Health Care Fraud Defense Lawyer

A federal health care fraud investigation rarely announces itself. It usually starts as a pattern in claims data, where a provider’s volume, procedure mix, or referral relationships sit outside the range for comparable practices, and it is worked quietly for months by payment integrity contractors, data analysts, and federal agents before anyone at the practice hears about it. The first outward sign is often a subpoena served on a billing vendor, a request for patient files, or agents arriving with a warrant. By that point the government already holds a claims-level picture of the practice and has settled on a theory about what the picture means.

That sequence matters, because the criminal question under 18 U.S.C. § 1347 is not whether claims were paid in error. It is whether someone knowingly and willfully executed a scheme to defraud a health care benefit program, or to obtain its money through materially false representations, in connection with the delivery of or payment for health care benefits, items, or services. Denied claims, coding disagreements, and thin records are ordinary features of medical practice and are not, standing alone, that offense. Law Offices Of SRIS, P.C. represents physicians, pharmacy owners, home health and hospice operators, telehealth companies, durable medical equipment suppliers, billing firms, and marketers who find themselves inside a federal health care investigation. To discuss a matter under § 1347, call (888) 437-7747.

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What 18 U.S.C. § 1347 Requires the Government to Prove

Section 1347 reaches two related things: a scheme or artifice to defraud a health care benefit program, and a scheme to obtain money or property owned by or under the custody or control of such a program by means of false or fraudulent pretenses, representations, or promises. Either branch must connect to the delivery of or payment for health care benefits, items, or services.

The phrase health care benefit program is broader than most providers assume. It is not confined to Medicare, Medicaid, and TRICARE, and commercial insurance plans can fall inside it, which is why a case built from federal program billing often expands into private payors once agents hold the full claims picture.

The contested element is almost always state of mind. The government must show that the defendant acted knowingly and willfully, and that the false representation mattered to the payment decision rather than being a clerical slip with no bearing on whether a claim would be paid. Section 1347 also addresses how much a defendant must know about the statute itself, and that provision shapes how intent is argued. Read the current statutory text with counsel before relying on any summary of it, including this one, because the wording controls and it can change.

Good faith is the other side of the same element. A provider who read a coverage rule differently from the payor, who relied on a billing company or a compliance vendor, or who documented poorly while delivering real care is describing a defense to intent rather than an admission of one.

How a Payment Dispute Becomes a Criminal Case

Most section 1347 prosecutions begin somewhere other than a criminal squad. A payment integrity contractor flags a provider, an audit produces an extrapolated overpayment demand, a former employee files a sealed whistleblower complaint under the civil False Claims Act, or a patient or competitor complains. Any of those can be referred to federal agents, and the referral usually arrives with an analytic package already attached.

What converts a payment dispute into a criminal theory is evidence of knowledge. Prosecutors look for earlier audit findings the provider received and did not address, internal messages warning that something was wrong, files created or altered after a request for records, identical narratives repeated across unrelated patients, services billed on dates when the provider or the patient was demonstrably elsewhere, and compensation arrangements that track billing volume rather than work performed.

Cooperating witnesses supply the rest. Marketers, patient recruiters, practice managers, and billing staff are frequently approached first, and their accounts often become the narrative wrapped around the data. Those accounts are testable against the same records the government is relying on, and testing them early tends to be more productive than answering the statistical case on its own terms.

The Provider Models That Draw Federal Attention

Northern Virginia and the wider Eastern District of Virginia see recurring fact patterns rather than random cases. Home health and hospice matters turn on whether the beneficiary population matched the certifying criteria and on who directed the certifications. Telehealth matters usually pair a call center or lead generator with a prescribing clinician and a downstream supplier, and the government’s theory is that the clinical encounter was a formality arranged to support an order that had already been sold.

Durable medical equipment and laboratory matters follow a similar shape, with orders arriving in volume from sources the supplier never treated. Pharmacy matters turn on dispensing records, inventory reconciliation, and whether the product billed matches the product acquired. Billing firms and management services organizations are charged when the government believes they set coding policy rather than merely executed a client’s instructions.

None of these models is unlawful in itself. Each is a lawful business structure that becomes criminal exposure only if the government can show that the paperwork describing it did not match what actually happened, and that someone involved knew as much.

Criminal, Civil, and Administrative Exposure Run Together

A section 1347 case is rarely the only proceeding. The same conduct can support a civil False Claims Act action brought by the Department of Justice or by a private relator, an administrative payment suspension while an investigation continues, an exclusion action affecting participation in federal health care programs, and a state licensing complaint. These tracks move on different timetables and answer to different burdens of proof.

The practical danger is that a step taken to resolve one track can damage another. Explanations given to an auditor, positions taken in a licensing response, and admissions embedded in a civil settlement can all reappear in a criminal file. Where suspension or exclusion is threatened, the governing regulations set the mechanics and any applicable period. Those figures are not stated here and should be confirmed against the current regulation with counsel.

Sequencing the proceedings, and deciding which to answer first and in what terms, is defense work that has to happen before deadlines in the civil and administrative tracks force the question.

How Sentencing Exposure Is Actually Built

If a section 1347 case reaches sentencing, the figure that drives the advisory Guidelines range is loss. The government usually proposes an amount built from claims data, sometimes extrapolated from a sample, and the defense position is frequently that the amount sweeps in services that were delivered, patients who qualified, and claims no payor would have refused had the paperwork been cleaner. Intended loss and actual loss are argued separately and can diverge sharply.

