Healthcare Fraud Attorney

By Elizabeth Franklin-Best, Esq., and Christopher Zoukis, JD, MBA

This page is written for providers under investigation — physicians, practice owners, executives, and the entities they run. If you are looking to report suspected fraud or to bring a whistleblower claim, this is not that page.

A federal health care fraud investigation is not one proceeding. It is three, and they run on separate tracks with different burdens, different decision-makers and different consequences.

The three-track exposure

Track	Authority	Burden	What it costs you
Criminal	18 U.S.C. § 1347; 42 U.S.C. § 1320a-7b(b)	Beyond a reasonable doubt	Imprisonment — 10 years under § 1347, 20 if serious bodily injury results, life if death results; 10 years under the Anti-Kickback Statute
Civil	False Claims Act, 31 U.S.C. §§ 3729–3733	Preponderance of the evidence	Treble damages plus a per-claim penalty of $14,308 to $28,619 for penalties assessed after 3 July 2025
Administrative	HHS-OIG exclusion, 42 U.S.C. § 1320a-7	Agency determination	Exclusion from all federal health care programs — a minimum of five years on a mandatory exclusion, and for most providers the end of a practice

Table: the three tracks. A provider can prevail on the criminal track and still lose the practice, because exclusion is a separate proceeding with a separate standard.

That third track is the one almost no competitor page explains, and it is frequently the one that matters most. Exclusion does not require a conviction on every route into it, and mandatory exclusion is not discretionary once its trigger is met. Any resolution of a criminal or civil health care matter that does not address exclusion is only part of a resolution.

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§ 1347: the criminal health care fraud statute

Section 1347 provides that whoever “knowingly and willfully executes, or attempts to execute, a scheme or artifice —

(1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both.”

The escalations are severe: “If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both; and if the violation results in death, such person shall be fined under this title, or imprisoned for any term of years or for life, or both.”

And subsection (b) removes a defense that providers commonly assume they have: “With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.”

That provision does not eliminate the mental state — the government must still prove the scheme was executed “knowingly and willfully.” What it eliminates is the argument that the defendant did not know § 1347 existed or did not specifically intend to violate it. In a field governed by tens of thousands of pages of billing rules, that distinction matters, and it is where a great deal of defense work is done: proving that a billing practice reflected a good-faith reading of ambiguous guidance rather than a scheme.

Reach beyond Medicare. Section 1347 protects any “health care benefit program,” which is broader than the federal programs — it reaches private insurers as well. A billing dispute with a commercial payer can be a federal felony.

Two companion offenses travel with it:

• 18 U.S.C. § 1035 — false statements relating to health care matters, reaching materially false statements “in any matter involving a health care benefit program,” with a five-year maximum. It requires no scheme and no loss.
• 18 U.S.C. § 1349 — conspiracy, carrying the same penalty as the completed offense and requiring no overt act. Section 1347 is in chapter 63, so § 1349 covers it. That is why nearly every health care fraud indictment leads with a conspiracy count.

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The kickback statutes, distinguished

The Anti-Kickback Statute and the Stark Law are conflated on a very large share of the pages that mention them. They are not variations on one another. They are different statutes with different natures.

	Anti-Kickback Statute — 42 U.S.C. § 1320a-7b(b)	Stark Law — 42 U.S.C. § 1395nn
Nature	Criminal — a felony	Civil — no criminal penalty
Mental state	Intent-based: “knowingly and willfully”	No intent element in the prohibition itself — a strict-liability referral ban
Who it reaches	Anyone — “Whoever”	Physicians only (and their immediate family members), plus the billing entity
What it reaches	Any remuneration — “any kickback, bribe, or rebate … directly or indirectly, overtly or covertly, in cash or in kind”	Referrals for designated health services where a financial relationship exists
Program reach	Any Federal health care program	Medicare designated health services
Penalties	Felony: $100,000 fine, 10 years, or both	Denial of payment, mandatory refund, civil money penalties up to $15,000 per service, and up to $100,000 per circumvention scheme
Relief from liability	Safe harbors — 42 C.F.R. § 1001.952	Exceptions — 42 C.F.R. §§ 411.355–411.357
The asymmetry	Failing to fit a safe harbor is not itself unlawful. The regulation says which practices “shall not be treated as a criminal offense”; it does not say the rest are	Failing to fit an exception IS a violation. The regulation prohibits the referral “[e]xcept as provided in this subpart”

Table: the AKS/Stark distinction as the statutes and regulations actually state it. The asymmetry in the last row is the practical consequence that follows from the different drafting, and it is stated wrongly almost everywhere.

