Medicaid Fraud Defense Attorneys

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Established Lawyers Representing Clients Accused of Medicaid Fraud

Brian Kuester
Attorney Brian Kuester
Medicaid Fraud Defense Team Lead
Former US Attorney
Former District Attorney
Ellen Comley
Attorney Ellen Comley
Medicaid Fraud Defense Team Lead
Senior Counsel
Roger Bach
Roger Bach
Medicaid Fraud Defense Team Consultant
Former Special Agent (OIG)

Medicaid fraud investigations can have severe and long-term consequences for providers in all facets of the health care industry. To protect yourself, your business, your patients, and your employees, you need to take a proactive approach focused on favorably resolving the investigation as quickly as possible. At The Criminal Defense Firm, our experienced healthcare fraud defense lawyers and former state and federal prosecutors provide aggressive legal representation for Medicaid fraud investigations across the nation.

Medicaid provides critical access to health care for millions of Americans. It also helps financially support countless medical practices, pharmacies, clinics, hospices, and other health care providers and facilities, and it plays a central role in the U.S. health care economy. Unfortunately, with state and federal government agencies paying hundreds of billions of dollars for beneficiaries’ treatment, medications, and palliative care every year, Medicaid has also become a primary target for fraud. With billions lost to fraud on an annual basis, prosecuting those who inappropriately take advantage of Medicaid has become a top priority at both the state and federal level.

With investigators, agents, and prosecutors aggressively pursuing individuals and organizations suspected of Medicaid fraud, many innocent and legitimate providers are finding themselves being targeted by the Office of Inspector General’s (OIG) Medicaid Fraud Control Units (MFCUs), and state Medicaid authorities. These investigations may seem harmless (often starting with requests for “interviews” of certain key personnel); but, the reality is that by the time you find out you are being investigated, the government already believes it may have a case against you. This means that avoiding charges for Medicaid fraud is an uphill battle, and it is one for which you need experienced legal representation.

Medicaid Fraud Defense Lawyers at The Criminal Defense Firm

The Criminal Defense Firm’s team of health care fraud defense lawyers brings decades of government and private-sector experience to representing providers in all sectors facing Medicaid fraud investigations. We have significant experience in health care fraud investigations at the state and federal levels, including numerous cases involving allegations of intentional and inadvertent Medicaid billing violations. With backgrounds in litigation and health care law compliance, our attorneys offer a material set of skills that can be custom-tailored to the needs of health care providers who are being targeted for Medicaid enforcement.

Common Issues in Medicaid Fraud Investigations

There are numerous forms of Medicaid fraud, and most investigations tend to focus on a number of common recurring issues. These issues have the potential to lead to both civil and criminal charges, and providers who are facing civil investigations must focus on ensuring that their investigations do not become criminal in nature. When we represent clients in Medicaid fraud investigations, we seek to determine the nature of the investigation as quickly as possible. We focus on limiting the issues in play in order to ultimately convince the prosecutor’s office that charges of any type are unwarranted.

Some of the most-common allegations in Medicaid fraud investigations include:

  • Accepting and paying kickbacks for patient referrals
  • Falsifying patient diagnoses
  • Inaccurate and fraudulent Medicaid invoicing
  • Billing for services, medication, or medical equipment not actually provided to patients
  • Billing for services, medication, or medical equipment that was not medically necessary
  • Ordering excessive, inappropriate, or unnecessary tests
  • Overutilization of medical procedures, equipment, or services
  • Unbundling, upcoding, and other Medicaid billing violations

Medicaid Fraud FAQs: Answers from Our Health Care Fraud Defense Lawyers

Q: What are the government’s priorities in targeting Medicaid fraud by health care providers?

In broad terms, the government’s goal is to stop all fraud, waste, and abuse resulting in unjustified payments from Medicaid. More specifically, state and federal authorities are using so-called “integrity” programs and initiatives to target:

  • incorrect and fraudulent decisions regarding Medicaid eligibility,
  • failure to meet state and federal Medicaid participation requirements,
  • medicaid billings for services that are either inappropriate or not medically necessary, and,
  • payments for eligible services to qualified providers that are made in incorrect amounts.

Q: How do state and federal authorities identify targets for Medicaid fraud investigations?

