Medicare Fraud Lawyer

A Medicare fraud case can bring up to 10 years in federal prison per count, massive restitution, loss of your license, and exclusion from Medicare, and it is prosecuted by dedicated Department of Justice strike forces that build cases from billing data before you are ever contacted. Doctors, home health and hospice agencies, hospitals, pharmacies, DME suppliers, telemedicine companies, and billing services are all frequent targets. Because Medicare fraud turns on proving intent, these cases are frequently defensible, but only with the right lawyer and an early start. If you or your practice is under investigation or audit in New York City, an experienced Medicare 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. Medicare 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 Medicare 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 Medicare fraud lawyer. The earlier our Medicare fraud defense lawyers are involved, the more they can do.

What Is Medicare Fraud?

Medicare fraud is the crime of knowingly using deception to obtain Medicare payments a provider is not entitled to, such as billing for services that were not provided, billing for more than was provided, billing for medically unnecessary care, paying or receiving kickbacks, or billing for services by unqualified staff. Medicare is a federal program, so Medicare fraud is charged under federal law and prosecuted by federal authorities. The defining element is intent, meaning the government must prove a knowing scheme to defraud, not a billing error or a good-faith coding mistake. That intent requirement is where an experienced Medicare fraud attorney concentrates the defense.

Who Investigates Medicare Fraud?

Medicare fraud is investigated by the Department of Health and Human Services Office of Inspector General, the FBI, and Department of Justice healthcare fraud strike forces, along with the contractors that audit Medicare claims, such as Unified Program Integrity Contractors and Medicare Administrative Contractors. These investigations rely heavily on billing-data analytics that flag providers whose patterns differ from their peers, and many cases begin as an audit or a records request that turns criminal, or with a whistleblower filing a False Claims Act suit. Because a routine audit can escalate into a criminal case, the response to that first contact is critical, and it is the most valuable time to bring in a Medicare fraud attorney.

What Are Examples of Medicare Fraud?

Common examples of Medicare fraud include billing for services never rendered, upcoding to higher-paying codes, unbundling services, billing for medically unnecessary care, home health and hospice fraud, DME fraud, and paying or receiving kickbacks for referrals. Certain areas, including home health, hospice, durable medical equipment, and telemedicine, draw especially heavy enforcement. In practice, Medicare fraud is rarely charged alone, and prosecutors frequently pair it with the Anti-Kickback Statute, conspiracy, and money laundering, stacking counts to increase both the pressure and the potential sentence.

Medicare Fraud and the Statutes Behind It

Medicare fraud is charged under a group of federal 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, for paying or receiving value for referrals (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)
• Exclusion from Medicare and other federal programs (42 U.S.C. § 1320a-7)

What Is a Medicare Audit?

A Medicare audit is a review of a provider's claims and records by a Medicare contractor to determine whether payments were proper, and it can lead to a repayment demand, a referral for fraud prosecution, or exclusion. Auditors often review a sample of claims and extrapolate the error rate across all of a provider's billing, which can turn a small sample into an enormous demand. How you respond to an audit, and how you challenge that extrapolation, can determine whether a matter stays civil or becomes criminal. Learn more on our Medicare audit defense page.

What Are the Penalties for Medicare Fraud?

Federal Medicare 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 mandatory 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 most providers, exclusion from Medicare is itself a practice-ending consequence. The severity of these penalties is exactly why an experienced Medicare fraud attorney should be involved as early as possible.

How Does Sentencing Work in a Medicare Fraud Case?

Federal Medicare 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 Medicare fraud case. Our Medicare 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 Medicare Fraud?

Medicare fraud turns on intent, and that is where the defenses concentrate. Every case is different, but the strategies our Medicare fraud lawyers commonly use include:

• No intent to defraud. Billing errors, coding mistakes, and good-faith disagreements about medical necessity are not crimes.
• Medical necessity. Showing the services were appropriate and supported by clinical judgment.
• Good-faith reliance. Reasonable reliance on billing staff, coders, or compliance advice can negate the required intent.
• Attacking the loss and extrapolation. Challenging the sampling and extrapolation methods that overstate the alleged loss.
• Documentation. Producing records that support the claims the government says were unsupported.
• 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 or Audit for Medicare Fraud?

If you learn you are under investigation for Medicare fraud, or receive an audit letter, subpoena, or visit from agents, do not talk to them, do not turn over records without counsel, and do not alter or destroy any documents. Call a Medicare fraud attorney immediately. Anything you say to an auditor or investigator can be used against you, and altering records after a matter 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 Medicare Fraud Attorneys Can Help You

Our Medicare 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.
• Audit defense. Challenging the sampling and extrapolation that drive repayment demands and fraud referrals.
• Protecting your license and enrollment. Coordinating the criminal defense with licensing-board and Medicare exclusion proceedings.
• Fighting the loss. Using forensic and clinical experts to challenge the government's damages methods.
• Motion practice and trial. Moving to dismiss defective counts, suppressing unlawfully obtained evidence, and trying cases before federal judges and juries.
• Sentencing and appeal. Challenging the loss calculation, arguing for variances, and pursuing appeals and post-conviction relief.

Is Medicare Fraud a Felony?

Yes. Federal Medicare fraud 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 mandatory exclusion from Medicare and Medicaid, which can permanently end a healthcare career or shut down a provider. That combination of criminal and program exposure is why every Medicare fraud allegation should be treated as serious from the start.

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

The cost of a Medicare 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, forensic and clinical analysis, and detailed motion practice, so they require real work. Our Medicare 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 Medicare 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 Medicare 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 Medicare Fraud Lawyer Now

If you are under investigation, are facing an audit that may be turning criminal, have received a subpoena, or have been charged with Medicare fraud anywhere in New York City, do not wait and do not talk to anyone but your lawyer. A Medicare 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.