Healthcare Fraud Lawyers: A Guide

A healthcare fraud lawyer is a legal professional who specializes in cases involving fraud and abuse in the healthcare industry. They represent individuals and entities, such as patients, providers, and insurance companies, in matters related to healthcare fraud.

health care fraud lawyer

What is Healthcare Fraud?

Healthcare fraud refers to intentional deception or misrepresentation committed by an individual or entity in order to receive unauthorized benefits from a health insurance program. It is illegal and can lead to significant penalties.

Some common examples of healthcare fraud include:

  • Billing for services not rendered: This is when a healthcare provider bills an insurance company for medical services that were never actually provided to the patient.
  • Upcoding services: This refers to billing for a more complex or expensive service than what was actually performed. For example, billing for a 60-minute therapy session when only a 30-minute session was provided.
  • Billing for unnecessary services: Ordering and billing tests, procedures, and services that are not medically needed.
  • Receiving kickbacks: This involves being paid to refer patients to a particular healthcare provider or service. The Anti-Kickback Statute prohibits this.
  • Falsifying patient diagnoses and information: This is done to justify tests, surgeries, prescriptions, etc. that otherwise would not have been approved or covered by insurance.
  • Identity theft: Using someone else’s insurance information to obtain healthcare services or prescription drugs.

Healthcare fraud drives up costs for private insurers as well as government health programs like Medicare and Medicaid. It is estimated that around 10% of total healthcare expenditures in the United States each year are due to fraudulent activities.

Why Hire a Healthcare Fraud Lawyer?

A healthcare fraud lawyer can provide valuable legal guidance and representation if you find yourself involved in a healthcare fraud investigation or case. Some key reasons to hire a healthcare fraud lawyer include:

1. They Understand Complex Healthcare Laws

Navigating healthcare laws can be extremely complex. There are many state and federal laws related to billing processes, payments, documentation, licenses, and more that healthcare professionals must comply with.

An experienced healthcare fraud lawyer understands these intricate legal issues and can effectively argue your case. They know how to critique evidence and spot legal violations by auditors, investigators, and prosecutors.

2. They Can Represent You in Audits & Investigations

If you come under audit or investigation for healthcare fraud, a knowledgeable lawyer can step in to handle responses and represent your interests. They understand investigation procedures and technologies.

They can also negotiate settlement agreements and help implement corrective action plans if needed. Having strong legal representation can help resolve cases as efficiently and positively as possible.

3. They Can Defend You Against Criminal Charges

Healthcare fraud can potentially lead to serious civil and criminal charges including huge fines and even imprisonment. Charges like violating the False Claims Act, anti-kickback/Stark laws, and HIPAA regulations often require legal defense in court.

An experienced healthcare fraud lawyer can evaluate your case specifics and build a defense to fight such charges if they lack adequate merit. This can help you avoid unjust penalties.

4. They Can Recoup Losses from Fraud

If you lost money due to someone else committing healthcare fraud, a lawyer can help you pursue compensation and damages. They can send demand letters, file lawsuits if needed, handle settlement negotiations, and more.

Recovering ill-gotten gains and other damages serves the cause of justice while also recouping your losses.

5. They Provide Compliance Support

Proactive healthcare fraud lawyers don’t just defend clients after the fact. They also consult with clients to improve compliance programs, policies, employee training, auditing protocols, and other fraud prevention measures.

Strengthening compliance helps reduce risk exposure in the future for both innocent mistakes and deliberate fraud. It also shows regulators and auditors that you take compliance seriously.

Healthcare fraud lawyers have specialized expertise handling a wide variety of legal cases stemming from healthcare fraud. Some of the main types of cases they represent clients on include:

False Claims Act Violations

The federal False Claims Act imposes liability on any person or organization that knowingly submits false claims for payment to the federal government. Healthcare programs like Medicare and Medicaid lose billions each year to False Claims violations.

As a whistleblower, you can file a “qui tam” lawsuit on behalf of the government to expose the fraud against them and receive a reward. Powerful whistleblower protection laws shield employees who report suspected False Claims violations from retaliation.

Healthcare fraud lawyers represent whistleblowers in preparing and filing these cases. They assemble evidence, draft the lawsuit, and litigate the case over months or years to reach settlement or win at trial.

The False Claims Act allows whistleblowers to receive 15-30% of the total settlement or judgement amount. Awards often reach into the millions, especially for healthcare fraud cases. Experienced lawyers maximize potential rewards.

