Medicaid Fraud Criminal Defense for Federal and State Charges

Under 18 U.S.C. § 1347, federal healthcare fraud involves knowingly and willfully executing or attempting to execute a scheme to defraud a healthcare benefit program or obtain its money or property through fraudulent means.

Related charges may include conspiracy under 18 U.S.C. § 1349, prohibited kickbacks under 42 U.S.C. § 1320a-7b(b), and false claims against the United States under 18 U.S.C. § 287.

Section 287 applies to qualifying false claims against the United States or a federal agency, not automatically to every state Medicaid claim. Anti-Kickback Statute allegations require separate consideration of statutory exceptions and regulatory safe harbors. Failure to meet a safe harbor does not independently establish a criminal violation.

State prosecutors may pursue charges under separate healthcare fraud statutes. New York Penal Law Article 177 establishes healthcare fraud offenses, while California Welfare and Institutions Code § 14107 addresses specified fraudulent Medi-Cal activities.

Individual liability depends on the accused person's conduct and the charged offense. Employment status alone does not establish criminal intent, although instructions, communications, and repeated participation may support the prosecution's allegations.

New York Penal Law § 177.30 provides a limited affirmative defense in Article 177 prosecutions for clerks, bookkeepers, and other qualifying employees who merely followed their employer's or an authorized superior's orders without personal benefit and did not exercise executive management and control of corporate affairs. Under § 25.00(2), the defendant must prove the defense by a preponderance of the evidence. It does not apply to separate federal charges.

Prosecutors may rely on emails, financial transactions, internal warnings, billing instructions, and witness statements to establish knowledge or participation. Defense counsel examines the accused person's authority over claims, understanding of billing practices, and reliance on information supplied by supervisors or colleagues.

Inaccurate coding may reflect a documentation problem rather than deliberate fraud. By contrast, instructions to misrepresent services or communications acknowledging false claims may support allegations of intentional misconduct.

Under § 1347, prosecutors need not prove that the defendant knew the statute itself or specifically intended to violate it. The government must still establish the elements of healthcare fraud beyond a reasonable doubt.

Patient charts, claims histories, and payment records help determine whether disputed services occurred and whether Medicaid reimbursed the claims. Provider authorization records, electronic access logs, and internal communications may identify who submitted claims, approved billing decisions, or knew about inaccuracies.

Comparing these materials may reveal coding disputes, missing documentation, or inconsistencies in the prosecution's interpretation. Witness accounts also require scrutiny because employees may have limited knowledge of particular transactions or conflicting explanations of who authorized them.

Complex billing disputes may require testimony from qualified medical coding or healthcare experts.

Before formal charges, an attorney can review subpoenas, assess objections and privileges, advise on interview risks, and coordinate lawful evidence preservation.

Separate representation may be necessary when business owners and employees have conflicting interests. An employer's attorney does not automatically represent individual employees.

Related government investigations may involve financial records, medical documentation, and electronic communications. Responses must account for production obligations and potential criminal exposure.

After prosecutors file charges, defense services may include discovery review, legal motions, plea negotiations, and trial preparation.

A disputed billing total does not independently establish criminal responsibility. In contested cases, trial representation may involve challenging the government's interpretation of treatment records, billing procedures, and witness testimony.

Medicaid fraud investigations may proceed alongside repayment demands, payment suspensions, and professional licensing reviews. Statements or documents submitted in one proceeding may become relevant to another.

Certain convictions require exclusion from federal healthcare programs under 42 U.S.C. § 1320a-7, while other circumstances permit discretionary exclusion. State licensing consequences depend on separate requirements.

These potential consequences should inform decisions about admissions, disclosures, and plea negotiations.