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Lowther | Walker’s Medicare fraud defense lawyers have over 20 years of experience and have successfully defended over 500 Medicare fraud cases nationwide.
Our Medicare fraud attorneys’ experience includes representing healthcare providers facing federal charges related to Medicare services, including:
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Call Us Today: (404) 496-4052
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 alleged participation in a telemedicine kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not medically necessary […]
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 alleged participation in a telemedicine kickback scheme that defrauded Medicare of approximately $30 million in reimbursements for not medically necessary […]
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 […]
Title 18 of the United States Code, Section 1347 defines Medicare Fraud as a federal crime to defraud government healthcare programs or obtain money, property owned, or property under the control of a healthcare benefit program using false or fraudulent pretenses. Proving these allegations requires criminal intent.
No matter how organized your medical office and how precise your billing practices are, you can face a Medicare audit and healthcare fraud charges if you submit many claims to the Centers for Medicare and Medicaid Services.
The latest data from the HHS-OIG (Health and Human Services Office of the Inspector General) show the government receives $11 for every $1 spent on Medicare fraud investigations. This figure from the Spring 2025 Semiannual Report to Congress covers October 1, 2024, to March 31, 2025. During this period, the OIG’s efforts resulted in over $16.61 billion in total monetary recoveries through federal Medicare fraud investigations.
This financial analysis underscores how aggressively the federal authorities and state Medicaid Fraud Control Units pursue Medicare and Medicaid fraud. In the same reporting period, federal and state authorities convicted more than a thousand healthcare providers and executives.
What begins as an administrative audit or overpayment review can quickly escalate into a full-scale federal investigation and prosecution.
Landmark Medicare fraud case results follow proven experience, as Lowther | Walker harnesses our history in healthcare fraud cases to help identify flaws at each stage of the prosecutor’s case against you. From healthcare professionals facing a Medicare audit to those appealing and facing a hearing before a judge, Lowther | Walker is adept at navigating complex fraud litigation and unraveling Medicare fraud charges.
Your professional reputation and freedom are on the line in Medicare fraud cases. Our Medicare fraud defense attorneys can respond quickly to clients across the United States. We meet with healthcare professional clients countrywide and can schedule a visit to your offices.
Our team has a comprehensive background in the prosecutorial side of government cases against healthcare professionals. Law firm partner attorney Murdoch Walker has experience leading a Department of Justice task force. This experience means Lowther | Walker is one of the country’s top Medicare fraud defense firms for effectively countering government prosecutor strategies.
Most Medicare fraud cases move through the same stages, from a billing audit to, in some cases, sentencing. Many end early, and the earlier a defense lawyer gets involved, the more likely the case stops at an audit or a civil resolution.
CMS data analytics, a whistleblower, or a contractor review flags unusual billing. A Medicare contractor may send records requests, conduct a site visit or run a statistical sampling audit that extrapolates a small error rate into a large overpayment.
CMS can stop paying claims based on a “credible allegation of fraud”, often without warning and before any charges. For many practices, this is the first sign of a fraud investigation.
HHS-OIG or FBI agents may call, visit the practice, or show up at an employee’s home. What you say in these first conversations can become evidence.
Investigators demand patient files, billing data, and communications through an HHS-OIG subpoena, a grand jury subpoena in a criminal case, or a civil investigative demand in a False Claims Act case. The type of demand tells you whether the government is pursuing a civil or criminal case.
When prosecutors worry records might be destroyed, agents execute a search warrant at the practice, seizing files, computers, and phones.
A federal target letter tells a provider that prosecutors consider them a likely defendant. It is often the last chance to present a defense before an indictment.
Many cases end in a declination, a repayment, or a civil settlement, sometimes with a Corporate Integrity Agreement. Others proceed to a grand jury indictment, plea negotiations. They can then go on to trial.
In federal fraud cases, the sentence is driven largely by the “loss amount” under Sentencing Guidelines §2B1.1. In health care cases, the total billed to Medicare can be treated as evidence of intended loss, and an extra 2 to 4 offense levels apply when loss to a government health care program exceeds $1 million. Challenging the loss calculation is often the most important part of a sentencing hearing.
Even after a case ends, providers face Medicare exclusion, state medical board action, and asset forfeiture of proceeds traced to the alleged fraud.
An innocent-seeming Medicare audit by a UPIC or MAC can quickly turn into a DOJ referral if handled improperly. Our lawyers intervene early to prevent administrative inquiries from crossing the line into federal criminal investigations.
The government can mistake poor record-keeping, misunderstandings of complex coding rules, or billing staff errors for calculated criminal fraud. A skilled lawyer knows how to demonstrate that an honest mistake does not equate to criminal intent.
