Medicare Fraud Defense · False Claims Act · Anti-Kickback Statute · Stark · Criminal

Medicare Fraud Defense Attorneys

Treble damages, exclusion, and federal prison on the same set of facts.

Medicare fraud, waste, and abuse allegations cross several federal statutes at once. The False Claims Act (31 USC § 3729) imposes treble damages plus per-claim civil penalties of up to $27,894. The Anti-Kickback Statute (42 USC § 1320a-7b) imposes criminal liability and is regularly charged alongside § 1347 healthcare fraud.

The Stark Law (42 USC § 1395nn) imposes strict-liability civil restrictions on physician self-referral. Federal criminal healthcare fraud (18 USC § 1347) carries up to 10 years per count, 20 years if serious bodily injury, and life if death. Mandatory HHS-OIG exclusion (42 USC § 1320a-7(a)) attaches to felony convictions, ending federal healthcare program participation.

Health Law Alliance defends Medicare fraud matters across pharmacies, physicians, hospitals, home health, hospice, DME, and wound care providers. Our defense framework coordinates the civil FCA track, the criminal track, the HHS-OIG exclusion track, and any state Medicaid Fraud Control Unit (MFCU) parallel proceeding from the first contact forward.

5,000+

Federal & State Healthcare Matters

100+

Combined Years at DOJ, HHS-OIG & CMS Co's

Levels of Medicare Appeal Through Federal Court

24/7

Response, From Document Request to ALJ

Medicare Fraud Defense Hotline · Direct Line

(800) 345 - 4125

Speak with counsel who has defended Medicare FCA, AKS, Stark, and criminal healthcare fraud matters nationwide. Privileged. Available 24/7.

Federal contact on a Medicare matter? Speak with counsel before you respond.

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What Happens Next

Within 2 hours: A Health Law Alliance attorney reviews your matter and the procedural posture.

Same day: Strategy call. We walk you through the contractor's framework, the document request response, the extrapolation methodology, and the appeal track from redetermination through ALJ.

Engaged or not: You leave the call with a clear read on the matter. No pressure, no retainer required.

The Stakes

A Medicare fraud allegation compounds three exposures at once: financial, liberty, and program-participation

False Claims Act treble damages and per-claim penalties produce eight-figure exposure on routine claim counts, and most matters reach the government through a qui tam relator before any federal contact. Parallel Anti-Kickback Statute and Stark Law theories pile on. Criminal healthcare fraud carries up to 10 years per count, 20 years if serious bodily injury, and life if death. Mandatory HHS-OIG exclusion ends federal healthcare program participation, which for most provider businesses is industry exit. The defense framework has to address all of these exposures from the first federal contact forward.

Treble damages plus per-claim penalties under the False Claims Act
Criminal exposure: up to 10 years per count under 18 USC § 1347
Mandatory exclusion ends federal healthcare program participation

Treble damages plus per-claim penalties under the False Claims Act

31 USC § 3729(a) imposes treble damages on the government's actual loss plus per-claim civil penalties of $13,946 to $27,894 per false claim (2026-indexed schedule). A claim count in the thousands produces a baseline penalty exposure in the tens of millions before damages are added. The math drives DOJ's settlement posture. Voluntary self-disclosure under DOJ's protocol can reduce the multiplier to 1.5x or 2x in qualifying matters; without VSD, the treble damages math is the floor for any negotiated resolution.

Financial Exposure

Criminal exposure: up to 10 years per count under 18 USC § 1347

Federal criminal healthcare fraud under 18 USC § 1347 carries up to 10 years per count, 20 years if the offense results in serious bodily injury, and life if it results in death. Conspiracy (§ 1349) is punishable to the same extent. The Anti-Kickback Statute (42 USC § 1320a-7b) carries up to 10 years per count and is regularly charged alongside § 1347. Federal healthcare fraud indictments routinely include 10 to 30 counts. USSG § 2B1.1 sentencing tables turn alleged loss amounts into prison-term math: a $1M alleged loss can produce a 41-to-51-month guideline range; $10M can produce 87-to-108 months.