Two further points belong on the hub, and both are statutory.

The AKS’s intent requirement is narrower than it sounds. Section 1320a-7b(h) provides that “a person need not have actual knowledge of this section or specific intent to commit a violation of this section.” So “knowingly and willfully” does not require knowledge of the AKS itself.

An AKS violation makes the claim false. Section 1320a-7b(g) provides: “a claim that includes items or services resulting from a violation of this section constitutes a false or fraudulent claim for purposes of subchapter III of chapter 37 of title 31” — that is, the False Claims Act. A kickback therefore converts every downstream claim into an FCA claim, with treble damages and a per-claim penalty attached. That single sentence is why AKS exposure and FCA exposure are effectively the same problem.

The full analysis, including the safe harbors, the Stark exceptions and the “one purpose” test, is on our stark law attorney page.

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The False Claims Act track

The FCA is where the money is, and the arithmetic explains why civil exposure so often dwarfs criminal exposure.

31 U.S.C. § 3729(a)(1) imposes liability on anyone who “knowingly presents, or causes to be presented, a false or fraudulent claim for payment or approval,” or “knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim.” Liability is three times the damages sustained by the government, plus a civil penalty for each claim.

The current penalty range is $14,308 to $28,619 per claim for penalties assessed after 3 July 2025 — 28 C.F.R. § 85.5, as adjusted effective that date (90 FR 29447). For penalties assessed after 12 February 2024 and on or before 3 July 2025, the range was $13,946 to $27,894.

These figures are inflation-adjusted annually, so any range stated without a date is unreliable. Confirm the current adjustment before relying on a number.

The arithmetic matters because in health care a “claim” is a line item. A practice that submitted 4,000 affected claims faces a penalty floor in the tens of millions before damages are trebled — a figure that bears no relation to the amount actually paid. That mismatch is itself an argument, and it is one of the reasons materiality under Escobar carries so much weight.

Three Supreme Court decisions define the current landscape, and they are set out in full on our false claims act attorney page:

• Universal Health Services v. United States ex rel. Escobar, 579 U.S. 176 (2016) — implied false certification is viable, but “[t]he FCA’s materiality requirement is demanding,” and if the government “pays a particular claim in full despite its actual knowledge that certain requirements were violated, that is very strong evidence that those requirements are not material.”
• United States ex rel. Schutte v. SuperValu, 598 U.S. 739 (2023) — “The FCA’s scienter element refers to a defendant’s knowledge and subjective beliefs — not to what an objectively reasonable person may have known or believed.” This narrowed a defense that had been available.
• United States ex rel. Polansky v. Executive Health Resources, 599 U.S. 419 (2023) — the government “may move to dismiss an FCA action under § 3730(c)(2)(A) whenever it has intervened — whether during the seal period or later on.”

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The fourth exposure most providers have never heard of

The three-track framework above is the organizing idea, but there is a fourth instrument, and it sits on the administrative track alongside exclusion: the Civil Monetary Penalties Law, 42 U.S.C. § 1320a-7a.

The CMPL lets HHS-OIG impose penalties and assessments administratively, without going to court and without a criminal conviction, on a standard of knowledge markedly lower than the criminal statutes.

The knowledge standard. The statute reaches conduct done “knowingly” or where the person “knows or should know.” And “should know” is defined: it “means that a person, with respect to information — (A) acts in deliberate ignorance of the truth or falsity of the information; or (B) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.”

What it reaches. Among other things: presenting a claim for an item or service “the person knows or should know was not provided as claimed”; a pattern or practice of upcoding — presenting claims “based on a code that the person knows or should know will result in a greater payment … than the code the person knows or should know is applicable to the item or service actually provided”; claims for a physician’s service where the person knows or should know the individual furnishing it was unlicensed or misrepresented their license; the kickback conduct described in § 1320a-7b(b); arrangements with excluded persons; and knowing of an overpayment “and [not] report[ing] and return[ing] the overpayment” as § 1320a-7k(d) requires.

The amounts. The statute provides for a civil money penalty of “not more than $20,000 for each item or service,” with specified higher figures for particular paragraphs — including $100,000 for each such act in kickback cases and $100,000 for each false record or statement. On top of the penalty, “such a person shall be subject to an assessment of not more than 3 times the amount claimed for each such item or service in lieu of damages” — and in kickback cases, “damages of not more than 3 times the total amount of remuneration offered, paid, solicited, or received, without regard to whether a portion of such remuneration was offered, paid, solicited, or received for a lawful purpose.”

