NYC Nursing Home Fraud Defense Lawyer
Federal prosecutors have made nursing home fraud a top enforcement priority, and the consequences for owners, administrators, and staff members charged with defrauding Medicare, Medicaid, and other federal healthcare programs are severe. In New York City, where the Department of Justice, HHS Office of Inspector General (HHS-OIG), and FBI actively investigate long-term care facilities, a federal nursing home fraud indictment can result in decades in prison, millions of dollars in fines and restitution, and permanent exclusion from federal healthcare programs. At Sosinsky Law, our
Manhattan healthcare fraud defense lawyer has spent more than 30 years defending healthcare providers and facility operators against the most serious federal criminal charges.
Types of Federal Nursing Home Fraud Charges
Federal nursing home fraud prosecutions in New York encompass a range of fraudulent conduct, all of which involve billing federal healthcare programs for services that were not provided, were not medically necessary, or were provided at a substandard level. The primary federal charges in these cases include healthcare fraud under 18 U.S.C. Section 1347, conspiracy to commit healthcare fraud under 18 U.S.C. Section 1349, violations of the Federal Anti-Kickback Statute under 42 U.S.C. Section 1320a-7b, and making false statements relating to healthcare matters under 18 U.S.C. Section 1035.
Billing for Services Not Rendered
The most straightforward form of nursing home fraud involves billing Medicare or Medicaid for skilled nursing services, therapy sessions, or medical treatments that were never actually provided to residents. Federal investigators identify these schemes through audits of billing records, comparison of staffing levels to billing volumes, and interviews with current and former employees, residents, and family members.
Upcoding and Inflating Patient Acuity
Nursing homes receive higher reimbursement rates from Medicare for patients who require more intensive levels of care. Upcoding fraud occurs when a facility systematically classifies residents at higher acuity levels than their actual medical conditions warrant in order to increase reimbursement. These cases often rely on expert medical testimony to establish that patient assessments were falsified and that the care documented in billing records was not consistent with the residents’ actual needs.
Falsified Therapy Records
Physical therapy, occupational therapy, and speech therapy are among the most frequently billed services at nursing homes, and they are also among the most common targets of fraud investigations. Federal prosecutors have brought cases against facilities where therapists documented full therapy sessions that never occurred, billed for skilled therapy services while providing only maintenance-level care, and continued billing for therapy services after patients were no longer benefiting from treatment. Our
Medicare fraud defense lawyer has experience defending facilities and individual therapists against these allegations.
Kickback Arrangements and Patient Referral Schemes
The Federal Anti-Kickback Statute prohibits nursing homes from paying for patient referrals. Federal prosecutors in New York have targeted arrangements where nursing facilities paid kickbacks to hospitals, physicians, or social workers in exchange for referring patients to their facility. These arrangements may take the form of direct cash payments, sham consulting agreements, inflated management fees, or free services provided to referring sources. Because kickback violations are often intertwined with
federal conspiracy charges, the sentencing exposure in these cases can be substantial.
Staffing Fraud and Falsified Personnel Records
Federal investigators have increasingly targeted nursing homes that submit false staffing data to Medicare and state regulators. Adequate staffing levels are a condition of participation in federal healthcare programs, and facilities that bill Medicare while operating with insufficient staff may face fraud charges. These schemes involve falsifying timesheets and payroll records to create the appearance of adequate staffing, billing for services allegedly provided by staff members who were not present or not qualified, and reporting inflated nurse-to-patient ratios to regulators to avoid compliance actions. Staffing fraud can also intersect with patient neglect allegations, which increases the severity of potential charges and the sentencing exposure for facility operators.
Federal Agencies That Investigate Nursing Home Fraud
Nursing home fraud investigations in New York are conducted by a network of federal and state agencies working in coordination. The HHS Office of Inspector General maintains a dedicated team focused on long-term care fraud, working alongside the FBI, the Medicaid Fraud Control Unit (MFCU) operated by the New York State Attorney General’s Office, and the U.S. Attorney’s Offices in the SDNY and EDNY.