Liberty Exposure

Mandatory exclusion ends federal healthcare program participation

42 USC § 1320a-7(a) imposes mandatory exclusion (minimum five years) from Medicare, Medicaid, TRICARE, FEHB, and any other federal healthcare program upon felony conviction for healthcare fraud, AKS, or other program-related crimes. Permissive exclusion under § 1320a-7(b) covers a broader set of conduct including misdemeanor convictions and FCA settlements. For most provider businesses, exclusion is industry exit; the exclusion outcome is often more consequential than the prison-time outcome. Charge-bargaining a felony down to a misdemeanor is the central exclusion-avoidance move.

Program Exposure

Why Medicare Fraud Defense Is Different

Four structural features make Medicare fraud defense fundamentally distinct from civil litigation or general white-collar practice

Medicare fraud sits at the intersection of complex healthcare regulation, federal civil and criminal procedure, and the Sentencing Guidelines. Defense counsel that does not know the regulatory framework misreads the materiality and intent issues. Defense counsel that does not know the parallel-proceeding framework misses the cross-track exposure. Both ends matter from the first federal contact forward.

Factor 01

Multiple statutes apply to the same conduct.

A single underlying matter can produce overlapping liability under the False Claims Act (civil treble damages), the Anti-Kickback Statute (criminal under § 1320a-7b, civil under § 1320a-7a), the Stark Law (strict-liability civil under § 1395nn), 18 USC § 1347 (criminal healthcare fraud), § 1349 (conspiracy), and the Civil Monetary Penalties Law. The defense framework has to address each statute on its own terms, identify the strongest defense across all of them, and avoid producing admissions in one statutory framework that compromise the defense in another.

Factor 02

Parallel civil and criminal proceedings share evidence.

Most federal Medicare fraud matters produce overlapping civil FCA exposure, criminal investigation, HHS-OIG investigation, and state MFCU matters. Evidence developed in one track typically becomes evidence in the others. Statements made to civil investigators can be used in the criminal case. The defense framework has to coordinate across all tracks from the first contact or risk locking in admissions that hurt the criminal defense later. The parallel proceeding doctrine and Fifth Amendment privilege issues are central to the coordination.

Factor 03

Pre-indictment is the highest-leverage window.

Once the indictment files, the public record fixes the posture. Pre-indictment, the prosecutor still has discretion: declination, deferred prosecution agreement (DPA), non-prosecution agreement (NPA), narrowed indictment, or charge-bargained plea. Pre-indictment moves include attorney proffer of the factual rebuttal, written submissions to the line prosecutor and supervisor, presentation to the U.S. Attorney's Office white-collar review committee, and engagement with HHS-OIG and the Fraud Section in Washington. Each of those moves is harder, slower, and less productive after the grand jury votes.

Factor 04

Exclusion analysis is often more consequential than the dollar number.

For most provider businesses, mandatory HHS-OIG exclusion under § 1320a-7(a) is industry exit. A felony conviction for healthcare fraud or AKS triggers mandatory five-year exclusion. A misdemeanor plea generally triggers only permissive exclusion under § 1320a-7(b), which gives HHS-OIG discretion. Charge-bargaining the felony down to a misdemeanor is the central exclusion-avoidance move and is meaningfully harder after the indictment files than before. Coordinating the criminal plea negotiation with the parallel HHS-OIG exclusion negotiation is essential. The defense framework should reflect that the exclusion outcome is often more consequential than the prison-time outcome.

The HLA Medicare Fraud Defense Process

A four-stage protocol built for parallel civil FCA, criminal, and HHS-OIG exclusion exposure

Our bench includes a former Assistant U.S. Attorney with DOJ Director's Award recognition and senior healthcare-company counsel. We have defended Medicare fraud matters across False Claims Act, Anti-Kickback Statute, Stark, and criminal healthcare fraud allegations. We have produced DOJ declinations on $6M alleged fraud after pre-charge presentation, defeated multi-count federal indictments through pre-trial motion practice, and produced sentencing reductions through USSG loss-amount advocacy. This is the protocol.

Document request response and audit scope evaluation
Initial determination engagement and statistical methodology challenge
Formal appeals: redetermination, QIC reconsideration, ALJ hearing
Parallel FCA and criminal coordination if the contractor refers

Conference room — Where defense is built

Document request response and audit scope evaluation

From the day the contractor's notice arrives: identify the contractor type (UPIC, RAC, MAC, SMRC, CERT), evaluate the audit type (prepayment review, postpayment review, focused medical review, automated review), the claim window covered, and the document request as written. Most document requests can be narrowed through written response on scope and timing. We conduct a privileged pre-production review of every document before it leaves the practice, which preserves defenses for the appeal track and avoids producing material that becomes evidence in any subsequent FCA or criminal matter.