Kickback & Physician Self-Referral Issues

Federal law prohibits paying or receiving bribes, kickbacks, or certain other financial incentives intended to influence healthcare referrals or purchases covered by government programs.

For example, a home health agency can’t pay a doctor to refer Medicare patients to them. That violates the Anti-Kickback Statute (AKS) and can lead to criminal penalties.

Meanwhile, the Stark Law restricts physician self-referral of Medicare patients to other healthcare providers/suppliers if they have a financial relationship. This helps avoid conflicts of interest driving up utilization and costs.

Healthcare lawyers advise clients on structuring arrangements to comply with kickback and self-referral regulations. They also defend clients against alleged violations.

Prescription Drug Fraud

According to the National Health Care Anti-Fraud Association, prescription drug fraud costs insurers billions annually in the United States.

Some common examples include:

  • Patients falsifying information to obtain controlled medications for diversion or abuse
  • “Doctor shopping” to obtain multiple prescriptions
  • Forged or altered prescriptions
  • Pharmacy or manufacturer coupon fraud
  • Illegal wholesale distribution of medications

A healthcare fraud attorney can represent pharmacists, physicians, and other parties accused of involvement in prescription drug schemes. They work to disprove allegations and avoid license suspension or revocation.

In cases of obvious drug diversion rings, the lawyer negotiates with prosecutors for reduced charges/penalties in exchange for cooperation. They also defend clients in related legal proceedings.

Medicaid & Medicare Fraud

Medicare and Medicaid lose tens of billions per year combined due to various healthcare fraud schemes trying to exploit these programs. Some common examples include:

  • Billing for unnecessary medical services
  • Billing for more expensive services than provided
  • Billing for services never performed
  • Falsely reporting diagnoses to qualify for coverage
  • Accepting kickbacks for referrals
  • Money laundering of fraud proceeds

A healthcare fraud lawyer represents providers accused of defrauding federal health programs. They rigorously contest unfounded allegations and work towards achieving suitable settlements when misconduct did occur.

Counsel helps clients implement corrective action plans to fix compliance deficiencies and negotiate corporate integrity agreements with oversight agencies. The goal is avoiding program exclusion and allowing the provider to continue caring for legitimately eligible beneficiaries.

Physician Licensure Issues

Doctors, nurses, pharmacists, and other licensed medical professionals found culpable for healthcare fraud often face disciplinary actions against their professional license. State medical boards take such cases very seriously given the violation of public trust.

A lawyer represents the licensed professional in board proceedings and advocates against overly-punitive sanctions. This can involve submitting explanatory materials, soliciting peer support, and even negotiating settlements ahead of rulings.

Maintaining licensure and avoiding restrictions allows professionals to continue serving patients. However, demonstrating remorse and outlining corrective actions is crucial for positive board outcomes.

Healthcare Fraud Whistleblowing

Most healthcare fraud schemes eventually get exposed by whistleblowers – employees, patients, competitors or others who recognize the misconduct and decide to report it. Federal and state false claims acts protect whistleblowers from retaliation and offer financial rewards if fraud judgements exceed certain thresholds.

An experienced healthcare fraud attorney advises whistleblowers on procedural intricacies, protections offered, and strategies to help maximize rewards. They also represent them throughout fraud proceedings and ensure protection from employer retaliation or other fallout. Maintaining confidentiality until formal charges get filed is critical as well.

The lawyer essentially quarterback’s the whistleblowing process to advance fraud allegations and safeguard the whistleblower’s interests simultaneously. This facilitates successful case outcomes.

Why are Healthcare Fraud Lawyers Important?

Healthcare fraud lawyers serve several crucial functions that help uphold integrity across the healthcare sector:

1. Deterring Fraud: The risk of severe penalties and litigation acts as a deterrent against healthcare fraud. Lawyers multiply this effect by aggressively pursuing maximum judgements and settlements in fraud cases.

2. Recouping Losses: Experienced lawyers maximize financial judgements and whistleblower rewards in successful cases. This helps recoup some losses enabling future fraud prevention investments.

3. Correcting Systems: Settlements often require implementing expanded compliance programs, stricter controls, training programs, and other corrective measures. This improves fraud detection moving forward.

4. Establishing Precedents: Lawyers argue key interpretations of statutes, standards of evidence, use of technologies/analytics, and other issues critical for fraud enforcement. Important precedents get established through key case outcomes.

5. Protecting the Innocent: When audits and investigations overreach or rely on circumstantial evidence, lawyers defend the rights of individuals and entities unjustly accused of fraud. This upholds the principle of “innocent until proven guilty.”