The threat isn’t just federal prison. You face the immediate suspension of your medical license, the loss of your DEA registration, and permanent exclusion from Medicare and Medicaid programs. Your attorney fights to keep your doors open and your career intact while the investigation unfolds.
When you are up against the combined force of the DOJ, the FBI, and HHS-OIG, the agencies have virtually unlimited time, funding, and personnel. You need a defense team with federal court experience to counter their aggressive tactics and protect your constitutional rights.
If agents show up at your clinic unannounced or you receive a grand jury subpoena, what you do in the first 24 hours is critical. A defense attorney acts as an immediate shield between you and federal investigators, ensuring you don’t incriminate yourself or your practice.
Any medical professional in a position where they receive or handle Medicare funds for patient care may face Medicare fraud charges. This list includes:
Whether you’re facing a Medicare audit or federal charges, proactively booking a free consultation with a defense attorney can help safeguard your practice and your reputation.
Medicare fraud cases rarely involve one agency. Most investigations combine federal agents, Medicare contractors and prosecutors, and the agency that contacts you first says a lot about where the case is headed.
HHS-OIG oversees Medicare and Medicaid and is the lead investigative agency in most Medicare fraud cases. OIG special agents interview providers and staff, serve OIG subpoenas, and work criminal cases with the FBI and DOJ. OIG also handles civil monetary penalties and Medicare exclusion. If an OIG agent has reached out, read what to do when HHS-OIG contacts you.
The FBI is the primary federal agency for health care fraud against both government and private insurers. FBI agents typically handle the interviews, surveillance, or search warrants at medical practices in larger criminal cases.
The Justice Department’s Health Care Fraud Section has more than 75 prosecutors dedicated to health care fraud and runs nine Strike Forces that pair prosecutors with HHS-OIG, FBI, CMS, and other agents. The Section uses data analytics to spot billing outliers and leads the national health care fraud takedowns. Local U.S. Attorney’s Offices prosecute many cases too, and DOJ’s Civil Division brings False Claims Act cases, often starting with a civil investigative demand.
Every state has an MFCU, usually inside the state attorney general’s office. MFCUs focus on Medicaid, but they regularly work joint Medicare and Medicaid fraud cases with federal agents when the same provider bills Medicare. Lowther | Walker’s Medicaid fraud defense lawyers can respond to complex overlapping state and federal health fraud cases.
UPICs are private contractors hired by CMS to find fraud.
They request records, conduct site visits, and run statistical sampling audits, and they can refer cases to HHS-OIG. A UPIC audit is often the first sign that a practice is being looked at.
CMS runs the data systems that flag unusual billing and can act without a criminal case: it can impose a Medicare payment suspension, revoke billing privileges, or demand repayment of overpayments. Because these agencies share information, a records request from a UPIC or a call from an OIG agent can become a criminal investigation. Speaking with a Medicare fraud defense lawyer at the first contact gives you the most options.
There is no official ranking of states by Medicare fraud. The best guide is where DOJ concentrates its prosecutors. The first Medicare Fraud Strike Force launched in Miami in March 2007, and today DOJ runs nine Strike Forces in the regions with the highest levels of billing fraud. The Central District of California alone has the most Medicare spending of any federal district.
| Strike Force | Federal districts and cities covered |
|---|---|
| Florida Strike Force | Southern and Middle Districts of Florida: Miami, Fort Lauderdale, Tampa, Orlando |
| Texas Strike Force | Southern District (Houston, South Texas) and Northern, Western and Eastern Districts (Dallas) |
| Los Angeles Strike Force | Central District of California |
| Midwest Strike Force | Eastern District of Michigan (Detroit) and Northern District of Illinois (Chicago) |
| Northeast Strike Force | Eastern District of New York (Brooklyn) and District of New Jersey (Newark) |
| Gulf Coast Strike Force | New Orleans, Baton Rouge and Gulfport |
| New England Strike Force | New England health care market, including New Hampshire, Maine and Vermont |
| Prescription Strike Force | Illegal prescribing and opioid distribution cases (DOJ’s historical list also includes the Appalachian Region: Kentucky, Tennessee, Ohio, Virginia, West Virginia, Alabama) |
| National Rapid Response Strike Force | Washington, D.C.; supports cases in U.S. Attorney’s Offices nationwide |
Lowther | Walker defends Medicare fraud cases in every Strike Force district and in U.S. Attorney’s Offices nationwide, including our Miami healthcare fraud, Chicago Medicare fraud, Atlanta healthcare fraud, and Philadelphia healthcare fraud practices.