That last clause is worth pausing on. In a CMPL kickback case, the trebled base is the entire payment, even where most of it compensated genuine services. It is the civil analogue of the “one purpose” rule under the criminal statute.

A separate provision at § 1320a-7a(b) reaches a hospital that “knowingly makes a payment, directly or indirectly, to a physician as an inducement to reduce or limit medically necessary services” to Medicare or Medicaid patients under that physician’s direct care — $5,000 per patient, imposed on the hospital and, separately, on any physician who knowingly accepts such a payment.

Note also that these figures are statutory base amounts and are subject to the same inflation-adjustment regime that governs FCA penalties. Confirm the current adjusted amounts before relying on a number.

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Exclusion: the track that ends practices

42 U.S.C. § 1320a-7 authorizes the HHS Office of Inspector General to exclude individuals and entities from participation in any Federal health care program. For most providers, exclusion is functionally the end of practice: no Medicare, no Medicaid, no TRICARE, and — because most hospitals, group practices and payers will not employ or contract with an excluded person — usually no employment in the field either.

Mandatory exclusion

Section 1320a-7(a) provides that “[t]he Secretary shall exclude” individuals and entities in four circumstances:

1. Conviction of a program-related crime — a criminal offense related to the delivery of an item or service under Medicare or a State health care program;
2. Conviction relating to patient abuse or neglect in connection with the delivery of a health care item or service;
3. A felony conviction relating to health care fraud — “fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct” in connection with the delivery of a health care item or service, or in a health care program financed by government;
4. A felony conviction relating to a controlled substance.

The minimum period is five years. Section 1320a-7(c)(3)(B) provides that “the minimum period of exclusion shall be not less than five years,” subject to a narrow waiver available only where a program administrator determines that exclusion would impose a hardship on beneficiaries and the person “is the sole community physician or sole source of essential specialized services in a community.”

The escalation is severe. Under § 1320a-7(c)(3)(G), for a conviction occurring on or after 5 August 1997, a person with one previous qualifying conviction faces “not less than 10 years,” and a person with two or more faces exclusion that “shall be permanent.”

Permissive exclusion

Section 1320a-7(b) lists a long set of grounds on which the Secretary may exclude, and several do not require a felony conviction at all — among them a misdemeanor conviction relating to fraud, theft or other financial misconduct in connection with health care; conviction for obstructing an investigation or audit; license revocation or suspension; failure to disclose required ownership information; failure to supply payment information; failure to grant immediate access to the OIG or a Medicaid Fraud Control Unit; and exclusion of entities controlled by a sanctioned individual.

That last ground deserves particular attention from practice owners. Under § 1320a-7(b)(8), the Secretary may exclude an entity where a person with “a direct or indirect ownership or control interest of 5 percent or more,” or who “is an officer, director, agent, or managing employee,” has been convicted, penalized or excluded. The statute also reaches transfers made “in anticipation of (or following)” such an event to “an immediate family member … or a member of the household” who continues to hold the interest — closing the obvious workaround.

Why this changes the strategy

Because exclusion follows automatically from certain convictions, the charge matters more than the sentence. A plea to a misdemeanor rather than a felony, or to an offense outside the mandatory categories, can be the difference between a five-year exclusion and none. A plea negotiation in a health care matter that focuses only on custody exposure has missed the point.

Applied Insight — Elizabeth Franklin-Best, Esq., Principal Attorney: In a health care matter the question is never only “what is the sentencing exposure.” It is “what does this resolution do to the license, to the exclusion status, and to the entity.” Those consequences follow from the offense of conviction, which means they have to be part of the negotiation from the first conversation with the prosecutor — not raised afterwards, when the charge is fixed.

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How these cases actually start

Providers are frequently astonished by how long an investigation has been running before they learn of it. Four routes account for most cases.

Data analytics. CMS and its contractors run billing data against peer benchmarks continuously. A provider whose use of a particular code, whose units per patient, or whose per-beneficiary spend sits far outside the distribution for their specialty and region will be flagged. Being an outlier is not fraud — it may reflect a sicker panel, a subspecialty, or a documentation habit — but it is what generates the file.

