Medicare/Medicaid Billing Fraud Charges

A billing dispute can turn into a criminal case alleging Medicaid fraud before a provider understands what investigators believe happened. Employee interviews may follow a request for records, payment holds, search warrants, or a grand jury subpoena. By that point, the government may already have compared years of claims against patient files, staffing records, referral data, and bank transactions.

Medicare and Medicaid billing rules are detailed, but a mistake is not automatically a crime. Prosecutors generally must prove that a person acted with the required criminal intent. That distinction can become the center of the defense. A Medicare/Medicaid billing fraud charges defense lawyer from The Criminal Defense Firm can examine whether the disputed claims resulted from deliberate conduct, unclear guidance, poor training, software problems, or routine coding errors.

What Medicare and Medicaid Billing Fraud Means

Medicare is a federal health insurance program, while Medicaid is funded by federal and state governments and administered through state programs. Providers that bill either program must comply with coverage rules, coding standards, documentation requirements, enrollment terms, and medical-necessity requirements.

Billing fraud allegations typically allege that someone knowingly sought payment using false information. The government may focus on a single billing method or argue that several people took part in a broader plan. An investigation can involve physicians, dentists, therapists, pharmacists, clinic owners, billing companies, office managers, and outside marketers.

Common Billing Practices That Draw Scrutiny

Investigators often look for claim patterns that appear inconsistent with patient care or program rules. A high volume alone does not prove fraud, but it can lead agencies to demand records and explanations.

Common allegations include:

• Billing for appointments, tests, supplies, or treatments that were not provided.
• Using a code that pays more than the service actually performed.
• Separating services that should have been billed together.
• Billing under another provider’s number without meeting supervision rules.
• Reporting false diagnoses to support coverage or medical necessity.
• Submitting duplicate claims to Medicare, Medicaid, or another insurer.
• Paying or receiving improper compensation for referrals.
• Altering records after an audit or investigation begins.

Some cases start with a data review. Others begin with a patient complaint, an employee report, a competitor’s allegation, or a qui tam lawsuit under the False Claims Act. Each source has limits. Billing data may lack clinical context, and a former employee may not know why a claim was coded in a certain way.

Laws Prosecutors Often Cite in Criminal Cases

Federal statute 18 U.S.C. § 1347 makes it a crime to purposely use false pretenses to obtain money from a healthcare benefit program. A standard violation can carry up to 10 years in prison. Higher maximums may apply when serious bodily injury or death results.

Prosecutors may also use 18 U.S.C. § 1349 for conspiracy, 18 U.S.C. § 1343 for wire fraud, and 18 U.S.C. § 1001 for false statements. Claims involving federal money may lead to charges under 18 U.S.C. § 287. The Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b), addresses certain payments intended to influence referrals or orders paid for by a federal health care program.

A charge is an accusation, not proof. The exact elements depend on the statute listed in the indictment. A Medicare/Medicaid billing fraud charges defense lawyer must compare the government’s theory with the words of each charged offense rather than treating every payment problem as the same crime.

Why Intent Matters

Complex billing systems create many ways for claims to be wrong without being fraudulent. Staff may select an incorrect code, misunderstand a coverage update, copy information into the wrong chart, or rely on software that applies a default setting. A provider may also disagree with an auditor about whether documentation supports the billed level of care.

The government may try to prove intent through emails, internal messages, training records, repeated warnings, altered files, or efforts to hide payments. The defense may point to compliance work, refund efforts, outside billing advice, good-faith interpretations, or records showing that services were actually delivered.

No single fact settles intent in healthcare fraud matters. Repeated errors can look suspicious, but repetition may also stem from a single system-wide coding flaw. A careful review asks who made each decision, what that person knew, and when the person learned of the issue.

How Investigations Usually Develop

A case may involve the FBI, the HHS Office of Inspector General, the Department of Justice, a Medicaid Fraud Control Unit, or program contractors. The FBI is the primary agency for investigating health care fraud involving federal and private insurance programs.

Investigators may use subpoenas, interviews, undercover contacts, claim analysis, search warrants, or cooperating witnesses. They can compare billing times with employee schedules, patient locations, prescription records, and electronic chart activity. Bank records may be used to trace payments to owners, marketers, or related companies.