These investigations often begin with whistleblower complaints filed under the False Claims Act by current or former employees, family members of residents, or competitors. The False Claims Act’s qui tam provisions allow whistleblowers to file lawsuits on behalf of the government and receive a percentage of any recovery, creating powerful incentives for insiders to report suspected fraud. If your facility has received a
federal grand jury subpoena or if you have learned that employees have been contacted by federal investigators, the investigation is likely well underway and immediate legal representation is essential.
Penalties for Federal Nursing Home Fraud Convictions
The criminal penalties for federal nursing home fraud are among the most severe in healthcare fraud law. A conviction for healthcare fraud under 18 U.S.C. Section 1347 carries up to 10 years in prison per count. If the fraud resulted in serious bodily injury to a patient, the maximum sentence increases to 20 years. And if the fraud resulted in the death of a patient, the defendant faces up to life in federal prison.
Beyond imprisonment, defendants face mandatory restitution to the federal healthcare programs that were defrauded, criminal fines that can reach hundreds of thousands of dollars, civil penalties under the False Claims Act including treble damages and per-claim penalties, mandatory exclusion from Medicare, Medicaid, and all other federal healthcare programs, and forfeiture of assets acquired with fraud proceeds.
For facility owners, the financial consequences extend beyond criminal penalties. The government can use civil forfeiture to seize the nursing home facility itself, along with bank accounts, real estate, and other assets connected to the fraud. Mandatory exclusion from federal healthcare programs effectively forces the closure of any facility that depends on Medicare or Medicaid reimbursement, which encompasses the vast majority of nursing homes in New York. Our
federal sentencing advocacy lawyer works to minimize these consequences through comprehensive mitigation strategies that address both the sentencing guidelines and the court’s discretion under 18 U.S.C. Section 3553(a).
Defense Strategies for Federal Nursing Home Fraud Charges
Challenging the Government’s Evidence of Intent
Federal healthcare fraud requires proof that the defendant knowingly and willfully participated in a scheme to defraud. In the complex regulatory environment of long-term care, legitimate disagreements about coding, patient classification, and medical necessity are common. Demonstrating that billing decisions were made in good faith reliance on clinical judgments, industry practices, or the advice of compliance professionals can undermine the government’s case.
Disputing Loss Calculations
The government’s loss calculation directly impacts sentencing exposure under the federal sentencing guidelines. Our firm works with forensic accountants and healthcare billing experts to challenge inflated loss figures, exclude legitimately provided services from the loss amount, and ensure that the sentencing guidelines are applied accurately.
Whistleblower Credibility Challenges
Many nursing home fraud cases originate from whistleblower complaints, and the whistleblower’s financial interest in the outcome of the case can compromise their credibility. Former employees may have personal grievances, and competitors may have financial motivations for reporting alleged fraud. Thoroughly investigating the whistleblower’s background, motivations, and the accuracy of their allegations is a critical component of the defense.
Parallel Civil and Criminal Proceedings in Nursing Home Fraud Cases
Nursing home fraud cases in New York frequently involve parallel civil and criminal proceedings. The government may pursue criminal charges through the U.S. Attorney’s Office while simultaneously pursuing civil recoveries under the False Claims Act. State regulatory agencies may also initiate proceedings that threaten the facility’s operating license. Navigating these overlapping proceedings requires an attorney who understands how decisions in one arena affect outcomes in the others.
For example, statements made during civil discovery or regulatory proceedings can potentially be used in criminal prosecution. A defense strategy that accounts for all pending proceedings is essential to protecting the client’s interests across every front. Our firm coordinates the defense across civil, criminal, and regulatory tracks to ensure that no misstep in one proceeding undermines the defense in another.
Whether your case involves a facility in
Manhattan, Brooklyn, Queens, or elsewhere in New York, Sosinsky Law provides the experienced defense that nursing home fraud cases demand.
Contact a New York Nursing Home Fraud Defense Attorney
If you are a nursing home owner, administrator, or healthcare professional facing federal investigation or criminal charges related to nursing home fraud in New York, the consequences you face are devastating and the government’s resources are vast. Contact Sosinsky Law at (212) 285-2270 for a free and confidential consultation. Attorney Fred Sosinsky has the experience and knowledge to protect your rights and your future at every stage of the federal criminal process.