At Varghese & Associates, P.C., we understand the devastating impact Medicare fraud allegations can have on medical professionals. Our team of dedicated Medicare fraud lawyers provides strategic defense representation for physicians, nurses, healthcare executives, and medical facilities facing federal investigations and charges.

What Constitutes Medicare Fraud in NYC?

Medicare fraud in NYC constitutes the intentional submission of false claims or misrepresentations to the Medicare program for financial gain. Under 18 U.S.C. § 1347, healthcare fraud is defined as knowingly executing a scheme to defraud any healthcare benefit program or obtaining money from healthcare benefit programs by false representations. Common forms include billing for services never provided, upcoding (billing for more expensive services than performed), kickbacks for referrals, providing unnecessary services, and falsifying patient records.

The penalties for Medicare fraud in NYC are severe, as defined in the False Claims Act (31 U.S.C. § 3729) and Anti-Kickback Statute (42 U.S.C. § 1320a-7b). Violations can result in civil penalties of up to $23,331 per false claim, treble damages (three times the federal government's loss), criminal fines, imprisonment for up to 10 years (20 years if resulting in serious bodily injury), exclusion from federal healthcare programs, and loss of professional licenses. The statute of limitations is generally six years from when the violation occurred or three years from when it was discovered.

How Our Medicare Fraud Defense Lawyers Can Protect Your Rights and Your Practice

At Varghese & Associates, P.C., our Medicare fraud lawyers implement comprehensive defense strategies designed to safeguard healthcare professionals facing federal investigations or charges in New York City.

• Early intervention: Our Medicare fraud defense lawyers engage with investigators at the earliest stages of an inquiry, often preventing allegations from developing into formal charges.
• Comprehensive case analysis: Our Medicare fraud lawyers meticulously review all documentation, billing records, and compliance procedures to identify weaknesses in the federal government's case and develop effective defense strategies.
• Government negotiations: Our Medicare fraud lawyers maintain professional relationships with federal prosecutors, enabling productive dialogue and potentially securing favorable pre-trial resolutions.
• Challenging evidence: Our healthcare fraud lawyers scrutinize the federal government's evidence, questioning statistical sampling methods, challenging witness credibility, and identifying procedural errors in the investigation.
• Intent defense strategies: Since Medicare fraud requires proof of knowing and willful intent, we often demonstrate that alleged violations resulted from administrative errors or misunderstandings of complex billing requirements.
• Compliance program implementation: Our Medicare fraud lawyers help establish or strengthen compliance programs that can serve as mitigating factors and demonstrate good faith efforts toward regulatory adherence.
• Trial representation: When necessary, our Medicare fraud lawyers provide aggressive courtroom advocacy, challenging the government's case with strategic cross-examination and compelling defense narratives.
• Sentencing advocacy: If conviction occurs, our Medicare fraud lawyers advocate for minimum penalties by presenting mitigating factors, personal circumstances, and alternative sentencing options.
• Administrative proceedings defense: Beyond criminal proceedings, our medicare fraud lawyers represent healthcare providers in licensure hearings, exclusion proceedings, and other administrative actions.

Varghese & Associates, P.C. understands the devastating impact Medicare fraud allegations can have on medical professionals. Our Medicare fraud lawyers are committed to protecting your professional reputation, practice, and freedom through strategic, comprehensive defense representation.

Common Medicare Fraud Charges For Medical Professionals

Medical professionals in New York may face various Medicare fraud allegations, which can lead to severe penalties under federal law. The following are common charges brought against healthcare providers:

• Billing for services not rendered: Submitting claims to Medicare for appointments, treatments, or procedures that never occurred.
• Upcoding: Billing for more expensive services or procedures than were actually provided or performed.
• Phantom billing: Charging for equipment, supplies, or services that patients never received.
• Kickbacks: Offering, paying, soliciting, or receiving remuneration (anything of value) in exchange for Medicare patient referrals, violating the Anti-Kickback Statute (42 U.S.C. § 1320a-7b).
• Medical necessity fraud: Ordering or performing tests, procedures, or services that are not medically necessary but billing Medicare for them.
• Unbundling: Submitting multiple bills for individual components when one comprehensive code exists, artificially increasing reimbursement.
• Stark Law violations: Engaging in prohibited physician self-referrals where a physician refers Medicare patients to entities with which they (or immediate family members) have financial relationships.
• Prescription fraud: Writing prescriptions for medications that are not medically necessary or diverting prescribed medications for unauthorized uses.
• Falsifying patient records: Altering medical documentation to justify unnecessary services or support fraudulent billing.
• Sample billing: Billing Medicare for free samples of medications or supplies provided by pharmaceutical companies.

Our medicare fraud lawyers understand that allegations don't always indicate intentional fraud. Many cases involve complex billing regulations, administrative errors, or documentation issues rather than deliberate attempts to defraud Medicare.Federal Enforcement of Medicare Fraud

Penalties of a Medicare Fraud Conviction in NYC

Our criminal defense attorneys witness the severe consequences that healthcare professionals face following Medicare fraud convictions under federal law. These penalties can devastate careers, personal finances, and professional reputations.