Around loss sit the adjustments that decide most of the range: the number of victims, whether the scheme used sophisticated means, the defendant’s role as organizer, manager, or minor participant, abuse of a position of trust where a licensed professional is involved, obstruction, and acceptance of responsibility. Restitution and forfeiture are decided on their own footing and can reach further than the custodial sentence.

No statutory ceiling appears on this page. The term available under section 1347 should be read from the current statutory text with counsel, because it turns on the facts alleged, and because Guidelines outcomes are driven far more by the loss and adjustment findings than by the ceiling itself.

Defense Work Before an Indictment

The period between the first subpoena and a charging decision is where outcomes in these cases actually move. The immediate tasks are preserving records and suspending routine deletion, identifying who at the practice carries individual exposure and needs separate counsel, and taking control of what employees are told so that nobody improvises an answer to an agent at their door.

Counsel-directed review of the same claims data the government is using often produces a different picture: patients who met the criteria, services corroborated by independent records, and volume explained by a referral source or a practice acquisition rather than by fabrication. Where that picture holds, presenting it before charges is worth more than presenting it after.

Whether to engage through a proffer, to seek a reverse proffer, or to say nothing at all is a judgment that depends on what the records show and on what cooperating witnesses have already said. There is no default answer, and the decision should not be made from a target letter alone.

Frequently Asked Questions

Is a billing error the same as health care fraud?

No. Section 1347 is a fraud offense, and it requires proof that someone knowingly and willfully executed a scheme to defraud a health care benefit program or to obtain its money through materially false representations. Denied claims, disputed codes, and incomplete records are ordinary in medicine and appear in practices nobody accuses of anything. What separates the two is evidence of intent and materiality, which the government builds from documents, communications, and witnesses rather than from claims data alone. That distinction is where most of the defense work in these cases sits.

I received a target letter. What does that mean?

A target letter tells you the prosecutor believes there is substantial evidence linking you to a crime and that a charging decision is under consideration. It is not a charge, and it does not mean the investigation is finished. It does mean the window for influencing the outcome is open and finite. The letter usually invites contact with the prosecutor, and whether that contact happens at all, when it happens, and what is said should be decided by counsel after assessing what the government is likely to already hold in its file.

Can federal agents interview my employees without notifying me?

Yes. Agents can approach current and former staff at home or at work, and those employees are generally free to speak or to decline. Employees have their own interests, which may not align with the practice, and some carry exposure of their own. A practice can tell staff that they may speak with agents, that they may decline, and that they may have counsel present, without instructing anyone what to say. Directing employees not to cooperate is dangerous and can create an obstruction theory that did not previously exist.

Does an audit have to conclude before criminal charges can be filed?

No. The administrative, civil, and criminal tracks are independent of one another. A payment review can be running, a whistleblower complaint can sit under seal, and a grand jury investigation can be proceeding at the same moment, sometimes without any of them being visible to the provider. That overlap is why positions taken in an audit response matter well beyond the audit. Written explanations given to a contractor are evidence, and they are read later against the records and against what witnesses eventually say happened.

Should I repay an identified overpayment while under investigation?

Repayment obligations and criminal exposure are separate questions that interact, so this is a decision for counsel rather than for a billing consultant. A repayment can be read as a correction or as an admission depending on how it is characterized and what accompanies it, and the characterization is often more consequential than the payment. The same is true of any written narrative submitted alongside it. Nothing on this page substitutes for advice given on a specific set of records, payors, and deadlines.

Does section 1347 apply to private insurance or only to government programs?

The statute reaches health care benefit programs, and that term is not confined to Medicare, Medicaid, and TRICARE. Commercial plans can fall within it. In practice this means an investigation that begins with federal program claims frequently widens once agents hold the complete billing picture, because the conduct alleged against one payor is usually alleged across all of them. Providers who assume their exposure is limited to the government share of their book of business are often measuring against the wrong base.

What happens to the practice while an investigation is pending?

That depends on which tools the government uses. A payment suspension can interrupt cash flow before any charge is filed. A search warrant can remove records and devices the practice needs in order to operate. Referral sources and payors sometimes react to news of an investigation independently of the merits. Continuity planning is therefore part of the defense rather than separate from it, and it covers who signs what, how patients and staff are informed, and how the practice keeps running without generating new evidence.

Working With Law Offices Of SRIS, P.C.

Health care fraud defense is records work before it is argument. The claims data, the clinical files, the payor correspondence, and the internal communications usually determine what the intent element can carry, and they need to be read before any position is taken with the government.

Mr. Sris, Owner and Founder of Law Offices Of SRIS, P.C., is a former prosecutor and is admitted in Virginia, Maryland, the District of Columbia, New Jersey, and New York. The firm has been practicing since 1997. Mr. Sris and the firm’s Of Counsel attorneys handle criminal defense matters across those jurisdictions, which matters in federal practice because a single investigation frequently reaches conduct, witnesses, and records in more than one state. Mr. Sris brings a background in accounting and information systems from George Mason University, applied to complex financial and technology-related cases.

The firm serves Northern Virginia from 1655 Fort Myer Dr, Suite 700, Room 719, Arlington, VA 22209 and central Virginia from 7400 Beaufont Springs Drive, Suite 300, Room 395, Richmond, VA 23225. By appointment. Call (888) 437-7747 to schedule. Request a consultation. Reach our location at (888) 437-7747.

This page provides general information about health care fraud under 18 U.S.C. § 1347 and does not create an attorney-client relationship. Case results depend on a variety of factors unique to each case. Results may vary.

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A health care fraud case is one part of fraud & financial crimes work, and our page on bank fraud defence covers the wider process.