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Lowther | Walker’s healthcare fraud defense attorneys, Joshua Sabert Lowther, Esq., and Murdoch Walker, II, Esq., represent medical professionals under investigation by federal agencies nationwide. Our experience spans decades of successfully shielding providers from aggressive government scrutiny, complex audits, and task-force probes led by agencies such as the FBI, HHS-OIG, and the Medicare Strike Force.
Our healthcare fraud practice focuses on protecting your license, your assets, and your future against allegations involving:
Complex Medical Billing Fraud: Defending against claims of upcoding, unbundling, and billing for services not rendered.
Medicare & Medicaid Fraud: Navigating high-stakes audits, ZPIC/UPIC investigations, and federal Strike Force indictments.
Anti-Kickback Statute (AKS) Claims: Refuting allegations of illegal remuneration, sham medical directorships, and illicit marketing arrangements.
Stark Law Violations: Untangling legitimate financial relationships and joint ventures from prohibited physician self-referrals.
Proactively book your free, confidential consultation online or call (877) 208-7146 to discuss our healthcare fraud defense services.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
If you’re charged with medical fraud, Lowther | Walker’s lawyers offer urgent responses founded upon hands-on experience in courtrooms nationwide.
As a leading healthcare fraud defense firm, we can offer:
Immediate Intervention: We immediately stand between you and the OIG/DOJ, routing all agent inquiries through our office to prevent you or your staff from making self-incriminating statements.
Shadow Investigation: Our attorneys conduct a confidential, parallel forensic audit of your patient billing data to identify the exact scope of exposure and protect favorable evidence before the government can secure it.
Pre-Indictment Services: We aggressively engage prosecutors early to present exculpatory evidence, aiming to downgrade criminal targets to civil administrative issues before charges are ever filed.
Intent Negation: We work to refute allegations of fraud by demonstrating that billing discrepancies resulted from ambiguous Medicare regulations, software flaws, or administrative errors rather than criminal intent.
Expert Counter-Attack: We deploy our network of independent medical and statistical experts to validate the medical necessity of your care and scientifically disprove the government’s flawed damage calculations.
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
Investigation terminated; no prosecution. DOJ notified our client, the CEO of a major hospital network, that he was the target of a multi-million-dollar healthcare fraud investigation related to “Medicare upcoding” that the FBI and HHS-OIG […]
The FBI and the HHS-OIG investigated our client for Health Care Fraud based on the client’s submitting over $7 million in alleged false claims to Medicare. The Government indicted our client on Conspiracy to commit […]
HHS-OIG investigated our client for Healthcare Fraud and Aggravated Identity Theft based on the client’s allegedly participating in a “telemedicine” kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not-medically-necessary durable medical […]
A private insurance company discovered that our client, a dentist, fraudulently billed it, various other insurance companies, and federal health care benefit programs for approximately $400,000 of services that our client did not provide. We […]
The Department of Justice’s Criminal Division, Fraud Section charged our client and nine other individuals in a $1.4 Billion health care fraud, wire fraud, and money laundering conspiracy (the largest health care fraud case that […]
Healthcare fraud is the intentional deception, misrepresentation, or submission of false claims to secure unauthorized financial benefits from health insurance programs.
Targeted Programs: Government benefit systems (Medicare, Medicaid, TRICARE) and private health insurance companies.
Investigated Entities: Physicians, hospital executives, pharmaceutical companies, medical marketers, testing laboratories, nursing facilities, surgical centers, and billing companies.
Americans spend $4.9 trillion on healthcare services annually. Healthcare spending is increasing 7.5% annually. The Government Accountability Office estimates that healthcare fraud, waste, and abuse account for 10 percent of all U.S. healthcare expenditures.
Healthcare fraud investigations involve allegations of fraud against government programs such as Medicare, Medicaid, or TRICARE, as well as private insurance companies. Medical professionals in a wide range of roles and industries can face fraud charges. Lowther | Walker has defended executives, healthcare providers, marketers, lab owners, rehabilitation facility owners, nursing facilities, surgical centers, and pharmaceutical companies.