• Criminal fines: Individuals convicted of Medicare fraud may face substantial fines reaching into hundreds of thousands or even millions of dollars, depending on the scope of the fraud.
• Imprisonment: Medicare fraud convictions can result in federal prison sentences ranging from 5 to 10 years per violation, with potential 20-year sentences if the fraud resulted in patient harm.
• Civil monetary penalties: Under the False Claims Act, each false claim can trigger penalties of $12,537 to $25,076 per false claim, in addition to treble damages (three times the amount of the government's loss).
• Program exclusion: Convicted providers face mandatory exclusion from participation in Medicare, Medicaid, and all federal healthcare programs for a minimum of five years.
• License revocation: State licensing boards typically revoke or suspend professional licenses following Medicare fraud convictions, ending the ability to practice medicine.
• Corporate integrity agreements: Healthcare entities may be required to enter into burdensome compliance programs with strict government oversight lasting 3-5 years.
• Asset forfeiture: The government can seize property, accounts, and other assets connected to the fraud or purchased with fraudulently obtained funds.
• Restitution: Courts typically order convicted healthcare providers to repay the full amount fraudulently obtained from Medicare.
• Loss of hospital privileges: Medical professionals lose hospital affiliations and privileges, further limiting their ability to practice in their field.

At Varghese & Associates, P.C., our Medicare fraud lawyers work diligently to prevent these devastating consequences through strategic defense approaches designed to challenge allegations before they lead to conviction.

Defense Our Medicare Fraud Lawyers May Use

At Varghese & Associates, P.C., our Medicare fraud lawyers develop strategic defenses tailored to the specific allegations and circumstances of each case, drawing on our deep understanding of federal healthcare regulations and criminal defense principles.

• Lack of intent: Medicare fraud requires proof that the provider knowingly and willfully intended to defraud the program, and we often demonstrate that billing errors resulted from administrative mistakes or misunderstandings of complex regulations.
• Technical billing errors: Our healthcare fraud attorneys challenge allegations by showing that coding or billing issues stemmed from legitimate interpretations of ambiguous Medicare guidelines rather than fraudulent intent.
• Good faith compliance efforts: Our Medicare fraud attorneys highlight existing compliance programs, internal audits, and corrective actions as evidence of the provider's commitment to following Medicare regulations.
• Medical necessity defense: When appropriate, we work with medical consultants to establish that contested services or procedures were medically necessary and aligned with accepted standards of care.
• Statistical sampling challenges: Our Medicare fraud lawyers question the methodology and reliability of extrapolation techniques used by investigators to estimate alleged fraud amounts from limited sample sizes.
• Statute of limitations: Our Medicare fraud lawyers may assert that some or all charges are time-barred under applicable federal statutes of limitations.
• Constitutional violations: We identify and challenge any Fourth Amendment search and seizure violations or Fifth Amendment due process concerns in the government's investigation.
• Alternative explanations: We present legitimate business justifications for arrangements that prosecutors may have mischaracterized as kickbacks or improper referrals.
• Lack of materiality: We demonstrate that alleged misrepresentations were not material to Medicare's payment decisions, a crucial element in False Claims Act cases.

At Varghese & Associates, P.C., our healthcare fraud defense lawyers employ these and other defense strategies to protect medical professionals from unjust accusations, working toward case dismissals, reduced charges, or favorable settlements that preserve your practice and professional standing.

Signs You're Being Investigated for Medicare Fraud

As Medicare fraud lawyers in New York City, we've observed that federal investigations often begin long before formal charges are filed, with certain warning signs that alert healthcare providers to potential scrutiny. Recognizing these indicators early can provide crucial time to prepare an effective defense.

• Audit requests: Medicare contractors or the OIG requesting extensive documentation beyond routine reviews may indicate that your billing practices are under investigation.
• Unusual claim denials: A sudden increase in Medicare claim denials or requests for additional documentation could signal that your billing patterns have triggered fraud detection algorithms.
• Patient interviews: If patients report being contacted by federal agents asking about services they received from your practice, this strongly suggests an active fraud investigation.
• Subpoenas: Receiving formal document requests through subpoenas for patient records, financial documents, or communications is a definitive sign of an investigation.
• Site visits: Unannounced visits from Medicare representatives, OIG agents, or other federal investigators to your practice location almost certainly indicate ongoing scrutiny.
• Employee interviews: Current or former staff members being approached by federal agents for questioning about billing practices or operations suggests you're under investigation.
• Suspension of payments: If Medicare implements a payment suspension for your claims, this indicates serious concerns about potential fraud that warrant immediate attention.
• Search warrants: The execution of search warrants at your practice or home represents an advanced stage of investigation where authorities believe they have sufficient evidence of wrongdoing.
• Target letters: Receiving formal notification identifying you as the target of a federal investigation is an unambiguous indication that charges may be forthcoming.