6. Protecting Whistleblowers: By law, whistleblowers are protected from retaliation when reporting suspected fraud in good faith. Experienced lawyers ensure these protections get honored in practice during fraud proceedings.

7. Justice & Deterrence: Ultimately fraud lawyers help bring perpetrators to justice for cheating healthcare payers and taxpayers, while establishing crucial deterrence against future fraud across the industry.

So in closing, the legal expertise provided by healthcare fraud lawyers plays an indispensable role in combating fraud, correcting non-compliance, recouping losses, protecting the innocent, and upholding integrity across healthcare organizations and regulatory systems.

Frequently Asked Questions

1. What are common penalties for healthcare fraud?

Healthcare fraud can lead to a combination of criminal, civil, and administrative penalties. On the criminal side, penalties may include prison sentences, fines, probation, community service, and the inability to work in healthcare.

Civil penalties often involve False Claims Act liability with large repayment obligations and additional fines based on a percentage of the fraudulent billings. Treble (triple) damages plus $11,000 – $22,000 per false claim are common.

Administrative sanctions can include exclusion from federally-funded healthcare programs, license/certification revocation, corporate integrity agreements, and repayment obligations.

2. Can a healthcare provider appeal audits or fraud charges?

Yes healthcare providers have the right to appeal audits by Medicare Recovery Audit Contractors (RACs) and other auditors, as well as charges of healthcare fraud. The appeals process enables providers to contest adverse findings and avoid unjustified liability.

Experienced healthcare lawyers represent clients in appealing audits and assessments before administrative law judges or in court. This advocacy can help overturn unfavorable audit outcomes and fraud judgements by challenging evidence adequacy, audit protocols, interpretations of billing requirements, etc.

3. How long do healthcare fraud investigations last?

Most healthcare fraud investigations range from several months to two or more years depending on case complexity. Gathering evidence through interviews, statistical sampling, medical record reviews, data analytics and other means is extremely time intensive.

Settlement negotiations also tend to involve extensive back and forth over penalty and damages calculations given the scope of most fraud schemes.

So while no case has a fixed duration, multi-year investigations are common with healthcare fraud issues. Experienced legal counsel guides clients through this prolonged period of scrutiny.

4. Can healthcare fraud charges lead to jail time?

Yes, healthcare fraud often carries criminal penalties that can include prison sentences depending on factors like the dollar amount involved, level of intent, and whether patient harm resulted.

However, experienced healthcare fraud lawyers negotiate with prosecutors to minimize potential jail time based on cooperation, demonstrating remorse/corrective actions, and negotiating alternative arrangements like deferred adjudication.

White collar financial crimes like healthcare fraud rarely result in maximum prison sentences except for most egregious intentional schemes involving patient harm. Even then, skilled legal counsel strives to avoid incarceration given its devastating professional and personal consequences.

5. How much do healthcare fraud attorneys cost?

Like all legal specialties, healthcare fraud lawyer fees vary based on experience, case complexity, duration, and other factors. Many lawyers work on a contingency fee basis for False Claims Act and other whistleblower fraud cases, collecting around 30% of any final settlement or court award.

For defense work on audits, investigations, or charges, healthcare lawyers normally bill by the hour. Rates range from around $250 per hour for newer attorneys to over $500 per hour for very experienced counsel from top firms. Significant provider fraud cases can easily incur hundreds of thousands in legal fees over time.

Fortunately legal fees spent on compliance improvements or successfully disputing fraud allegations often save much larger long run costs from fines and program exclusion. So the investment pays dividends.

health care fraud lawyer


Healthcare fraud harms all stakeholders across the healthcare sector. Preventing and combating this fraud through coordinated public-private efforts is crucial for improving healthcare affordability, access, and delivery.

Experienced healthcare fraud lawyers serve on the front lines of this fight – deterring crime through precedent setting cases, correcting non-compliance across organizations, recouping stolen funds, and upholding justice against unethical actors. They protect the innocent from unjust allegations.

Most importantly healthcare fraud attorneys give whistleblowers the power and security to call out fraud against payers and patients. They facilitate corrective actions while seeing justice done.

So while the legal system has its flaws, healthcare fraud lawyers working within it play an invaluable role upholding integrity across this vital sector of society and the economy. They defend the rights and interests of patients, ethical providers, taxpayers and more.

The next time we wonder why healthcare costs keep rising while access declines, we must remember the hugely corrosive impact of fraud and abuse across the system. We must recognize those professionals working diligently to combat this fraud at its source – the healthcare fraud lawyers determined to make a constructive difference despite the challenges.

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