Medical Billing Fraud Attorney

Medical billing fraud is a type of healthcare fraud that accuses a provider of submitting false or inflated claims to Medicare, Medicaid, or a private insurer, and a conviction can carry up to 10 years in prison per count, along with heavy restitution, loss of your license, and exclusion from federal programs. These cases often turn on how a service was coded, whether it was medically necessary, and whether a billing pattern reflects fraud or ordinary error, and they are frequently built from billing-data analytics before you are ever contacted. Because the government must prove intent, medical billing fraud is often defensible, but only with the right lawyer and an early start. If you or your practice is under investigation in New York City, an experienced medical billing fraud attorney should be your first call.

Varghese & Associates, P.C. is a federal criminal defense firm on Wall Street, in the heart of the Southern District of New York. Medical billing fraud defense is a core part of our healthcare fraud defense practice, and the firm is led by Vinoo Varghese, a former prosecutor and one of the most recognized criminal defense attorneys in the country. Our medical billing fraud attorneys handle these matters in house, from the first audit or subpoena through investigation, indictment, trial, sentencing, and appeal. Matters are not routed out to other firms.

Call now for a confidential consultation with a New York City medical billing fraud lawyer. The earlier our medical billing fraud defense lawyers are involved, the more they can do.

What Is Medical Billing Fraud?

Medical billing fraud is the crime of knowingly submitting false, inflated, or misleading claims to a healthcare program or insurer in order to obtain payments a provider is not entitled to, such as billing for services not provided, coding a service as more expensive than what was done, or billing for medically unnecessary care. It is a form of healthcare fraud charged under federal and state law. The defining element is intent, meaning the government must prove a knowing scheme to defraud, not a billing error, a coding disagreement, or a good-faith mistake. That intent requirement is where an experienced medical billing fraud attorney concentrates the defense.

What Are the Types of Medical Billing Fraud?

The main types of medical billing fraud are upcoding, unbundling, phantom billing, double billing, and billing for medically unnecessary services. Each describes a different way the government claims a provider inflated or falsified claims:

• Upcoding, billing for a more expensive service or a higher level of care than was actually provided.
• Unbundling, billing separately for services that should be billed together under a single code.
• Phantom billing, billing for services, tests, or visits that never happened.
• Double billing, submitting the same claim more than once or to more than one payer.
• Medically unnecessary services, billing for care the government says was not needed.
• Misrepresentation, billing under the wrong provider or for services performed by unlicensed staff.

What Is Upcoding?

Upcoding is a form of medical billing fraud in which a provider bills using a code for a more expensive service, a longer visit, or a higher level of care than was actually provided, in order to receive a larger payment. It is one of the most commonly alleged types of billing fraud, because it can be spotted in billing data when a provider's codes skew toward higher-paying levels. But a higher-level code is not automatically fraud. It may reflect a genuinely complex patient, a documentation issue, or a coding judgment call. Whether an upcoding allegation is fraud or a good-faith coding decision is often the central question, and it is where our medical billing fraud attorneys focus the defense.

Who Is Investigated for Medical Billing Fraud?

The government investigates physicians, medical practices, hospitals, clinics, billing companies, and practice managers for medical billing fraud, along with the individuals who oversee coding and submit claims. These cases are built by the FBI, HHS-OIG, Medicaid Fraud Control Units, and private-insurer investigators, often using billing-data analytics that flag providers whose patterns differ from their peers. A provider can be pulled into a case based on statistics alone, before anyone has looked at whether the care was actually appropriate. Because these allegations can arise from data rather than any real misconduct, an early and well-documented defense is critical.

Medical Billing Fraud and the Statutes Behind It

Medical billing fraud is charged under federal and New York statutes, and prosecutors often use several at once. The charges most often in play include:

• Healthcare fraud (18 U.S.C. § 1347)
• False statements relating to healthcare matters (18 U.S.C. § 1035)
• Federal Anti-Kickback Statute, where referrals are involved (42 U.S.C. § 1320a-7b(b))
• Conspiracy to commit healthcare fraud (18 U.S.C. § 1349)
• The civil False Claims Act, which often runs alongside a criminal case (31 U.S.C. §§ 3729 through 3733)
• New York health care fraud (N.Y. Penal Law Article 177)

What Are the Penalties for Medical Billing Fraud?

Federal medical billing fraud carries up to 10 years in prison per count, up to 20 years if a patient suffered serious bodily injury, and up to life if it resulted in death, along with heavy fines, restitution, forfeiture, and exclusion from Medicare and Medicaid. Because each claim can be charged as a separate count, exposure can multiply quickly, and the civil False Claims Act can add treble damages on top. For a provider or a billing company, exclusion from federal programs is itself a business-ending consequence. The severity of these penalties is exactly why an experienced medical billing fraud attorney should be involved as early as possible.

How Does Sentencing Work in a Medical Billing Fraud Case?