Navigating Complex Regulatory Frameworks
Healthcare laws are notoriously intricate. An experienced attorney understands dense federal and state statutes such as the False Claims Act (FCA), the Anti-Kickback Statute (AKS), and Stark Law, parsing nuances that general defense lawyers may overlook.
Distinguishing Errors from Intent
Federal prosecutors must prove intent (that you knowingly submitted false claims). A specialized attorney knows how to demonstrate that billing discrepancies stem from administrative confusion, electronic health record (EHR) errors, or human mistake rather than criminal intent.
Challenging Data Analytics and Extrapolation
Government agencies frequently rely on advanced data mining and statistical extrapolation to claim widespread overbilling. An experienced defense team works with independent medical coders and statistical experts to rigorously challenge these flawed government methodologies.
Mitigating Severe Penalties and Asset Seizure
Convictions or civil judgments under laws like the FCA can lead to mandatory multi-million-dollar fines, triple damages, asset forfeiture, program exclusion (losing the ability to bill Medicare/Medicaid), and lengthy federal prison sentences. Counsel fights to minimize or avoid these exposures.
Protecting Your Professional License
Beyond criminal or civil liability, an investigation threatens your medical, nursing, or pharmacy license. A targeted defense strategy specifically prioritizes safeguarding your credentials so you can continue practicing.
Managing Government and Law Enforcement Interactions
Federal agents (FBI, HHS-OIG) often use aggressive tactics, such as unannounced interviews or Civil Investigative Demands (CIDs). An attorney acts as a shield, managing all communications, preventing staff coercion, and ensuring you do not accidentally incriminate yourself.
Intercepting Cases Early (Pre-Indictment Intervention)
The goal of a seasoned attorney is often to engage investigators early, before formal charges are filed. They can present exculpatory evidence to convince prosecutors to drop the case or successfully negotiate a civil resolution instead of a criminal indictment.
Anticipating the government’s next move is crucial for a successful defense. While every case is unique, federal and state healthcare fraud inquiries typically follow a predictable trajectory:
Investigations rarely begin with a knock on the door. Federal algorithms constantly monitor billing codes, peer comparisons, and prescription volumes. Statistical outliers are quietly flagged for human review long before you realize you are under suspicion.
What initially appears to be a routine records request is frequently a targeted probe by aggressive Medicare and Medicaid contractors, such as Unified Program Integrity Contractors (UPICs) or RACs. For example, you may receive a letter from SafeGuard Services, the Unified Program Integrity Contractor for the Northeast jurisdiction, which conducts Medicare and Medicaid program integrity audits across pharmacies, physicians, wound care providers, and DME suppliers. The government uses its own medical coders and subject-matter experts to scrutinize your clinical decisions, attempting to build a narrative that your services lacked medical necessity, were improperly supervised, or were intentionally upcoded.
The investigation formally escalates when you receive a government subpoena or CID demanding massive volumes of patient files, financial ledgers, and corporate communications. How you respond to this critical juncture dictates the trajectory of the entire case and requires immediate strategic oversight.
As the government finalizes its case, agents from the FBI or OIG may approach your current or former employees at their homes or offices. They use high-pressure tactics to secure statements before you can speak with a healthcare fraud attorney. Securing representation immediately ensures your staff is not coerced and can assert their rights.
Following the evidence-gathering phase, prosecutors determine whether to pursue a criminal indictment, file a civil lawsuit, or seek an administrative settlement. A proactive defense strategy intercepts the process at this stage, exposing flaws in the government’s theory before charges are officially filed.
Our leadership team includes former DOJ prosecutors and experienced federal trial lawyers. We understand how the government builds fraud cases and how entities such as the Medicare Strike Force investigate and prosecute fraud.
With 30 years of federal defense experience, we possess an encyclopedic understanding of U.S. healthcare law, including the False Claims Act, the Anti-Kickback Statute, and the Stark Law. We speak the language of healthcare law compliance to challenge government assumptions.