In most cases, Medicaid fraud investigations result from analyses of billing data which identifies providers and transactions as “outliers” or “anomalies” when compared to the larger universe of Medicaid billing. While this method can be effective, it is also the reason that many innocent providers are facing unwarranted investigations. There are several things that can make a provider stand out besides engaging in Medicaid fraud. It is our goal to make sure the investigators and prosecutors understand that your business or practice has a unique Medicaid billing record for legitimate reasons.

Q: What consequences can I face as a result of a Medicaid fraud investigation?

The consequences of facing a Medicaid fraud investigation can be extreme. First, even if the investigation does not lead to charges, it may trigger the requirement to provide disclosure to certain regulatory authorities, and it may lead to independent licensing action by state licensing boards. If you, your business, or your practice is found civilly liable, you could face severe monetary penalties (including fines, treble (triple) damages, and recoupment). You could also face prepayment review or exclusion from health care benefit programs. In a criminal case, a conviction for Medicaid fraud can carry huge fines and state or federal incarceration in addition to program exclusion.

Q: Where can I learn more about the government’s enforcement of Medicaid billing rules and regulations?

Information on the federal government’s enforcement of Medicaid billing rules and regulations can be found in the Code of Federal Regulations (CFR) and in certain provisions of the Social Security Act. For more information, see:

For advice specific to your situation, we encourage you to contact our offices to arrange a free and confidential case assessment.

Q: How often do Medicaid fraud investigations lead to charges and convictions?

Only a small fraction of Medicaid fraud investigations lead to charges, and an even smaller number lead to convictions. Of course, providers’ success rates are greatly dependent upon their decision to engage legal counsel quickly, and their choice of legal representation. Here are some sample statistics from the OIG based upon data compiled for 2016:

  • Total Medicaid Fraud Investigations by MFCUs: 15,509
  • Total Medicaid Fraud Indictments Resulting from MFCU Investigations: 1,249
  • Total Medicaid Fraud Convictions Resulting from MFCU Investigations: 1,160
  • Statistics for California: 1,169 investigations, 147 indictments, 90 convictions
  • Statistics for Florida: 606 investigations, 61 indictments, 41 convictions
  • Statistics for Texas: 1,236 investigations, 97 indictments, 51 convictions

Total criminal recoveries topped $368 million, while civil recoveries exceeded $1.5 billion. During the year, MFCUs spent more than $258 million to fight Medicaid fraud.

Q: What should I do when I am contacted by a Medicaid fraud investigator?

If you have been contacted by an investigator with an MFCU or any other state or local law enforcement authority, it is critical that you engage an attorney as soon as possible. You should let your attorney communicate with the authorities on your behalf, and you should not supply any information to the government unless advised to do so. State and federal investigators use a variety of tactics to solicit information that providers and their employees are not legally required to disclose. So you need an experienced medicaid fraud defense attorney who can advise you of your rights and help you avoid mistakes that could jeopardize your defense.

Facing a Medicaid Fraud Investigation? Choose The Criminal Defense Firm

At The Criminal Defense Firm, we take a strong team approach that affords each client the full weight of our attorneys’ decades of combined health care fraud experience. We believe in providing each client with the strongest possible defense, and we work closely with our clients to ensure that the details that matter is brought to light. Oftentimes, when mistakes have been made, it is a simple human error that is to blame. If this is the case for you, we can show the investigators and prosecutors the relevant evidence and work quickly to absolve you of criminal responsibility.

Why do health care providers nationwide choose The Criminal Defense Firm? We believe the answer is because:

  • We offer depth of knowledge and breadth of experience in state and federal health care law matters, including Medicaid fraud investigations.
  • We have the resources of a team of experienced health care fraud defense lawyers and former prosecutors who know Medicaid fraud investigations from the inside out.
  • We have a material record of success in health care fraud investigations, and we approach every case with the goal of helping our client avoid facing civil or criminal charges.
  • We provide straightforward answers and give our clients the tools they need to avoid common mistakes, and make any changes needed to remedy actual or potential Medicaid compliance issues.
  • We champion a zealous approach to representation and a relentless effort to secure the best possible results for our clients.

Schedule a Free Medicaid Fraud Case Assessment Now With Skilled Federal Attorneys

If you are facing a Medicaid fraud investigation, or if you have concerns that you may need to remedy a compliance issue in your business or practice, we encourage you to contact us promptly for a free case assessment. To speak with a member of The Criminal Defense Firm’s, health care fraud defense team in confidence, please call 866-603-4540 or get in touch online now.

Not all attorneys of The Criminal Defense Firm are licensed in California and nothing contained in here is meant to constitute the unauthorized practice of law.

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