Question 1

What is the difference between healthcare fraud and the Anti-Kickback Statute?

Accepted Answer

Healthcare fraud under 18 U.S.C. § 1347 involves submitting false or fraudulent claims to federal healthcare programs, billing for services not rendered, upcoding, using stolen patient identities, or ordering medically unnecessary procedures. The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) is different: it prohibits giving or receiving anything of value in exchange for patient referrals billed to Medicare or Medicaid. Both are felonies, but the AKS can be violated even when the underlying medical services were legitimate. Many SDFL cases involve both charges simultaneously.

Question 2

Can a doctor be charged with healthcare fraud for decisions made in good faith?

Accepted Answer

Yes, and this is one of the most contested issues in federal healthcare fraud defense. Prosecutors frequently argue that a physician's medical judgment was a pretext for fraudulent billing. The government relies on statistical outliers, paid informants, and cooperating witnesses. A strong defense requires expert medical testimony, detailed records review, and challenging the government's billing analysis. We retain independent medical experts who can credibly testify about clinical standards and the legitimacy of treatment decisions.

Question 3

What is a CID (Civil Investigative Demand) and should I be worried?

Accepted Answer

A Civil Investigative Demand is a pre-litigation document request used by the DOJ in False Claims Act investigations. Receiving one means federal attorneys believe there may be fraudulent Medicare or Medicaid billing, and they are building a civil or criminal case. Many criminal healthcare fraud prosecutions begin as CID investigations. You should not respond without experienced healthcare fraud counsel reviewing every document before production.

Question 4

What happens to a doctor's DEA registration and medical license during a federal healthcare fraud investigation?

Accepted Answer

Federal charges or even grand jury target status can trigger parallel administrative proceedings, DEA registration suspension, Florida DOH licensing investigations, and exclusion from Medicare/Medicaid under the OIG. We coordinate defense strategy across all three tracks simultaneously: federal criminal defense, DEA administrative defense, and professional licensing protection. Protecting your ability to practice is as important as the criminal defense itself.

Question 5

What is 'telemedicine fraud' and why is the SDFL so aggressive about it?

Accepted Answer

Telemedicine fraud involves using remote patient consultations as a front to order expensive diagnostics, durable medical equipment (DME), or prescription drugs without legitimate medical necessity, then billing Medicare or Medicaid. South Florida has been the epicenter of telemedicine fraud prosecutions because of the concentration of telehealth platforms, DME suppliers, and Medicare-enrolled providers in Miami-Dade, Broward and Palm Beach counties. The SDFL has prosecuted hundreds of millions in alleged telemedicine fraud schemes since 2020.

Question 6

What is the maximum sentence for federal healthcare fraud?

Accepted Answer

18 U.S.C. § 1347 carries up to 10 years per count, 20 years if the offense results in serious bodily injury, and life imprisonment if it results in death. Each false claim, billing cycle, or patient encounter can be charged as a separate count, so a single billing scheme commonly produces 10 to 30 counts of statutory exposure. Actual sentences are driven less by the statutory maximum than by the federal sentencing guidelines, USSG § 2B1.1 for fraud and § 2B4.1 for kickbacks. The 'loss amount' calculated by the government, which in healthcare fraud cases is typically the full amount billed to Medicare and Medicaid rather than the actual financial loss, drives offense levels and adds years to sentences. Loss calculation is the single highest-leverage sentencing fight in any healthcare fraud case.

Question 7

What is the difference between healthcare fraud (§ 1347) and false statements under § 1035?

Accepted Answer

18 U.S.C. § 1347 prohibits a scheme to defraud a healthcare benefit program, the broader 'scheme' offense that captures fraudulent billing, upcoding, and medically unnecessary services. 18 U.S.C. § 1035 is narrower: it prohibits knowingly and willfully making materially false statements in connection with healthcare benefits, services, or payments. Prosecutors frequently charge both in the same indictment because § 1035 captures specific written or oral misstatements (claim forms, credentialing applications, audit responses) while § 1347 captures the broader scheme. § 1347 carries 10 years per count; § 1035 carries 5 years per count. The two statutes overlap deliberately to give prosecutors maximum flexibility in framing the charges and stacking counts.