Early decisions can shape the entire case. A provider should avoid guessing during an interview, changing records, deleting messages, or directing employees to give a shared account. An attorney can communicate with agents, identify the investigation’s scope, and help preserve records without creating new risks.

Evidence That May Support the Defense

The most useful material often extends beyond the medical chart. Patient schedules can show that appointments occurred, while device logs may confirm equipment use. Payroll records can establish that qualified staff members were present, and written advice from a billing consultant may explain why a code was selected.

Other important evidence may include credentialing files, prior authorization records, claim corrections, repayment records, audit responses, training materials, and communications with Medicare or the state Medicaid agency. The defense should also examine the government’s calculations. An alleged loss figure may include properly paid claims or assume that every claim with one defect was worthless.

A Medicare/Medicaid billing fraud charges defense lawyer may work with coding professionals, medical experts, accountants, or data analysts. Their role is not to excuse false billing. It is to test whether the government’s conclusions align with the records and governing rules.

Civil, Criminal, and Administrative Exposure

The same billing conduct can lead to more than one type of action. Criminal prosecution may involve prison, fines, restitution, and forfeiture. A civil False Claims Act case can seek repayment and added penalties. Administrative agencies may suspend payments, revoke billing privileges, or exclude a person or company from federal health care programs.

Exclusion can threaten a professional’s career even when a sentence does not include prison. Federal law requires or permits exclusion in several situations involving program-related convictions, fraud, obstruction, licensing action, or other misconduct.

These tracks can overlap. Statements made during an audit may later appear in a criminal case. A settlement that resolves repayment issues may not end a separate investigation unless the agreement says so. Defense planning should account for criminal risk, financial exposure, licensing concerns, and continued program participation.

Recent Medicare and Medicaid Fraud Statistics

Recent federal data shows the scale of questionable billing across Medicare and Medicaid. For fiscal year 2025, the Centers for Medicare & Medicaid Services estimated that Medicare Fee-for-Service made $28.83 billion in improper payments. That represented 6.55% of the payments reviewed. CMS reported that many of these payments involved missing records or documentation that did not adequately support medical necessity.

Medicaid fraud investigations also produce a substantial number of criminal cases. HHS-OIG reported that state Medicaid Fraud Control Units obtained 1,185 convictions during fiscal year 2025. Their criminal and civil cases resulted in almost $2 billion in combined recoveries, including approximately $1.3 billion tied to criminal convictions. The units also reported 674 civil settlements and judgments.

These numbers do not mean every incorrect claim involved fraud. An improper payment may result from missing documentation, eligibility errors, coding errors, or other failures to comply with payment rules. Fraud charges generally require evidence that the accused knowingly took part in a false billing scheme.

Building a Defense Around the Actual Records

A sound defense begins with the indictment, subpoena, audit letter, or search warrant. The next step is to map each accusation to the relevant claim, patient, employee, and rule. Broad labels such as upcoding or phantom billing do not answer what happened on a specific date.

We may also look for breaks in the government’s story. The prosecution may rely on an employee who handled only part of the billing process. A spreadsheet may combine claims from different providers. An expert may apply a later policy to older claims. Patient testimony may confirm that care occurred even when a note is incomplete.

Frequently Asked Questions

Does repaying the money end a criminal investigation?

Not necessarily. Repayment may reduce financial exposure or show corrective action, but it does not erase possible criminal intent. Counsel should review the timing and wording before submitting a refund.

Can prosecutors use personal purchases as evidence?

They may use spending records to argue motive or trace proceeds. The defense can challenge whether those purchases were connected to disputed payments or came from lawful income.

What happens to patient records after a practice closes?

Record duties may continue under federal and state rules. You should lawfully preserve, secure, and transfer all pertinent files, especially during an active investigation.

A Medicare/Medicaid Billing Fraud Charges Defense Attorney is Ready to Help

The defense strategy will depend on the case. It may involve seeking to prevent charges, challenging a search, narrowing the alleged loss, negotiating a resolution, or preparing for trial. A Medicare/Medicaid billing fraud charges defense lawyer with The Criminal Defense Law Firm will keep the focus on evidence, intent, and the elements the government must prove. You can schedule a free consultation by using our online contact form.

Last Updated: 08-25-2026