At Varghese & Associates, P.C., our Medicare fraud lawyers recommend seeking immediate legal representation if you notice any of these warning signs, as early intervention by experienced healthcare fraud defense lawyers often provides the best opportunity to influence the investigation's outcome and protect your rights.

What To Do If Charged with Medicare Fraud

If you've been charged with Medicare fraud, taking immediate and strategic action is crucial to protecting your rights, your professional practice, and your future. The following steps can help you navigate this challenging situation effectively.

• Contact a Medicare fraud lawyer immediately: Secure representation from an attorney with specific experience in healthcare fraud defense before speaking to investigators or prosecutors about your case.
• Preserve all documentation: Maintain complete copies of all medical records, billing information, communications, and compliance materials that may be relevant to your defense.
• Limit communications: Avoid discussing your case with colleagues, employees, or on social media, as these communications could potentially be used against you.
• Review your insurance policies: Professional liability or errors and omissions policies may provide coverage for legal defense costs in regulatory proceedings or investigations.
• Conduct an internal audit: Work with your Medicare fraud lawyer to review your billing practices and identify any compliance issues that may need to be addressed.
• Evaluate settlement options: Consider whether negotiating a resolution with prosecutors might be preferable to protracted litigation, based on case strength and potential penalties.
• Prepare financially: Develop a financial plan to manage potential disruptions to your practice while defending against fraud allegations.
• Implement enhanced compliance measures: Demonstrate good faith by strengthening compliance protocols, which may serve as a mitigating factor in your case.
• Consider self-disclosure: In limited circumstances, voluntary disclosure of billing errors might help reduce penalties, but this strategy should only be pursued under the guidance of your Medicare fraud lawyer.

At Varghese & Associates, P.C., our healthcare fraud defense lawyers provide strategic guidance through every stage of Medicare fraud proceedings, working to achieve the most favorable outcome possible while minimizing damage to your professional reputation and practice.

Take Action Now to Protect Your Professional Future

When facing Medicare fraud allegations, timely legal representation can make the critical difference. At Varghese & Associates, P.C., our Medicare fraud lawyers provide strategic defense representation tailored to your unique circumstances. Contact us today for a confidential consultation to discuss your case and explore your legal options.

Medicare Fraud Defense Lawyer FAQs

What sets Varghese & Associates apart from other Medicare fraud lawyers?

Varghese & Associates, P.C. combines deep knowledge of federal healthcare regulations with extensive criminal defense experience in the New York City federal court system. Our Medicare fraud lawyers maintain professional relationships with federal prosecutors and investigators, enabling productive dialogue that often leads to favorable resolutions.

How quickly should I contact a Medicare fraud lawyer if I suspect an investigation?

Contact a Medicare fraud lawyer immediately upon noticing any signs of an investigation. Early intervention often provides the greatest opportunity to influence outcomes, protect your rights, and potentially prevent formal charges from being filed.

Will my case likely go to trial?

Many Medicare fraud cases resolve without trial through negotiated settlements or plea agreements. Our healthcare fraud defense lawyers thoroughly evaluate each case to determine whether fighting charges or negotiating a resolution will yield the most favorable outcome based on evidence strength and potential penalties.

How are Medicare fraud investigations typically initiated?

Medicare fraud investigations commonly begin through whistleblower (qui tam) complaints, data analysis identifying unusual billing patterns, patient complaints, or referrals from other law enforcement agencies. Understanding the investigation's source helps our Medicare fraud lawyers develop appropriate defense strategies.

What is a Corporate Integrity Agreement?

A Corporate Integrity Agreement (CIA) is a settlement option where healthcare providers agree to specific compliance obligations for 3-5 years in exchange for continued program participation. These agreements typically require independent monitoring, staff training, and regular reporting to the Office of Inspector General.

How long do Medicare fraud investigations take?

Medicare fraud investigations often continue for years before charges are filed. The investigative timeline depends on case complexity, cooperation level, and the prosecutor's caseload. Our Medicare fraud lawyers work to expedite resolutions when beneficial to clients.

Can I still practice medicine during an investigation?

In most cases, healthcare providers can continue practicing during investigations, though payment suspensions may occur. If formally charged, court-imposed conditions or licensing board actions may restrict practice. Our healthcare fraud defense lawyers fight to maintain your ability to practice throughout proceedings.

Does my malpractice insurance cover Medicare fraud defense?

Standard malpractice policies typically exclude coverage for fraud allegations, though some policies offer limited coverage for regulatory investigations or administrative proceedings. Our Medicare fraud lawyers can help you evaluate potential coverage options.

What if billing errors were made by my staff or billing company?

While you may not have personally submitted improper claims, healthcare providers often retain legal responsibility for their practice's billing. Our Medicare fraud lawyers help establish that errors resulted from negligence rather than intentional fraud, which can significantly impact case outcomes.

How can I protect my practice from future Medicare fraud allegations?

Implementing a robust compliance program—including regular audits, staff training, and documented oversight—serves as both preventive protection and a potential defense if allegations arise. Our healthcare fraud defense lawyers provide guidance on establishing effective compliance programs tailored to your practice.