Question 8

How does the government prove a doctor or clinic acted 'knowingly and willfully' in a healthcare fraud case?

Accepted Answer

Healthcare fraud under § 1347 requires proof of knowing and willful conduct. Prosecutors rarely have direct evidence of intent, so they build it circumstantially through: billing patterns that deviate sharply from peer providers (statistical outlier analysis from the CMS Fraud Prevention System), patient interviews showing services were never rendered, cooperating witnesses (typically marketers, billers, or former employees) testifying about internal practices, and corporate documents like training materials, billing instructions, and email correspondence. The defense response is to develop the counter-narrative: legitimate medical decision-making, reliance on billing companies or coders, ambiguity in CMS guidance, and the absence of personal financial benefit. Good faith reliance on professional advice is a complete defense to willfulness when properly developed.

Question 9

Can federal healthcare fraud charges be dropped or reduced before trial?

Accepted Answer

Yes, and the pre-indictment phase is where most successful reductions happen. Once a grand jury indicts, prosecutors are heavily invested in the charging decision and reductions become more difficult. Pre-indictment opportunities include: persuading the U.S. Attorney's Office to convert the criminal investigation to a civil False Claims Act resolution; negotiating a charge bargain that reduces § 1347 felony counts to § 1035 charges or to a single conspiracy count; structuring cooperation under USSG § 5K1.1 that yields a substantial assistance motion at sentencing; and challenging the loss calculation to reduce the guidelines range. After indictment, motions to dismiss based on grand jury irregularities, statute of limitations, or jurisdictional defects can also produce dismissals or significant count reductions.

Question 10

Should I talk to HHS-OIG or FBI agents if they show up at my clinic or home?

Accepted Answer

No. HHS-OIG and FBI agents who appear without notice are not conducting an investigation to clear you; they are looking for admissions, inconsistencies, and consciousness of guilt that will become trial evidence. Any statement you make is admissible under Federal Rule of Evidence 801(d)(2), and any inconsistency between what you say and what the documents show can be charged separately under 18 U.S.C. § 1001 as a false statement, even if the underlying healthcare fraud case is weak. Decline the interview politely, ask for the agents' contact information, and call counsel immediately. Agents are familiar with this response and are required to accept it. The decision to provide a proffer, if any, comes later, on your terms, with counsel present, and only after we understand the scope of the investigation.

Federal Healthcare Fraud Defense

Why Healthcare Fraud Prosecutions Are Different

The Most Common Healthcare Fraud Charges in South Florida

Our Defense Approach

Related Results

Frequently Asked Questions

Justice Watch Analysis

DOJ Just Funded 15 New Federal Prosecutors for Medicaid Fraud. Florida Is on the List. Here Is What That Means for Providers and Anyone Pulled Into a Kickback Investigation.

The 2026 DOJ Healthcare Fraud Takedown Is Already Being Built: What the National Fraud Enforcement Division Means for SDFL Providers in the Next 12 Months

Florida Anti-Kickback Statute Defense: What a Recent DME Plea Tells You About Federal Exposure in 2026

Inside the $2 Billion Moscow Telemedicine Fraud Case: What Florida Pharmacy Owners, Telehealth Doctors, and Billing Operators Need to Know

$1 Billion Telemedicine Conviction in the Southern District of Florida: What the HealthSplash Verdict Signals for Telehealth Operators, DME Suppliers, and Marketing Companies

DME and Telemedicine Fraud: Why Physicians Are Now the Primary Federal Targets

$90 Million Medicare Fraud Indictment: What Happens Next and Why Your Defense Starts Now

DOJ Built a New Healthcare Fraud Machine for 2026. Florida Providers Need to Pay Attention.