Federal healthcare regulations cross state lines. We provide elite, coordinated defense for medical professionals and clinics nationwide facing multi-jurisdictional investigations.
While many firms push for quick settlements, our attorneys are formidable federal litigators. We prepare every case with the meticulous detail required to litigate against the DOJ, HHS-OIG, and state Medicaid Fraud Control Units in federal court.
Federal healthcare fraud cases rarely rest on a single charge. Prosecutors typically build cases around several overlapping statutes at once, and understanding which ones apply shapes the entire defense strategy.
The primary criminal statute: knowingly and willfully executing, or attempting to execute, a scheme to defraud a healthcare benefit program, or to obtain money or property from one by false pretenses.
Prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce or reward patient referrals reimbursable by Medicare, Medicaid, TRICARE, or another federal healthcare program. “Anything of value” reaches far beyond direct payments — consulting agreements, medical directorships, and below-market leases can all trigger liability.
The government’s primary civil enforcement tool for billing fraud, and the statute most likely to be running quietly in the background of a practice under scrutiny. Allows private whistleblowers to file qui tam suits and collect a share of any recovery, often without the provider’s knowledge until the case is unsealed.
Unlike the AKS, Stark is a strict liability statute — the government doesn’t need to prove intent. If a prohibited financial relationship exists between a physician and an entity receiving Medicare referrals, and no exception applies, a violation has occurred regardless of intent.
Governs the “closed system” of drug distribution. Diversion allegations — prescribing, dispensing, or billing for controlled substances outside legitimate medical purpose — are charged under this statute and frequently appear alongside healthcare fraud counts in provider cases involving opioids or DME.
Because healthcare fraud schemes typically involve more than one person (a marketer, a referring physician, a billing company), prosecutors frequently add a conspiracy count, which only requires proof of an agreement and an act in furtherance of it — a lower bar than proving the underlying fraud itself.
Lowther | Walker’s federal criminal defense team has broad experience defending healthcare fraud cases in federal courts throughout the U.S. Medical providers turn to our attorneys for both their wide knowledge of healthcare fraud law and their proven success. The firm is known for defending its client in one of the largest healthcare fraud cases the DOJ has ever prosecuted.
Medical billing fraud refers to charging patients for unnecessary tests, procedures, or treatments, or billing for services not provided. CMS hires UPIC contractors to analyze billing data and find outliers, then refers cases to the OIG. The OIG investigates potential fraud, raids practices, and can exclude doctors from federal programs. Whistleblower complaints (Qui Tam Lawsuits) are a leading source of medical billing fraud charges.
Medicare fraud can include unbundling, phantom billing, double-billing, and upcoding. Investigations are typically handled by the Department of Justice (DOJ) and the Office of Inspector General (OIG).
Convictions for Medicare fraud may result in prison time, exclusion from federal programs, and substantial fines under the False Claims Act. Turn to our team to challenge the data analytics or audit findings that underlie the fraud allegations.
Medicaid fraud charges may include kickbacks, unbundling, and personal use of Medicaid funds. Medicaid fraud cases can involve both state and federal agencies, including Medicaid Fraud Control Units (MFCUs).
State and federal Medicaid investigations may result in civil or criminal penalties depending on the nature of the alleged scheme. Our federal attorneys have extensive experience intervening to help providers navigate audits, subpoenas, and interviews, and reduce the risk of criminal referral.
Stark law violations occur when a physician refers Medicare or Medicaid patients to a healthcare business with which they have a financial relationship.
Even inadvertent Stark Law violations can trigger False Claims Act liability and expose providers to treble damages. These cases often hinge on technical details within financial agreements or physician compensation structures.
Lowther | Walker’s attorneys will review compliance protocols and negotiate with regulators before they file charges.
Phantom billing is one of the most common forms of healthcare fraud. This includes billing for “ghost patients” and billing for services completed at another facility.
Prosecutions rely on billing discrepancies, patient interviews, and documentation. Investigators may allege a provider billed for non-existent patients or services performed elsewhere.
Upcoding refers to submitting claims to a federal healthcare program for more expensive services than the patient received.