A sealed qui tam complaint. Under 31 U.S.C. § 3730(b)(2), a relator’s complaint “shall be filed in camera, shall remain under seal for at least 60 days, and shall not be served on the defendant until the court so orders.” In practice the seal is extended repeatedly while the government investigates. A provider can be under investigation for years without knowing a case exists, while the government issues subpoenas, interviews former employees, and analyses the billing — and the first notice is often a Civil Investigative Demand or an agent at the door.

An OIG subpoena or a Civil Investigative Demand. The OIG has subpoena authority; the Department of Justice has CID authority under 31 U.S.C. § 3733, which reaches documents, interrogatories and oral testimony. A CID is a strong signal that an FCA investigation — and quite possibly a sealed qui tam — exists.

A payment suspension. Under 42 C.F.R. § 455.23, a State Medicaid agency “must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending,” unless good cause exists not to. For many practices, that is the first indication of anything — and it arrives as a cash-flow emergency rather than as a legal notice. Our medicare fraud attorney page sets out the regulation, the good-cause exceptions and the notice timing in detail.

Who is investigating. Federal health care fraud is worked by HHS-OIG, the FBI, the DEA where controlled substances are involved, the Department of Justice’s Health Care Fraud Unit and its Strike Force teams, and — on the Medicaid side — state Medicaid Fraud Control Units. Private payers have their own special investigations units, and their referrals feed the federal pipeline.

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What the government has, and how it got it

A health care fraud case is assembled from data before anyone is interviewed. Understanding what already exists is the first task.

Claims data. Every claim submitted to Medicare or Medicaid is a permanent, structured record: the beneficiary, the date, the code, the rendering provider’s NPI, the referring provider, the amount billed and the amount paid. The government has all of it, for every year, and can sort it any way it likes. There is no version of a health care case in which the billing data is in dispute — only what it means.

Peer comparison. The same data supports comparison against every other provider in the specialty and the region. That is how outlier status is established, and it is also how the government builds the visual exhibits a jury sees.

The medical records. Obtained by subpoena from the practice, and frequently from the hospital, the imaging center and the pharmacy independently — which means the government may hold records the practice itself has not reviewed. EHR audit logs are part of this: they record who opened a record, when, and what changed. That is why late edits are so damaging, and why they are always discovered.

Former employees. Billing staff, coders, medical assistants and practice managers. Some are relators. Some are simply people who left and were contacted at home. Their accounts of “how things were done here” are frequently the intent evidence.

Beneficiary interviews. Patients are contacted and asked whether a service was provided. Their recollections are years old and often imprecise, which is a legitimate subject of cross-examination but is also persuasive to a jury when it lines up with the billing data.

The practice’s own compliance file. Audits, coding reviews, compliance-hotline reports and consultant memoranda. This material cuts both ways with unusual force: a compliance review that identified a problem and was not acted on is the government’s best exhibit, and one that considered the question and reached a defensible answer is the defense’s.

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The theories that recur

Health care fraud allegations are, at bottom, allegations about billing. Six theories account for most of them.

Billing for services not rendered. The starkest theory, and the one with the least room for a good-faith defense where the records show no encounter. The defense is usually documentary and about attribution — who submitted, on whose credentials, from what records.

Upcoding. Billing a higher-level code than the documentation supports. This is a documentation dispute at least as often as it is a fraud, and expert coding review frequently narrows the government’s figures substantially.

Medically unnecessary services. The government’s theory is that the service was not needed; the defense is clinical judgment. This is the theory where physician defendants have the most substantive ground, because medical necessity is a professional judgment made prospectively on incomplete information, and reasonable clinicians differ.

Unbundling. Billing components separately that should have been billed as a single code.

Kickback-tainted claims. Any arrangement with a referral source. Because of § 1320a-7b(g), a kickback converts every resulting claim into a false claim.

Telehealth and DME arrangements. Marketing companies, call centers and “telemedicine” platforms generating orders that a physician signs with limited or no patient contact, and durable medical equipment or genetic testing billed on those orders. These are the highest-volume prosecutions in the field, and the physicians involved are frequently people who signed orders in bulk for a per-order fee without appreciating what they were part of.

Retained overpayments. A seventh theory that is not about how a claim was submitted but about what happened afterwards. 42 U.S.C. § 1320a-7k(d) requires a provider who “has received an overpayment” to report and return it “by the later of — (A) the date which is 60 days after the date on which the overpayment was identified; or (B) the date any corresponding cost report is due.” An overpayment is “any funds that a person receives or retains … to which the person, after applicable reconciliation, is not entitled.” And the enforcement provision is the sting: “[a]ny overpayment retained by a person after the deadline … is an obligation (as defined in section 3729(b)(3) of title 31) for purposes of section 3729” — that is, an FCA reverse false claim, with treble damages and per-claim penalties. A provider who discovers a billing error and does nothing has converted a refund problem into an FCA case. The mechanics are covered on our medicare fraud attorney page.

