment of illness or injury," as defined in Section 1862(a)(1)(A) of the Social Security Act.
• Kickbacks for Referrals: Offering, paying, soliciting, or receiving remuneration to induce patient referrals. The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) makes this a criminal offense, stating it is illegal to "knowingly and willfully offer or pay any remuneration...to induce such person...to refer an individual for the furnishing of any item or service."
• Stark Law Violations: Physician self-referrals to entities with which the physician has a financial relationship. Under 42 U.S.C. § 1395nn, "if a physician...has a financial relationship with an entity...the physician may not make a referral to the entity for the furnishing of designated health services."
• Prescription Drug Fraud: Writing prescriptions for medications that are not medically necessary or diverting prescription drugs for illegal use. The Controlled Substances Act (21 U.S.C. § 841) makes it unlawful for any person to "knowingly or intentionally distribute or dispense a controlled substance" outside the course of professional practice.
• False Certifications: Falsely certifying that services were necessary or provided as described. The False Claims Act (31 U.S.C. § 3729) imposes liability on any person who "knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim."
• Phantom Billing: Submitting claims for patients who are deceased, no longer in treatment, or otherwise not receiving services. Our healthcare fraud defense lawyer team regularly defends against these allegations, which violate 18 U.S.C. § 1347 when done with knowledge and intent.
• Identity Theft and Misrepresentation: Using another provider's identification or credentials to bill for services. The Aggravated Identity Theft statute (18 U.S.C. § 1028A) adds a mandatory consecutive two-year sentence for "knowingly transfer[ring], possess[ing], or us[ing], without lawful authority, a means of identification of another person" during healthcare fraud.
• Electronic Health Record Manipulation: Falsifying electronic health records to justify services or increase reimbursement. Under HITECH Act regulations (45 CFR § 170.314), certified EHR systems must maintain an audit log that makes such alterations detectable.
• Billing for Non-covered Services as Covered: Misrepresenting services not covered by Medicare or Medicaid as covered services. Our NYC criminal defense lawyer professionals note this violates the False Claims Act as it involves "knowingly present[ing]...a false or fraudulent claim for payment or approval."
• Patient Brokering: Paying individuals to recruit patients for treatment programs, particularly in substance abuse treatment. Many states, including New York under N.Y. Pub. Health Law § 4308, explicitly prohibit this practice.
• Fraudulent Cost Reporting: Inflating operational costs to increase reimbursement from Medicare. Under 42 U.S.C. § 1320a-7b(a), it is a felony to "knowingly and willfully make[] or cause[] to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program."

If you are under investigation for any of these activities, it is crucial to consult with a healthcare fraud defense lawyer immediately. At Varghese & Associates, our NYC criminal defense lawyer team provides strategic defense against these complex allegations, working to demonstrate lack of fraudulent intent, compliance with regulatory safe harbors, or appropriate interpretation of ambiguous billing guidelines.

What To Do If Charged with Healthcare Fraud in New York

Our healthcare fraud defense lawyers understand that being charged with healthcare fraud can be overwhelming and frightening for medical professionals. Taking immediate, strategic action is essential to protect your rights, reputation, and future in this critical moment.

• Contact a Healthcare Fraud Defense Lawyer Immediately: Before speaking with investigators, prosecutors, or even colleagues, consult with an experienced attorney who can protect your rights and begin building your defense strategy from the earliest stages.
• Preserve All Documentation: Secure and organize all relevant patient records, billing documents, correspondence with insurers, internal memoranda, and electronic communications without altering or destroying any potential evidence.
• Limit Communications About Your Case: Our healthcare fraud defense lawyer team advises against discussing your case with anyone except your attorney, as statements to colleagues, employees, or friends could potentially be used against you later.
• Understand the Specific Allegations: Work with your attorney to obtain and review the charging documents, search warrants, or subpoenas to clearly identify exactly what conduct is being alleged and what evidence the prosecution claims to have.
• Assess Parallel Proceedings Risk: Recognize that healthcare fraud often triggers multiple simultaneous actions, including criminal charges, civil lawsuits, administrative sanctions, and licensing board investigations requiring coordinated defense strategies.
• Implement a Response to Licensing Boards: Our NYC criminal defense lawyer professionals can help you properly notify and respond to state licensing authorities while protecting your right against self-incrimination in related criminal proceedings.
• Evaluate Insurance Coverage Issues: Determine whether your professional liability or directors and officers insurance policies provide coverage for defense costs in fraud allegations and properly notify carriers if coverage exists.
• Secure Expert Witnesses Early: Work with your healthcare fraud defense lawyer to identify and retain medical, coding, billing, and compliance experts who can analyze records and testify regarding industry standards and practices.
• Consider Internal Investigation Benefits: In some cases, conducting a thorough internal investigation with attorney-client privilege protection can identify exculpatory evidence and compliance efforts that demonstrate good faith.
• Address Media Inquiries Strategically: Develop a media response plan with your legal team to protect your reputation while avoiding statements that could damage your legal position in pending proceedings.
• Evaluate Potential Conflicts of Interest: If multiple providers or staff members are under investigation, our healthcare fraud defense lawyer team can assess whether separate representation is necessary to avoid conflicts between defendants.
• Review Compliance Programs: Examine existing compliance programs to identify strengths that demonstrate good faith efforts to prevent fraud and weaknesses that may need to be addressed in defense strategy.
• Prepare Financial Resources: Understand the potential financial impact of the case, including legal fees, potential fines, and practice interruption, and organize financial resources accordingly with appropriate professional guidance.
• Consider Proactive Settlement Possibilities: In some situations, our NYC criminal defense lawyer team may recommend approaching prosecutors early with corrective action plans, compliance improvements, or settlement proposals before positions harden.