Federal prosecutors may view upcoding as intentional inflation of reimbursements. However, coding disputes can stem from subjective medical judgment or ambiguous documentation. As your upcoding fraud defense lawyers, we can challenge these allegations by consulting expert coders and demonstrating compliance with the CPT coding guidelines established by the Centers for Medicare & Medicaid Services.
Providing or billing for medical services without an active medical license is a serious violation of federal law. Charges may involve allegations of impersonation, fraudulent credentialing, or supervision failures. Our attorneys typically focus on demonstrating a lack of criminal intent, administrative confusion, or reliance on staff representations to mitigate penalties.
You may face duplicate medical billing charges if you submit multiple claims for a patient undergoing the same healthcare service on the same date of service.
Duplicate claim allegations often arise from administrative or billing software errors, especially in large medical practices. Federal fraud investigators may treat repeated submissions as evidence of intentional fraud. Our attorneys audit claim histories, identify system malfunctions, and seek civil settlements before criminal prosecution begins.
Providers who overstate the patient’s diagnosis to secure a higher payment from a government healthcare program face substantial fraud charges.
Accusations of misrepresenting diagnoses or procedures often involve upcoding, falsified records, or improper documentation. Federal authorities take these cases seriously because they can demonstrate a pattern of intent to deceive payors. Legal defense strategies typically focus on expert review of medical necessity, documentation accuracy, and the physician’s clinical rationale for the coding decisions.
Unbundling is the process of separating charges for procedures covered by a government healthcare program to increase payment.
The Anti-Kickback Statute prohibits knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce or reward patient referrals or generate business payable by federal healthcare programs such as Medicare and Medicaid. Violations are felonies, punishable by up to 10 years in prison, fines over $100,000, and exclusion from federal programs.
Even indirect payments or consulting fees can trigger liability if they are linked to referrals. With a decades-long background defending Anti-Kickback Statute violations, our work often hinges on proving legitimate business arrangements, showing fair market compensation, and the absence of intent to induce referrals.
Under federal law, drug diversion is defined as the illegal distribution or transfer of any controlled substance from its legally authorized channel of distribution or use into an illegal or unauthorized channel. This concept is central to the Controlled Substances Act (CSA), which establishes a “closed system” of distribution requiring that every step—from manufacturing and wholesaling to prescribing and dispensing—be strictly monitored by DEA-registered entities.
Since 2007, when the DOJ established the Health Care Fraud Unit within the Criminal Division’s Fraud Section, more than 5,400 individuals have faced fraud charges, relating to over $27 billion in fraudulent healthcare claims.
Penalties for healthcare fraud include millions of dollars in fines and lengthy prison sentences.
A medical provider convicted of fraud may also face probation, which limits their ability to practice, instead of jail time. Probation terms for a healthcare fraud conviction in federal court could last from 12 months to three years.
Medical providers and practice owners facing health care fraud charges must respond to government agencies, such as the FBI, the Drug Enforcement Administration, and the Department of Health and Human Services. These federal agencies have countless resources to pursue criminal prosecutions.
The Lowther | Walker attorneys protect provider reputations and defend their practices against prosecutors. Our firm’s experience in healthcare fraud matters includes intervening during audits, handling criminal inquiries from Medicaid and Medicare fraud investigators, responding to target letters for healthcare providers, and representing you in Grand Jury hearings.
We defend healthcare professionals across the medical sectors, including:
Do not answer questions without a lawyer, even off the record. Anything you say can be used against you in court.
Never delete emails, shred documents, or alter files. Destroying evidence is a separate federal crime (obstruction of justice) carrying up to 20 years in prison.
Write down: agent names and badge numbers, exact questions asked, documents seized, witnesses present, and date/time of contact.
We’ll take over all communication with investigators and protect your rights. Lowther | Walker’s healthcare fraud attorneys are available 24/7 for a free and confidential consultation.