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Who is the defendant: the individual, the entity, or both

In health care matters the practice, the hospital, the laboratory or the management company is a potential defendant in its own right, and the interests of the entity and of the people who run it diverge early.

The entity’s exposure. A corporation can be criminally liable for acts of its employees committed within the scope of employment and at least in part to benefit it. Civilly, the FCA and the Civil Monetary Penalties Law both reach entities, and 42 U.S.C. § 1320a-7(b)(8) permits exclusion of an entity controlled by a sanctioned individual — reaching anyone with “a direct or indirect ownership or control interest of 5 percent or more” or who “is an officer, director, agent, or managing employee.” For a practice, exclusion is terminal.

The divergence. Entities resolve these matters by negotiation, and cooperation credit is generally conditioned on identifying the individuals involved and producing the facts about them. An entity acting rationally will disclose. That is the incentive the system creates, and it means that a physician or executive who relies on the practice’s lawyer is relying on someone whose client’s interests may soon be adverse to their own.

Corporate Integrity Agreements. Where an entity settles with HHS-OIG, the resolution frequently includes a Corporate Integrity Agreement — a multi-year undertaking covering compliance infrastructure, training, claims review by an independent review organization, reporting obligations, and, in some cases, board and management certifications. A CIA is the negotiated alternative to exclusion, which is what makes it worth having, but it is an expensive and intrusive obligation whose terms are themselves negotiable. Its scope, duration and reporting burden should be treated as part of the deal rather than as boilerplate.

Individual accountability. Individuals are increasingly the point of these investigations rather than a by-product of them, and a settlement by the entity does not resolve exposure for its officers. Independent counsel from the outset is not a formality.

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Sentencing exposure

Health care fraud is referenced to U.S.S.G. § 2B1.1 and driven by the loss figure, plus a health-care-specific enhancement that appears nowhere else.

§ 2B1.1(b)(7) provides that if the defendant was convicted of a federal health care offense involving a government health care program, and the loss to that program was more than $1,000,000, increase by 2 levels; more than $7,000,000, increase by 3; more than $20,000,000, increase by 4.

Two further points are specific to this area.

The loss figure is contested in almost every case, and the fight is over methodology. The government’s usual starting point is the total amount billed or paid on the claims in issue. That is rarely the right measure where services were actually rendered and were of some value, where the alleged defect was documentation rather than absence, or where a statistical extrapolation from a sample has been applied to a universe of claims. Extrapolation in particular is challengeable on sample design, sample size and confidence interval — and the difference between a properly and an improperly extrapolated figure is routinely several offense levels.

Amendment 836, effective 1 November 2025, struck § 2B1.1 Application Note 21 in its entirety and Chapter Five, Part H is now listed in the Manual as “[Deleted].” Mitigation in these cases — a career of legitimate practice, the community’s need for the provider, restitution — must now be presented as a variance under 18 U.S.C. § 3553(a) rather than as a departure. Our federal sentencing pages explain how that is built.

We do not predict sentences and we do not publish ranges for a reader’s case.

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Where these cases are actually defended

Six lines of attack recur, and the first three are where most of the work is.

Intent, in a field of ambiguous rules. Section 1347 requires that the scheme be executed “knowingly and willfully,” and although § 1347(b) removes the requirement of knowledge of the statute, it does not remove the mental state. Medicare’s coverage rules, local coverage determinations, national coverage determinations, contractor guidance and the coding manuals frequently conflict, change, and are silent on real clinical situations. A billing practice adopted on a defensible reading of ambiguous guidance, applied consistently, and documented at the time is not a scheme. Contemporaneous evidence of how the practice reached its position — a compliance memorandum, a coding consultant’s advice, a payer’s own instruction, a prior audit that passed — is the most valuable material in the file.

Whether the service was rendered and was reasonable. The medical record is the case. Where the government says a service was not provided, the record answers. Where it says the service was unnecessary, the answer is clinical and requires an expert who will say what a reasonable practitioner would have done with the information available at the time — not with the benefit of the outcome.

