Medicare Fraud Defense Lawyer
Federal Criminal Defense for Physicians, Clinics, and Healthcare Providers Accused of Medicare Fraud
Allegations of Medicare fraud can destroy a healthcare professional’s career and livelihood. With federal prosecutors aggressively targeting billing practices, referral relationships, and reimbursement claims, doctors, clinic administrators, and healthcare business owners in New York City are increasingly finding themselves at the center of criminal investigations. If you or your medical practice has been contacted by federal agents, received a subpoena, or learned of a pending indictment, you need an experienced federal criminal defense attorney to step in immediately.
At Sosinsky Law, we defend clients facing federal Medicare fraud charges throughout New York City and beyond. With decades of experience handling complex white-collar criminal cases, including healthcare fraud, conspiracy, and violations of the False Claims Act, we understand the investigative tactics used by the government and how to dismantle their case before it reaches the courtroom.
Whether you are under investigation by the Department of Justice (DOJ), Office of Inspector General (OIG), or Centers for Medicare & Medicaid Services (CMS), Sosinsky Law is prepared to defend you aggressively and effectively.
What Is Medicare Fraud?
Medicare fraud involves knowingly submitting false or misleading information to receive payment from the Medicare program. It is a federal crime prosecuted under statutes including 18 U.S.C. § 1347 (Healthcare Fraud) and 31 U.S.C. §§ 3729–3733 (False Claims Act).
Common Allegations of Medicare Fraud Include:
- Billing for services not provided
- Upcoding – using higher-paying billing codes than appropriate
- Unbundling – billing separately for procedures that should be grouped
- Billing for medically unnecessary services or equipment
- Falsifying documentation or patient records
- Kickbacks for patient referrals (violations of the Anti-Kickback Statute)
- Using unqualified or non-credentialed staff to deliver services
- Fraudulent enrollment or use of stolen Medicare IDs
Even small discrepancies in billing, when viewed as a pattern, can trigger massive federal investigations and result in serious criminal charges. Healthcare providers can be held criminally liable even if the billing was done by office staff, billing contractors, or third-party management companies.
Who Is At Risk in Medicare Fraud Investigations?
The government casts a wide net in Medicare fraud cases. You may be targeted if you are a:
- Physician or specialist
- Clinic owner or operator
- Home health agency administrator
- Chiropractor, therapist, or outpatient provider
- Billing manager or medical coder
- Medical equipment supplier (DME provider)
- Marketer or consultant tied to Medicare patient recruitment
Even non-physician roles, such as office administrators or marketers, can be swept into a conspiracy indictment if the government alleges you were part of a scheme to defraud Medicare.
Federal Agencies Involved in Medicare Fraud Enforcement
Medicare fraud is primarily enforced at the federal level. You may be investigated or prosecuted by:
- Department of Justice (DOJ)
- U.S. Attorney’s Office (Southern or Eastern District of New York)
- Department of Health and Human Services, Office of Inspector General (HHS-OIG)
- Federal Bureau of Investigation (FBI)
- Centers for Medicare & Medicaid Services (CMS)
- Medicare Fraud Strike Force (part of the Health Care Fraud Prevention and Enforcement Action Team, or HEAT)
These agencies have access to sophisticated data analytics systems that flag billing anomalies and statistical outliers. They often use civil subpoenas, search warrants, informants, and undercover agents to build their cases.
Signs You May Be Under Investigation for Medicare Fraud
If you’ve encountered any of the following, it’s essential to seek legal counsel immediately:
- A target letter or grand jury subpoena
- A civil investigative demand (CID)
- A request for billing or patient records
- A knock at the door from federal agents
- Notification of a Medicare payment suspension or audit
- Involvement in a qui tam whistleblower lawsuit filed under the False Claims Act
Early legal intervention is crucial. Once prosecutors have decided to indict, it’s often too late to avoid charges. The sooner you contact Sosinsky Law, the better your chances of resolving the matter favorably.
