Health Care Fraud
Facing allegations of health care fraud can be overwhelming and damaging—not only to your career, but to your future. Federal authorities aggressively investigate and prosecute individuals and organizations accused of fraud against government healthcare programs such as Medicare, Medicaid, and Tricare. At Jayne Law Group, P.C., we defend clients accused of health care fraud at every stage of the process, from investigation to trial.
Health care fraud refers to knowingly submitting false information to receive payment from a health care benefit program. Charges may arise from a wide range of conduct—whether billing for services not rendered, exaggerating the complexity of care provided, or accepting improper payments in exchange for patient referrals.
Although each case is different, most federal prosecutions center on allegations that the accused knowingly and willfully devised a scheme to defraud a health care program and executed that scheme with the intent to gain a financial benefit.
Examples of common health care fraud allegations include:
- Billing for services not actually performed
- Upcoding (billing for a more expensive service than was provided)
- Unbundling (submitting multiple claims for services that should be billed together)
- Providing medically unnecessary services
- Accepting kickbacks or engaging in referral arrangements in violation of the Anti-Kickback Statute
- Falsifying patient records or diagnoses to justify claims
- Double billing a patient and insurer for the same service
- Submitting false eligibility information to receive program benefits
- Pharmacy and prescription fraud, including billing for non-dispensed medication or over prescribing controlled substances
These charges often arise from audits, whistleblower reports, or data analytics flagging irregular billing patterns.
Health care fraud investigations are typically handled by multiple federal agencies. These agencies use billing data, patient interviews, surveillance, and medical record audits to build their cases. Once the government believes it has sufficient evidence, the matter may be presented to a grand jury for indictment.
Penalties and Collateral Consequences
A conviction for health care fraud can carry severe penalties, including:
- Up to 10 years in federal prison per offense (up to 20 years if bodily injury occurs, or life if death results)
- Fines up to $250,000 per count
- Mandatory exclusion from Medicare and Medicaid programs
- Forfeiture of assets connected to the alleged fraud
- Restitution to government programs or insurers
- Revocation of professional licenses
- Long-term reputational harm and loss of employment
Civil suits under the False Claims Act can lead to treble damages and additional financial penalties. Even those not criminally convicted may still face administrative sanctions or civil liability.
At Jayne Law Group P.C., we work with medical experts, certified billers, and compliance professionals to challenge both the legal and factual basis of the government’s case. Whether negotiating with prosecutors, seeking dismissal, or defending at trial, we fight to protect your freedom and professional standing.