The loss and damages methodology. Discussed above, and worth as much attention as liability. Statistical extrapolation, in particular, is challengeable on sample design, sample size and confidence interval, and the government’s headline number frequently does not survive examination.

Materiality, on the civil side. Escobar holds that the FCA’s materiality requirement is “demanding,” that a requirement is not material merely because it was labeled a condition of payment, and that continued government payment with knowledge of noncompliance “is very strong evidence that those requirements are not material.” Establishing what the payer knew and continued to pay is discovery worth taking.

Attribution within a practice. Who chose the codes, who signed, who set the policy, who had authority. In group practices, hospital systems and management-company arrangements, billing decisions are frequently made by people who never saw the patient — and the physician whose NPI appears on the claim may have had no role in the coding at all.

Reliance on compliance advice. A compliance officer’s clearance, outside counsel’s opinion, a billing consultant’s guidance, or an OIG advisory opinion for a materially similar arrangement all bear directly on intent. Asserting advice of counsel waives privilege over the subject matter, so the decision has to be made deliberately and early.

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What to do when a health care investigation surfaces

1. Do not alter a record. Not to clarify, not to complete, not to correct. Late edits to a medical record are detectable in the audit log of every modern EHR, and they convert a defensible billing dispute into an obstruction case. If a record genuinely needs an addendum, it must be dated and identified as one.
2. Preserve everything, including the billing system. A litigation hold across the EHR, the practice management system, email and personal devices used for work.
3. Do not speak to agents without counsel, and understand that 18 U.S.C. § 1001 exposure attaches to the interview independently of the underlying conduct.
4. Warn staff of their rights and get them separate counsel where appropriate. Employees will be contacted at home, in the evening, without notice. They are free to decline to speak and free to have counsel; telling them so is lawful, and telling them what to say is not.
5. Address the payment suspension immediately. Under 42 C.F.R. § 455.23 a provider has “the right to submit written evidence for consideration by [the] State Medicaid Agency,” and there are enumerated good-cause grounds — including where the provider “is the sole community physician or the sole source of essential specialized services in a community” or “serves a large number of beneficiaries within a HRSA-designated medically underserved area.”
6. Map the three tracks from day one. Criminal, civil and administrative. A strategy built for one of them can be actively harmful in another.
7. Consider whether a sealed qui tam exists. A CID, an unusual pattern of former-employee interviews, or a subpoena focused narrowly on one service line all point that way.

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Related health care fraud pages

• medicare fraud attorney — how Medicare and Medicaid cases are investigated and charged, the Strike Force and Medicaid Fraud Control Units, payment suspension under 42 C.F.R. § 455.23, and the 60-day overpayment rule.
• stark law attorney — the Anti-Kickback Statute and Stark in full, the safe harbor and exception frameworks, and the “one purpose” test.
• false claims act attorney — the FCA, the seal, intervention and declination, and the Escobar/SuperValu/Polansky line.

Health care prosecutions routinely carry counts covered on other pages of this site. Every claim submitted electronically is a potential wire fraud count; practice revenue moved between accounts adds money laundering counts, and § 1957 needs only a transaction over $10,000 in criminally derived property; unreported income adds tax counts; funds taken from the practice itself add embezzlement counts; and a practice loan or pandemic-relief application carrying the same revenue figures adds bank fraud counts. How they group at sentencing is covered under white collar crime lawyer. Where a health care company’s securities are involved, see securities fraud attorney, and where a regulator opens its own file, SEC investigation defense. Where a conviction has already been entered, direct review runs through federal appeals and claims outside the trial record through a § 2255 motion; guideline calculation and § 3553(a) advocacy are covered in our federal sentencing pages. Every page in this section is written for the provider or entity under investigation. Searches in this area return a great deal of material written for beneficiaries wanting to report fraud and for whistleblowers wanting to bring a case; those readers are on the other side of these matters. Elizabeth Franklin-Best, P.C. is a federal criminal defense attorney practice representing providers and health care entities nationwide.

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Frequently Asked Questions About Healthcare Fraud Charges

Facing a Healthcare Fraud Investigation?

A civil investigative demand, a payment suspension, or an agent at the door all mean the same thing: the government is already building a record. What you say and produce in the first weeks shapes everything after.

Request a Consultation (843) 620-1100

Representation begins with a paid, one-hour consultation — a working session in which we review where matters stand and tell you honestly what options remain. We do not promise outcomes.

Reviewed for legal accuracy by Elizabeth Franklin-Best, Esq., Principal Attorney·September 2026