Penalties for Medicare Fraud
Medicare fraud is a federal felony offense that carries severe penalties, including:
- Up to 10 years in federal prison per count (20 years if serious injury results)
- Fines of up to $250,000 for individuals, and $500,000 for organizations
- Civil penalties under the False Claims Act, including treble damages
- Exclusion from Medicare and Medicaid participation
- Loss of medical licenses, DEA registration, and board certifications
- Asset forfeiture, including seizure of bank accounts, properties, and business assets
If charged under both criminal and civil statutes, a defendant may face parallel proceedings, compounding the risk of financial and personal ruin.
How Sosinsky Law Defends Medicare Fraud Charges
We bring more than just courtroom experience—we bring strategic insight into how federal healthcare investigations are built and how to dismantle them. Every case is different, but our defense strategies often include:
1. Challenging Intent
To convict under 18 U.S.C. § 1347, prosecutors must prove willful and knowing intent to defraud. We work to show that any billing errors were unintentional, clerical, or due to complex CMS guidelines, not criminal conduct.
2. Disputing the Government’s Audit Findings
We scrutinize Medicare audit data, coding decisions, and statistical models. These methods are often flawed, relying on extrapolated data that misrepresents the full scope of care provided.
3. Asserting Lack of Involvement or Knowledge
Many defendants are named in fraud cases simply due to their role in the organization. We show that you lacked knowledge of fraudulent practices or relied in good faith on the expertise of billing or compliance professionals.
4. Using Expert Witnesses
We partner with certified medical coders, billing experts, and compliance auditors who can testify about industry standards, coding practices, and medical necessity, often contradicting the government’s conclusions.
5. Negotiating with Prosecutors
If a favorable resolution is possible, we engage early with U.S. Attorneys to pursue non-prosecution agreements, civil settlements, or deferred prosecution agreements (DPAs) that avoid prison and preserve your career.
6. Preparing for Trial
If no resolution can be reached, Sosinsky Law is trial-ready. We know how to cross-examine government witnesses, expose weaknesses in audit methodologies, and present a compelling case to the jury.
Medicare Fraud and Whistleblower (Qui Tam) Lawsuits
Many Medicare fraud cases begin with a whistleblower complaint under the False Claims Act. These “qui tam” lawsuits are filed by former employees, competitors, or insiders seeking a percentage of the government’s recovery.
While these cases may be civil in nature at first, the DOJ often intervenes and pursues criminal charges. If your name appears in a False Claims Act lawsuit or related government complaint, you must act quickly to protect yourself.
Frequently Asked Questions About Medicare Fraud
Can I go to prison for billing mistakes?
If the government believes the mistakes were part of an intentional scheme, yes. But many errors are civil in nature. We work to demonstrate a lack of criminal intent and resolve the matter without charges.
What should I do if I receive a subpoena or target letter?
Contact an attorney immediately. Do not speak with federal agents or provide documents without legal guidance. Early mistakes can be costly.
What is the Anti-Kickback Statute and how does it relate to Medicare fraud?
The Anti-Kickback Statute prohibits offering or receiving anything of value in exchange for referrals paid by federal healthcare programs. Violations are often prosecuted alongside Medicare fraud charges.
Can I be held liable for actions of billing staff or consultants?
Possibly. If prosecutors believe you were aware of—or willfully ignored—fraudulent conduct, you may be held responsible. We work to prove you acted in good faith and lacked intent.
Is it possible to resolve a Medicare fraud case without going to trial?
Yes. Many cases are resolved through civil settlements, non-prosecution agreements, or favorable plea deals. Our goal is always to protect your interests with the least possible damage to your reputation and freedom.
Contact a Medicare Fraud Defense Lawyer in NYC
If you are being investigated for Medicare fraud, do not wait for formal charges to be filed. These cases are aggressively pursued by federal prosecutors and carry life-changing consequences. You need a defense attorney with real experience, real results, and the confidence to take on the federal government.
At Sosinsky Law, we stand ready to defend your name, your practice, and your future. Our reputation for excellence in federal white-collar defense has made us a trusted advocate for New York’s healthcare professionals. Call Sosinsky Law today for a confidential consultation with an experienced Medicare fraud defense attorney in New York City.