Federal medical billing fraud sentences are calculated under the United States Sentencing Guidelines, where the single biggest driver is the intended or actual loss, meaning the amount the government says was fraudulently billed. Prosecutors often calculate loss by treating every questioned claim as fraudulent, or by extrapolating from a sample, which dramatically overstates the number. Challenging that loss figure and the sampling behind it is one of the most valuable fights in a billing fraud case. Our medical billing fraud attorneys contest the loss calculation, challenge enhancements, present detailed mitigation, and argue for a sentence below the guideline range.

What Are the Defenses to Medical Billing Fraud?

Medical billing fraud turns on intent and on how services were coded, and that is where the defenses concentrate. Every case is different, but the strategies our medical billing fraud lawyers commonly use include:

• No intent to defraud. Coding errors, documentation gaps, and good-faith coding judgments are not crimes.
• Correct coding. Showing that the codes billed were supported by the records and the complexity of the care.
• Medical necessity. Demonstrating that the services were appropriate for the patient.
• Good-faith reliance. Reasonable reliance on billers, coders, or compliance advice can negate the required intent.
• Attacking the data and extrapolation. Challenging the statistical methods that turn a sample into a large alleged loss.
• Suppression. Where records were obtained through an unlawful search or subpoena, moving to suppress under the Fourth Amendment.

What Should You Do If You Are Under Investigation for Medical Billing Fraud?

If you learn you are under investigation for medical billing fraud, or receive an audit letter, subpoena, or visit from agents, do not talk to investigators, do not turn over records without counsel, and do not alter or recreate any records or claims. Call a medical billing fraud attorney immediately. Anything you say can be used against you, and altering records after an investigation begins can create a separate obstruction charge. You have the right to remain silent and the right to counsel. Preserve everything, say nothing without counsel, and let your lawyer engage the auditors and prosecutors.

How Our Medical Billing Fraud Attorneys Can Help You

Our medical billing fraud defense lawyers defend these matters at every stage, and they look for the earliest possible point at which the case can be won or shrunk:

• Early intervention. Responding to audits, subpoenas, and target letters to keep a matter civil where possible and to negotiate a declination or reduced charges before an indictment.
• Coding and documentation defense. Working with coding and clinical experts to show the billing was correct or, at worst, an honest error.
• Fighting the loss and extrapolation. Challenging the government's damages and sampling methods.
• Protecting your license and enrollment. Coordinating the criminal defense with licensing-board and Medicare or Medicaid exclusion proceedings.
• Motion practice and trial. Moving to dismiss defective counts, suppressing unlawfully obtained evidence, and trying cases before federal and New York judges and juries.
• Sentencing and appeal. Challenging the loss calculation, arguing for variances, and pursuing appeals and post-conviction relief.

Is Medical Billing Fraud a Felony?

Yes. Medical billing fraud charged under the federal healthcare fraud statute is a felony, punishable by up to 10 years in prison per count, and up to 20 years or life if a patient suffered serious bodily injury or death. Beyond prison, a conviction brings fines, restitution, forfeiture, loss of licensure, and exclusion from federal healthcare programs, which can permanently end a medical career or shut down a billing business. That combination of criminal and professional exposure is why every medical billing fraud allegation should be treated as serious from the start.

How Much Does It Cost to Hire a Medical Billing Fraud Lawyer in New York City?

The cost of a medical billing fraud lawyer in New York City depends on whether the matter is a civil audit or a criminal case, the volume of billing and medical records, whether a parallel False Claims Act case exists, and whether it resolves before or goes to trial. These cases involve extensive record review, coding and clinical analysis, and detailed motion practice, so they require real work. Our medical billing fraud attorneys are transparent about fees from the first conversation and structure the representation to fit the matter. Given the prison exposure and the threat to your license and livelihood, the more important question is usually what an inadequate defense can cost you.

A Medical Billing Fraud Attorney the National Media Turns To

When the biggest federal cases in the country are in the news, networks and newspapers call Vinoo Varghese to explain what is really happening in the courtroom. That is the same judgment and credibility our medical billing fraud attorneys bring to your case.

Vinoo Varghese has provided legal analysis and commentary for CBS News, Fox News, Fox Business, CNN, MSNBC, Court TV, HLN, BBC, Inside Edition, i24 News, Sky News Arabia, and Nancy Grace's Crime Stories, and has hosted true-crime legal analysis for Vanity Fair. He has been quoted as a legal authority by The New York Times, The Wall Street Journal, the New York Law Journal, Law360, the New York Daily News, and the New York Post. A former prosecutor from the Brooklyn District Attorney's Office, he is a nine-time National Trial Lawyers Top 100 honoree, an eight-time New York Metro Super Lawyer, rated AV Preeminent by Martindale-Hubbell, and has served on the visiting faculty of Harvard Law School's Trial Advocacy Workshop.

Contact a New York City Medical Billing Fraud Lawyer Now

If you or your practice is under federal or state investigation, is facing an audit that may be turning criminal, has received a subpoena, or has been charged with medical billing fraud anywhere in New York City, do not wait and do not talk to anyone but your lawyer. A medical billing fraud attorney who has stood in the courtroom and tried the cases can change what happens next.

Call Varghese & Associates, P.C. for a confidential consultation. Our office is located at 2 Wall Street, Suite 310, New York, NY 10005, steps from the federal courthouses of the Southern District of New York.