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Healthcare Fraud

Healthcare Fraud Attorney

Healthcare fraud allegations are among the most aggressively investigated and prosecuted offenses in the federal system. When the government believes that providers have submitted false claims to Medicare, Medicaid, or other federally funded healthcare programs, or engaged in unlawful kickback arrangements, it may pursue both civil and criminal penalties. At Aaron L. Wiley, P.C., we defend clients facing healthcare fraud investigations and prosecutions with strategic insight built on decades of experience.

Healthcare Fraud Attorney

Who Faces Healthcare Fraud Charges

Healthcare fraud charges are not limited to the person who typed the claim. Physicians, nurse practitioners, clinic owners, hospital administrators, pharmacy operators, home health agency owners and billing company employees have all faced federal charges related to the same scheme. So do office managers who approve billing codes they don’t fully understand.

The government does not need to prove that you personally submitted a false claim. Supervisory authorities, signing off responsibility, or having a financial stake in the outcome may be enough to lead to an investigation. A doctor who never touches billing software can still face liability if prosecutors believe fraud occurred under a scheme they authorized or benefited from.

This is why healthcare fraud investigations move slowly and expand quickly. What starts as a review of one provider’s claims can involve a billing company, a referring physician, and a hospital system before charges are even filed.

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False Claims Act Investigations

The False Claims Act is a powerful enforcement tool that allows the government to pursue providers for allegedly submitting claims that are false, fraudulent, or based on non-compliant services. These cases often begin with whistleblower complaints or data analysis that triggers suspicion of overbilling, upcoding, medically unnecessary services, or billing for services not rendered.

Civil False Claims Act cases can result in treble damages and significant financial penalties. Criminal investigations carry the risk of felony charges, restitution, and prison time. The government often uses parallel proceedings, where a civil case runs alongside a criminal inquiry. Navigating this dual exposure requires a coordinated defense strategy and immediate legal intervention.

At Aaron L. Wiley, P.C., we work closely with clients to review billing practices, respond to subpoenas, and defend against both civil and criminal allegations. We understand the complexities of Medicare and Medicaid billing and how to identify weaknesses in the government’s case. Our goal is always to protect our clients’ legal interests while minimizing reputational and professional damage.

Many of these cases begin as qui tam lawsuits filed under seal by a whistleblower, often a current or former employee, on behalf of the federal government. Before the provider even knows there is a case, the whistleblower’s lawyer and the Department of Justice investigate. If the government gets involved, the original complaint is made public and the provider is informed for the first time.

How a Federal Healthcare Fraud Investigation Unfolds

Most cases start quietly. A Medicare Administrative Contractor or a Recovery Audit Contractor flags an unusual billing pattern, or a whistleblower’s attorney files a sealed complaint. From there, the HHS-OIG or FBI opens a file and begins pulling records through administrative subpoenas or grand jury subpoenas.

Investigators interview current and former employees, sometimes patients, often without telling them that a case is open. Search warrants are less common than subpoenas, but they do happen, especially when investigators believe records may have been altered or destroyed.

If the case is heading toward criminal charges, the government typically sends a target letter before seeking an indictment from a grand jury. That letter is not a formality. It usually means that the decision to prosecute has already been made internally, and the response in the days that follow can shape what happens next.

Anti-Kickback Statute Violations

The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value in exchange for referrals for services reimbursable by a federal healthcare program. Violations can lead to criminal charges, civil penalties, exclusion from federal programs, and licensing consequences.

Allegations involving kickbacks often center on business relationships, consulting agreements, marketing arrangements, or payments for referrals. Even when there is no intent to violate the law, the government may view common industry practices as unlawful inducements. These cases frequently involve interpretation of contract language, communications, and financial records.

Aaron L. Wiley uses his experience as a former prosecutor to challenge the government’s assumptions about motive and intent. He conducts a thorough review of the relationships in question and builds a defense focused on legal compliance, business justification, and the absence of criminal intent. Where appropriate, he also works to resolve matters without litigation, through negotiated settlements or voluntary disclosures.

What to Do If You Receive a Subpoena or Target Letter

A subpoena or a target letter is not something to ignore. Contact an attorney before you respond, before you speak to investigators, and before deciding what records to collect.

Do not destroy or alter documents, even those that seem unfavourable. Obstacle charges carry their own penalties and can turn a civil matter into a criminal one. Do not talk to federal agents without a lawyer present, even if the conversation seems informal or routine. Agents are allowed to use what you say and a poorly phrased answer can do more harm than silence.

Preserve records now, calculate response deadlines immediately, and let an attorney manage communication with the government from that point forward.

Learn More About Government Issued Target Letters & Subpoenas

Experienced Healthcare Fraud Defense

Healthcare fraud cases are highly complex and carry significant risk. A single investigation can threaten a provider’s license, practice, and livelihood. At Aaron L. Wiley, P.C., we provide experienced, strategic counsel from the moment an inquiry begins. Whether the issue involves billing practices, referral arrangements, or alleged misrepresentations to government payers, we are prepared to respond quickly and effectively.

If you are under investigation for healthcare fraud, have received a subpoena or target letter, or are concerned about your exposure to potential false claims or kickback allegations, contact Aaron L. Wiley, P.C. 

Common Healthcare Fraud FAQs

Intent is the dividing line. Billing errors happen when a coder or biller makes a mistake, such as using the wrong code or documentation, or a system glitch occurs. Healthcare fraud involves knowing that a claim is false, fraudulent or not supported by medical records, and submitting it anyway. The government can recoup payments through overpayment demands. Fraud charges require proof of knowledge, though federal law also considers reckless disregard for truth in a claim to be knowledge.

Yes. Supervisory responsibility, sign-off authority, or financial stake in a scheme can support charges, even if someone else enters the billing codes. Prosecutors regularly charge physicians, owners and administrators who authorize or benefit from a billing practice, whether they touch the software themselves or not.

Federal regulations allow CMS to suspend Medicare payments to a provider based on a credible allegation of fraud, before any charges are filed and before any hearing. The suspension can last through the length of the investigation, which cuts off a provider’s primary revenue source at the exact moment legal fees are mounting. Challenging a suspension requires a specific administrative process, and moving quickly is important.

It’s a lawsuit filed by a private individual called a relator on behalf of the federal government under the False Claims Act. The relator is usually a current or former employee with inside knowledge of alleged fraud. The case remains sealed while the Department of Justice investigates and the provider named in the suit often has no idea that it exists until the government decides to intervene.

Not without an attorney present, agents are trained to ask questions in a way that sounds conversational. Anything said can be used, regardless of how informal the setting may feel. Politely declining to answer, and saying you will have your attorney contact them, is not an admission of guilt. It is a right every person has.

Criminal convictions under 18 U.S.C. § 1347 can carry up to ten years in federal prison per count, or up to twenty years if the fraud results in serious bodily injury. The Civil False Claims Act adds treble damages plus a per-claim penalty that adjusts annually for inflation beyond the courtroom. A conviction typically triggers exclusion from Medicare and Medicaid, and can end a medical license.

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