Medicare fraud isn’t one crime. Prosecutors and regulators choose criminal statutes and civil laws, often in combination. A single billing practice can lead to a criminal indictment, a False Claims Act lawsuit, and exclusion from Medicare at the same time.
| Law | What it prohibits | Maximum penalty |
|---|---|---|
| 18 U.S.C. § 1347 (health care fraud) | Knowingly carrying out a scheme to defraud Medicare or any health care benefit program, or to obtain its money by pretenses | 10 years per count; 20 years if the scheme causes serious bodily injury; life if it results in death; plus fines |
| 18 U.S.C. § 1349 (attempt and conspiracy) | Agreeing with others, or attempting, to commit health care fraud or related wire, mail, or bank fraud | The same penalties as the underlying offense |
| 18 U.S.C. § 1035 (false statements) | Falsifying or concealing a material fact, or making a false statement or document, in connection with health care benefits or payment | 5 years per count, plus fines |
| False Claims Act (31 U.S.C. §§ 3729–3733) | Knowingly submitting false claims, using false records, or keeping known overpayments | Civil: three times the government’s losses, plus $14,308 to $28,619 per claim |
| Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) | Knowingly and willfully paying, offering, soliciting or receiving anything of value for referrals of Medicare-covered items or services | Criminal: 10 years and $100,000 per violation. Civil: up to $127,973 per kickback plus three times the remuneration |
| Stark Law (42 U.S.C. § 1395nn) | Physician referrals for designated health services to entities the physician or a family member has a financial relationship with, unless an exception applies | Civil only (no intent required): repayment of claims, up to $31,670 per service, and up to $211,146 per circumvention scheme |
| Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a) | HHS-OIG’s administrative penalties for false claims, beneficiary inducements, employing excluded people, and similar conduct | Up to $25,595 per item or service, plus up to three times the amount claimed and exclusion |
A conviction for a Medicare-related crime also triggers mandatory exclusion from Medicare for at least five years, and a claim tainted by a kickback is automatically a false claim under the False Claims Act. Read more in our guide to the Anti-Kickback Statute.
Penalty amounts: the FCA range is from 28 CFR 85.5; the AKS civil, Stark, and CMP amounts are the latest figures in 45 CFR 102.3. Both tables are adjusted for inflation every year, so recheck them annually.
You’ve worked tirelessly for your healthcare career. Don’t take any chances with your future.
Lowther | Walker’s healthcare fraud defense lawyers will harness their in-depth knowledge of billing codes and Medicare policies to bridge the knowledge gap and build a compelling defense of your office’s Medicare work.
Book your free consultation or call now to discuss our Medicare fraud defense services.
Lowther | Walker is the leading U.S. healthcare fraud defense firm for medical professionals facing Medicare fraud charges. Call today to schedule your free consultation.
No-obligation. Fully confidential.
Call Us Today: (404) 496-4052
The cost depends mostly on how far the government’s case has gone. The main factors are:
The cost of waiting is often higher: early representation can keep an audit from becoming a criminal case. Schedule a free, confidential consultation for an estimate based on your situation.
Yes, Medicare fraud accusations can jeopardize your medical license, even before you’re convicted of any crime. State medical boards often initiate their own disciplinary proceedings when they learn of fraud allegations, and they operate independently from criminal or civil cases. A conviction for Medicare fraud almost always triggers license suspension or revocation.
However, even accusations alone can prompt board investigations. Additionally, if you’re excluded from participating in federal healthcare programs (placed on the OIG’s List of Excluded Individuals and Entities), many state boards view this as grounds for disciplinary action. An experienced attorney can help coordinate your criminal defense with strategies to protect your license, including working with healthcare licensing attorneys and preparing responses to medical board inquiries that don’t compromise your legal defense.
Yes, you can technically still practice medicine if excluded from Medicare, but your career options become severely limited. Exclusion means you cannot bill Medicare, Medicaid, or any federal healthcare program for your services. Patients covered by these programs cannot use their benefits to pay you, even if they want to pay directly for your services.
Most hospitals, healthcare systems, and group practices won’t employ excluded physicians because they risk losing their own Medicare funding by doing so. You would be restricted to treating only patients with private insurance or those paying entirely out-of-pocket in a private practice setting. For many physicians, exclusion effectively ends their career. The exclusion period typically lasts a minimum of five years, but can be permanent depending on the severity of the fraud. This is why avoiding exclusion or negotiating the terms of any settlement is a critical priority in your defense.
Not necessarily. Medicare fraud requires proof of intent, that you knowingly and willfully submitted false claims. Honest mistakes, coding errors, or misunderstandings of complex Medicare rules generally don’t constitute fraud, though they may result in overpayment demands or civil penalties.