Protect Your Practice, Reputation, and Future

Don't face healthcare fraud allegations alone. Contact Varghese & Associates today for a confidential consultation with a healthcare fraud defense lawyer who understands the complexities of these cases and will vigorously defend your rights at every stage of the process.

Healthcare Fraud Defense Lawyer FAQs

When should I involve a healthcare fraud defense lawyer if I receive a request for documentation from Medicare?

While routine audits are common in healthcare, certain red flags suggest you should consult a healthcare fraud defense lawyer immediately: requests covering multiple years of records, unusually broad document requests, involvement of law enforcement agencies, or requests focusing on specific billing codes that have been problematic in recent enforcement actions. Early intervention by counsel can often prevent routine reviews from escalating into formal investigations.

How does the statute of limitations apply to healthcare fraud cases?

Federal healthcare fraud charges typically carry a five-year statute of limitations under 18 U.S.C. § 3282, while cases brought under the False Claims Act have a longer six-year period. However, our healthcare fraud defense lawyer team cautions that certain exceptions can extend these timeframes. The government may argue for the "continuing offense" theory to extend the period, or in cases involving conspiracy, the clock may start only when the last overt act occurred.

Can my practice continue operating during a healthcare fraud investigation?

In most cases, healthcare practices can continue operating during investigations, though with potential restrictions. Our NYC criminal defense lawyer professionals often negotiate arrangements with prosecutors to allow continued practice while implementing enhanced compliance measures. However, if the criminal charges include allegations of patient harm or severe compliance failures, administrative authorities may impose temporary suspensions or restrictions during the pendency of the case.

Are whistleblower complaints in healthcare fraud cases kept confidential?

Federal False Claims Act whistleblower (qui tam) complaints remain under court seal for at least 60 days while the government investigates, often extended for months or years. During this period, healthcare providers typically remain unaware they are under investigation. Once unsealed, the whistleblower's identity usually becomes public, though our healthcare fraud defense lawyer team can sometimes negotiate confidentiality provisions in settlement agreements.

How are "intent" and "knowledge" proven in healthcare fraud cases?

Prosecutors typically establish intent through circumstantial evidence such as pattern of conduct, departure from standard practices, ignoring compliance warnings, unusual financial arrangements, or attempts to conceal activities. Internal communications, including emails and text messages about billing practices, often become critical evidence. Our healthcare fraud defense lawyer team works to demonstrate good faith efforts to comply with complex regulations and absence of specific intent to defraud.

What role do statistical sampling and extrapolation play in healthcare fraud cases?

Government agencies often review a limited sample of claims and extrapolate findings across a larger universe of claims to calculate overpayment amounts or damages. Our NYC criminal defense lawyer professionals frequently challenge these methodologies as statistically invalid or legally inappropriate, particularly when unique patient circumstances make each claim determination fact-specific rather than suitable for extrapolation.

How do healthcare fraud investigations impact hospital privileges and insurance network participation?

Mere investigations can trigger reporting obligations to hospitals and insurance networks, potentially resulting in suspension of privileges or network participation pending resolution. Our healthcare fraud defense lawyer team can often negotiate arrangements allowing continued participation with enhanced monitoring or other temporary safeguards, preventing devastating practice interruptions during what may be lengthy investigations.

What happens if healthcare fraud is discovered during a merger or acquisition?

Discovering potential fraud during due diligence can derail transactions or significantly impact valuations. The acquiring entity may face successor liability unless proper disclosure and resolution occur. Our healthcare fraud defense lawyer team can assist with voluntary disclosures, compliance program implementation, and negotiation with government agencies to facilitate transactions while mitigating liability risks.

Can healthcare providers be held responsible for fraud committed by billing companies or consultants?

Yes. While providers may delegate billing functions, they cannot delegate legal responsibility for claims submitted under their provider numbers. Our NYC criminal defense lawyer professionals advise implementing oversight mechanisms for third-party billing companies, including regular audits, compliance certifications, and indemnification provisions to mitigate these risks.

How do electronic health record systems affect healthcare fraud investigations?

Modern EHR systems create detailed audit trails showing exactly who accessed records, when changes were made, and what was modified. Government investigators now routinely analyze these metadata during fraud investigations. Our healthcare fraud defense lawyer team works with forensic IT experts to evaluate EHR evidence and challenge misleading interpretations of routine documentation practices.