Initial determination engagement and statistical methodology challenge

When the contractor issues findings: respond on the substantive defense for each flagged claim and challenge the statistical methodology where postpayment extrapolation is used. The methodology challenge focuses on sample frame defects, sample size deficiencies, RAT-STATS application errors, and Cochran formula objections. A successful methodology challenge at this stage often reduces the recoupment demand by a meaningful percentage before the matter reaches the formal appeal track.

Formal appeals: redetermination, QIC reconsideration, ALJ hearing

The Medicare appeal track requires the right record at every level. We draft and file the redetermination request to the MAC within the 120-day window, prepare the QIC reconsideration with the substantive and statistical record, and present to the Administrative Law Judge with witness preparation, expert testimony where applicable, and a procedural record built to support the ALJ's decision. The record built at the redetermination and QIC stages is the record the ALJ reviews; defense counsel that skips ahead loses the procedural foundation.

Parallel FCA and criminal coordination if the contractor refers

When Medicare audit findings produce a referral to HHS-OIG, the DOJ Civil Division, or the local U.S. Attorney's office: civil FCA defense (CID response, intervention or declination engagement, Rule 9(b) motion practice) and criminal defense (target letter response, attorney proffer, grand jury subpoena management) run in parallel with the Medicare appeal. Our former-federal-prosecutor bench coordinates the Medicare appeal, the civil FCA matter, and the criminal track as one matter to avoid locking in admissions in one forum that hurt the defense in another.

Common Medicare Fraud Triggers

The six patterns that produce a federal Medicare fraud investigation

Medicare fraud matters surface through specific channels. The trigger shapes the procedural posture, the realistic exposure, and the parallel-proceeding analysis that should drive the response framework.

Data analytics flags from peer comparator analysis.

CMS provides contractors with claims data and peer comparator analytics. Providers whose billing patterns fall in the top decile of their peer group on a specific code, code combination, or modifier usage face elevated review frequency. Common high-risk patterns include high E/M code distribution (CPT 99214 and 99215 over 80% of visits), high modifier 25 utilization, high modifier 59 utilization, and outlier reimbursement per beneficiary on Part B drug administration.

Qui tam relator or whistleblower complaint referral.

A qui tam complaint filed with DOJ under seal can produce a contractor referral when the DOJ Civil Division wants the contractor's billing analysis to support the FCA case. Internal whistleblower hotline reports, when escalated outside the company, can produce the same referral pipeline. The contractor's document request often does not identify the underlying relator complaint, but the document scope tracks the relator's allegations closely enough that experienced defense counsel can identify the underlying matter.

Prior contractor findings cascade across review tracks.

A RAC overpayment determination, a MAC medical review with high error rate, an SMRC focused review with adverse findings, or a CERT sample finding can produce a downstream UPIC review. Each contractor inherits the prior contractor's findings as the starting point for its own review and can expand the scope materially. Providers who have closed a prior contractor matter without a clean record should anticipate the next contractor's follow-up.

Specialty-specific enforcement initiatives.

CMS contractors run focused enforcement initiatives targeted at specific specialties or service lines. Recent examples include skin substitute applications following the Apex Medical $309M FCA settlement, debridement coding following the Vohra $45M settlement, hospice eligibility review, home health face-to-face documentation, and remote patient monitoring billing. Providers operating in an initiative-targeted area face elevated review regardless of individual billing patterns.

Medicare Drug Integrity Contractor (MEDIC) referral on Part D.

For Part D matters (pharmacies dispensing Medicare prescription drug benefit claims), the Medicare Drug Integrity Contractor identifies suspicious patterns and refers them to the UPIC for parallel medical review. The MEDIC and UPIC tracks coordinate, which means a Part D investigation at the pharmacy level can produce a UPIC review at the prescriber level (or vice versa). Cross-track exposure is common in opioid, GLP-1, and specialty drug dispensing patterns.

State Medicaid Fraud Control Unit (MFCU) cross-referral.