However, the government may try to establish a pattern that suggests intent, such as repeated errors that always favor higher reimbursement, billing for services after being warned about improper coding, or ignoring compliance training. Your defense attorney will work to demonstrate that errors were inadvertent, that you acted in good faith, that you relied on your billing staff or outside billing companies, or that Medicare’s guidelines were ambiguous.
Documentation showing you sought compliance guidance, corrected errors when discovered, or participated in training can strongly support a lack-of-intent defense. Even if criminal fraud charges aren’t warranted, you may still face civil False Claims Act liability, which has a lower burden of proof and doesn’t require criminal intent.
Wait for your attorney. While your instinct may be to explain yourself or cooperate to show you have nothing to hide, anything you say to investigators can and will be used against you. Medicare fraud investigators are skilled at obtaining statements that seem innocent but can be twisted to suggest guilt.
Do not speak with OIG agents, FBI investigators, or other federal officials without legal representation present. Politely decline to answer questions and state that you’d like to consult with your attorney first. Do not allow investigators to search your office or access records without a warrant or subpoena, and even then, have your attorney review the document first. Similarly, do not destroy, alter, or hide any documents, as this constitutes obstruction of justice and will make your situation far worse.
Your attorney can communicate with investigators on your behalf, negotiate the terms of any interviews, and ensure your rights are protected throughout the process. In some cases, your attorney may advise limited cooperation as part of a strategic defense, but this decision should only be made with legal counsel.
The False Claims Act is a federal law that imposes civil liability on individuals and entities that knowingly submit false or fraudulent claims for payment to the government, including Medicare. Under this law, you can be held liable for submitting claims for services not rendered, upcoding, billing for medically unnecessary services, or any other false statement to obtain Medicare payment.
The FCA allows for treble damages (three times the amount of false claims) plus penalties of thousands of dollars per false claim submitted. The law also has a “whistleblower” provision that allows private individuals, often employees or former employees, to file qui tam lawsuits on behalf of the government and share in any recovery. Even without criminal intent, you can face substantial civil liability under the FCA if the government proves you acted with “deliberate ignorance” or “reckless disregard” of the truth. Many Medicare fraud cases are pursued civilly under the FCA rather than criminally because the burden of proof is lower.
Medicare fraud criminal penalties are severe and can include lengthy prison sentences, substantial fines, and restitution. Under federal law, healthcare fraud can result in up to 10 years in prison for each count. If the fraud results in serious bodily injury to a patient, the sentence can increase to 20 years. If a patient dies as a result of the fraud, you could face life imprisonment.
Financial penalties are equally devastating. Criminal fines can reach $250,000 per count for individuals, and you’ll likely be ordered to pay restitution to Medicare for all fraudulently obtained funds. You’ll also face mandatory exclusion from all federal healthcare programs, effectively ending your ability to treat Medicare and Medicaid patients.
Additionally, a felony conviction results in loss of your DEA license to prescribe controlled substances and will almost certainly lead to state medical board action against your license. These consequences underscore why experienced legal representation is essential from the moment you learn of an investigation.
Upcoding occurs when a healthcare provider bills Medicare for a more complex, expensive service than was actually performed. For example, billing for a comprehensive office visit (higher-level E&M code) when only a brief consultation occurred, or coding a simple procedure as a complex one to receive higher reimbursement.
Upcoding is considered fraud when done knowingly and intentionally to increase payment. However, the line between honest coding errors and fraudulent upcoding can be blurry.
The government looks for patterns, such as a provider whose distribution of high-level codes is statistically abnormal compared to peers, consistent billing of the highest-level codes regardless of patient complexity, or documentation that doesn’t support the billed codes. If you’re accused of upcoding, your defense may focus on demonstrating good faith coding practices, reliance on billing staff or coding software, compliance with your understanding of coding guidelines, or the complexity of Medicare’s coding rules. Medical necessity documentation is crucial in defending against upcoding allegations.
Yes, you can potentially be held liable for your billing staff’s actions under the legal doctrine of “respondeat superior” (employer liability) and because providers must ultimately sign off on or be responsible for claims submitted under their National Provider Identifier (NPI). As the treating physician, you’re expected to ensure proper oversight and compliance in your practice.
However, reliance on billing staff can also be part of your defense if you can demonstrate that you implemented reasonable compliance measures, provided proper training and supervision, had no knowledge of improper billing, and acted in good faith. If an employee engaged in fraudulent billing without your knowledge or contrary to your policies, this may support a lack-of-intent defense.
Willful blindness or deliberate ignorance of obvious red flags won’t protect you. You must demonstrate that you maintained adequate compliance systems and oversight. This is why having documented compliance policies, regular audits, and staff training is so important. It provides evidence of good faith efforts to prevent fraud.