Lowther | Walker’s federal criminal defense team brings extensive, nationwide experience to defending medical professionals against complex government allegations. Whether you are under a Medicaid billing audit, an OIG investigation, or formal charges for Medicare fraud, our team is equipped to protect you. We understand that many fraud allegations stem from administrative confusion or errors in complex billing software rather than malicious intent.
By intervening early in the legal process, we can challenge data analytics, consult with certified coding experts, negotiate with federal regulators, and build a robust defense strategy to shield you from fines, exclusion from federal healthcare programs, and criminal liability.
Lowther | Walker defends healthcare providers in all 50 states. Our health care fraud defense lawyers are available 24/7 to respond to your urgent legal questions. Call (877) 208-7146 or schedule a free consultation online.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
The primary difference is intent. A billing error is a mistake, such as a typo or a misunderstanding of a complex coding rule. Fraud implies that you knowingly and willfully executed a scheme to defraud a healthcare benefit program, such as Medicare or Medicaid. However, the government may view a pattern of “reckless disregard” for the rules as fraud, even without direct proof of malicious intent.
Healthcare fraud investigations are often triggered by:
Whistleblowers (Qui Tam actions): Often disgruntled employees or competitors filing a suit under the False Claims Act.
Data Mining: CMS (Centers for Medicare & Medicaid Services) uses algorithms to identify providers who are statistical outliers in billing (e.g., billing the highest-level evaluation codes significantly more than peers).
RAC Audits: Recovery Audit Contractors can identify patterns of overpayments that get flagged for OIG (Office of Inspector General) investigation.
We represent the full spectrum of healthcare providers, including individual practitioners, group practices, hospitals, home health agencies, DME suppliers, pharmacies, laboratories, and other healthcare businesses of all sizes.
If you are investigated, having a robust, pre-existing compliance program is one of your best defenses. It demonstrates that you were trying to follow the law and that any errors were inadvertent. If the government sees you have a compliance officer, regular training, and internal auditing, they are more likely to view discrepancies as mistakes rather than intentional fraud.
Yes. Under federal law, you are responsible for claims submitted under your NPI (National Provider Identifier). You cannot delegate liability. If you signed the charts or the orders that generated the claims, the government argues you “caused” the false claim to be presented. “Blaming the biller” is rarely a successful defense unless you can prove active deception by the billing company against you.
In a healthcare fraud context, target letters indicate federal prosecutors have substantial evidence implicating you in crimes such as Medicare billing fraud schemes, illegal kickbacks, or Medicaid fraud. The OIG target letter signals you are a primary suspect, not merely a witness, and that a grand jury indictment is likely imminent
RAC (Recovery Audit Contractor) audits generally look for overpayments to recover money on a contingency basis.
UPIC (Unified Program Integrity Contractor) audits specifically look for fraud. If a UPIC requests your records, they are likely already suspicious. They are the primary bridge between a routine audit and a referral to the FBI or OIG for criminal prosecution.
Yes. Through a “pre-indictment restraining order” or civil forfeiture seizure warrants, the government can freeze assets it believes are “traceable” to the healthcare fraud. This is a strategic move to cut off your ability to hire high-quality private counsel.
We defend against all healthcare fraud allegations, including Medicare fraud and Medicaid fraud. We represent doctors and other healthcare providers, as well as healthcare business owners on the following charges:
Routinely waiving copays or deductibles can be viewed by federal prosecutors as an illegal inducement to entice patients to use your services, violating the Anti-Kickback Statute and the False Claims Act. Exceptions exist only if the waiver is not advertised, is not routine, and is based on a documented, good-faith assessment of the patient’s financial hardship, or if reasonable collection efforts have failed.
Our federal attorneys represent medical providers and healthcare business owners nationwide in Medicare fraud cases. Our experience covers all stages of Medicare fraud defense, from initial audits to appealing Medicare fraud convictions.
Lowther | Walker holds decades of experience managing Medicare audits, Medicaid audits, and follow-ups for healthcare providers nationwide.
Prompt, proactive responses to a healthcare fraud investigation can help mitigate potential charges. Lowther | Walker intervenes during FBI, OIG, and DEA investigations.