State MFCUs investigate Medicaid fraud and refer matters to CMS contractors for parallel Medicare review when the provider participates in both programs. The MFCU investigation can produce a Medicare review that the provider did not anticipate. The state-federal coordination is increasingly tight, and defense counsel that handles only one side often misses procedural exposure on the other.

Recent Medicare Audit Defense Outcomes

Representative Case Results

Outcomes are summarized for confidentiality. Client names, precise geography, and identifying facts are redacted.

Recoupment Reversed

Statistical Extrapolation Challenge Reduces Recoupment by Substantial Margin.

Provider received a postpayment review finding with statistical extrapolation across a multi-year claim window. Health Law Alliance challenged the contractor's sample frame, sample size methodology, and RAT-STATS application errors at the redetermination and QIC reconsideration stages. The extrapolated recoupment demand was reduced to the actual sample-claim amount, a small fraction of the original number. The procedural record built at the redetermination level supported the QIC's reduction without requiring an ALJ hearing.

Federal · Healthcare provider · 2024

DOJ Declination

DOJ Declines Civil and Criminal Action After Medicare Audit Referral.

Healthcare company received a Medicare contractor referral that produced a Civil Investigative Demand from the DOJ Civil Division covering alleged $6M in false claims. Health Law Alliance produced documents under a negotiated rolling schedule, presented the factual rebuttal of the government's theory in a meeting with the line attorneys, and prepared a written submission addressing the materiality and falsity defects. DOJ declined both civil intervention and criminal referral. Pre-unsealing engagement, when the matter surfaces through other channels, is the highest-leverage window in any FCA matter.

National scope · Healthcare company · 2024

Indictment Dismissed

Federal Healthcare Fraud Indictment Following Medicare Audit Referral Collapses.

Solo physician faced a multi-count federal indictment that included healthcare fraud counts following an upstream Medicare contractor referral to the local U.S. Attorney. Health Law Alliance filed responsive motions, built the procedural record, and challenged the government's theory through pre-trial motion practice; the indictment collapsed before trial. The Medicare-audit-to-criminal escalation risk is real in matters where the contractor's findings include intent evidence; a unified defense across the appeal track and the parallel criminal track is the most efficient way to avoid the criminal exposure.

Northeast · Solo physician · 2025

Attorney advertising. Prior results do not guarantee a similar outcome. Case summaries are generalized for confidentiality and are not a substitute for legal advice on your specific matter.

Medicare Fraud Defense FAQ

Frequently Asked Questions

Seven questions that come up on almost every first call. The answers below are general; specific situations require privileged consultation.

What is the difference between Medicare fraud, waste, and abuse? +

CMS distinguishes three categories. Fraud is the intentional deception or misrepresentation made for personal gain or to obtain benefits not entitled to (false claims, kickbacks, identity theft). Waste is overuse of services or other practices that result in unnecessary costs to the Medicare program (typically not intentional). Abuse is provider practices that are inconsistent with sound medical or business practices and result in unnecessary costs (often involving billing for services not medically necessary or not meeting recognized standards). Fraud allegations carry the highest exposure (False Claims Act treble damages, criminal prosecution under 18 USC § 1347, mandatory exclusion). Waste and abuse typically produce administrative remedies (overpayment recovery, prepayment review). The category determines the procedural framework and the realistic exposure.

What statutes apply to Medicare fraud cases? +

Several federal statutes apply, often charged together. The False Claims Act (31 USC § 3729) imposes treble damages plus per-claim civil penalties on knowing presentation of false claims. The Anti-Kickback Statute (42 USC § 1320a-7b) imposes criminal liability on knowing and willful payment or receipt of remuneration to induce referrals. The Stark Law (42 USC § 1395nn) imposes strict-liability civil restrictions on physician self-referral. Healthcare fraud (18 USC § 1347) is the primary criminal healthcare fraud statute carrying up to 10 years per count, 20 years if serious bodily injury, life if death. Conspiracy (18 USC § 1349) makes attempt and conspiracy punishable to the same extent. The Civil Monetary Penalties Law (42 USC § 1320a-7a) and the Beneficiary Inducement Statute add specialized exposure in particular contexts.

