Medicare billing fraud carries severe civil and criminal penalties, including treble damages, program exclusion, and lengthy prison sentences. If you are facing an investigation or indictment, Griffin Durham Tanner & Clarkson LLC provides strategic, aggressive defense to protect your career, finances, and freedom.
Contact our Atlanta white-collar criminal defense lawyers today for immediate legal representation.
Understanding Medicare billing fraud
Medicare fraud occurs when false or misleading claims are submitted to the Medicare program to receive unauthorized payments. Common examples include:
- Billing for services not provided – Submitting claims for procedures, tests, or treatments that were never performed.
- Upcoding – Using incorrect billing codes to inflate reimbursements.
- Unbundling – Billing separately for services that should be grouped together under a single code.
- Kickbacks and self-referrals – Violating the Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) or the Stark Law (42 U.S.C. § 1395nn) by offering or receiving improper financial incentives for patient referrals.
- Falsifying patient records – Altering documentation to justify medically unnecessary services.
Medicare billing fraud is prosecuted aggressively, often leading to both civil and criminal penalties under federal law.
Penalties for Medicare billing fraud
Medicare billing fraud carries severe civil and criminal penalties, and it is often prosecuted under the False Claims Act (FCA) and other federal statutes.
Civil penalties
- Treble damages – Defendants may be required to pay three times the fraudulent claim amount.
- Civil monetary penalties – Fines range from $13,508 to $27,018 per false claim.
- Exclusion from Medicare and Medicaid – Individuals and businesses may be barred from federal healthcare programs.
- Anti-Kickback Statute liability – Civil penalties apply even without intent, particularly for illegal referrals or kickbacks.
The FCA also allows whistleblowers (qui tam relators) to file lawsuits and claim a percentage of recovered funds, further increasing financial exposure.
Criminal penalties
For willful and intentional Medicare fraud, criminal prosecution can result in:
- Up to 10 years per offense (18 U.S.C. § 1347), with enhanced sentences for bodily injury (20 years) or death (life imprisonment).
- Wire fraud (18 U.S.C. § 1343) and mail fraud (18 U.S.C. § 1341) – Up to 20 years in prison.
- Conspiracy to commit healthcare fraud (18 U.S.C. § 371) – Up to 5 years in prison.
- Anti-Kickback Statute violations (42 U.S.C. § 1320a-7b(b)) – Up to 10 years in prison and $100,000 per violation.
Given the serious legal and financial consequences, individuals and businesses accused of Medicare fraud should seek immediate legal representation to mitigate exposure and protect their rights.
Defending against Medicare billing fraud charges
A strong legal defense is crucial to avoiding criminal prosecution and minimizing civil penalties.
1. Challenging intent and knowledge
The government must prove intent to defraud. We argue that billing errors or coding mistakes do not constitute criminal fraud.
2. Disputing the evidence
We scrutinize billing records, patient files, and audit reports to challenge the validity of the prosecution’s case.
3. Fighting whistleblower claims
Many False Claims Act cases are based on whistleblower lawsuits (qui tam actions). We examine the credibility of the relator and challenge unsubstantiated claims.
4. Negotiating settlements or reduced charges
When appropriate, we negotiate favorable settlements with federal agencies to reduce financial exposure and avoid criminal prosecution.
5. Asserting procedural violations
If the government obtained evidence illegally, we challenge the admissibility of improperly gathered data and seek case dismissal.
Why choose Griffin Durham Tanner & Clarkson LLC?
Medicare fraud charges can result in significant financial penalties, loss of professional licenses, and lengthy prison sentences. At Griffin Durham Tanner & Clarkson LLC, we provide:
- Experienced defense from former federal prosecutors – Our attorneys have insider knowledge of DOJ, HHS-OIG, and CMS enforcement strategies.
- Proven results in complex healthcare fraud cases – We have successfully defended physicians, healthcare executives, and business owners facing FCA and Medicare fraud allegations.
- Comprehensive case strategy – We prevent charges whenever possible, fight aggressively in court, and negotiate favorable resolutions when necessary.
- Discreet, high-level defense – Our firm is known for handling high-stakes white-collar cases with discretion and professionalism.
If you are under investigation for Medicare billing fraud or facing charges, you need aggressive legal representation immediately. At Griffin Durham Tanner & Clarkson LLC, we defend healthcare professionals and organizations nationwide against DOJ investigations, HHS-OIG audits, and federal indictments.
Call (404) 891-9150 or schedule a confidential consultation online to discuss your case with our experienced healthcare fraud defense attorneys.