How does the Anti-Kickback Statute differ from the Stark Law? +

Two distinct statutes with different intent requirements and different reach. The Anti-Kickback Statute (42 USC § 1320a-7b) is criminal and requires specific intent (knowing and willful). It applies to any item or service for which payment may be made under a federal healthcare program, regardless of who refers. Safe harbors at 42 CFR § 1001.952 protect specified arrangement structures. The Stark Law (42 USC § 1395nn) is a strict-liability civil statute (no intent required). It applies only to physician referrals for designated health services to entities with which the physician has a financial relationship. Stark exceptions are different from AKS safe harbors and have to be satisfied in their entirety. The two often overlap in compensation and referral arrangements; the analysis has to address both frameworks separately.

What is mandatory exclusion from federal healthcare programs? +

42 USC § 1320a-7(a) imposes mandatory exclusion (minimum five years) from Medicare, Medicaid, TRICARE, FEHB, and any other federal healthcare program upon conviction of certain offenses: program-related crimes, patient abuse or neglect, felony healthcare fraud, and felony controlled substance offenses. Permissive exclusion under § 1320a-7(b) is at HHS-OIG's discretion and applies to a broader set of conduct including misdemeanor convictions, license revocation, and FCA settlements. For most provider businesses, exclusion is industry exit; the exclusion outcome is often more consequential than the prison-time outcome. Charge-bargaining a felony down to a misdemeanor is the central exclusion-avoidance move and is meaningfully harder after the indictment files than before.

What is voluntary self-disclosure (VSD) and when does it make sense? +

Both DOJ Civil Division and HHS-OIG publish voluntary self-disclosure protocols. A qualifying VSD reduces the FCA damages multiplier from treble (3x) to between 1.5x and 2x and can avoid HHS-OIG exclusion or a corporate integrity agreement. To qualify, the disclosure has to be timely (before the government already has the information from another source), complete (full scope of the conduct, the affected claims, and the calculated damages), and accompanied by remediation (discipline of responsible individuals, repayment, corrective compliance measures). VSD makes sense when the conduct is provable, an internal investigation has confirmed the scope, and the risk of an independent relator filing first is meaningful. VSD makes less sense when the matter is borderline, the privileged investigation is incomplete, or disclosure would expose unrelated conduct.

Can a single matter produce parallel civil FCA and criminal exposure? +

Yes, regularly. Most federal Medicare fraud matters produce overlapping exposure: a civil FCA action through DOJ Civil Division (CID, qui tam complaint, intervention or declination), a criminal investigation through the local U.S. Attorney or DOJ Fraud Section (target letter, grand jury subpoena, potential indictment under § 1347 or § 1349), an HHS-OIG investigation that runs in parallel, and often a state Medicaid Fraud Control Unit (MFCU) matter. Evidence developed in one track typically becomes evidence in the others. Statements made to civil investigators can be used in the criminal case. The defense posture has to coordinate across all tracks from the first contact or risk locking in admissions that hurt the criminal defense later.

When should I engage counsel in a Medicare fraud matter? +

At the first sign of any federal contact: a CID, an HHS-OIG subpoena, a grand jury subpoena, an FBI or HHS-OIG agent at the door, a target letter, a DOJ Fraud Section opening letter, or a Medicare contractor referral that includes intent indicators. Pre-indictment is the highest-leverage window in any criminal healthcare fraud defense; pre-unsealing is the highest-leverage window in any qui tam matter. The earlier counsel is engaged, the more options the defense has: declination, deferred prosecution agreement, non-prosecution agreement, charge bargaining, civil-only resolution, voluntary self-disclosure with reduced multiplier. Engagement after the indictment files or after the qui tam unseals materially constrains the available moves.

Speak with Medicare Fraud Defense Counsel Today

Medicare fraud allegations cross several federal statutes at once — the defense framework has to address all of them from day one

Before the indictment files, before the qui tam unseals, before the HHS-OIG exclusion track locks in, have a privileged conversation with attorneys who defend Medicare fraud matters across False Claims Act, Anti-Kickback Statute, Stark, and criminal healthcare fraud allegations. Free, confidential, no retainer.

"We received a Civil Investigative Demand and a target letter within the same week. Health Law Alliance coordinated the civil and criminal defense as one matter from day one, presented the factual rebuttal of the government's theory in two separate meetings, and produced documents on a rolling schedule that protected every available privilege. DOJ declined both civil intervention and criminal prosecution. The defense started before the indictment could attach." - General counsel, healthcare services company (anonymized client, 2024)

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