Healthcare fraud, or fraud related to federal health programs and benefits (health insurance companies), is one of the most strictly prosecuted and harshly punished federal crimes. Healthcare fraud has become a national endemic over the last decade, with tens of billions of dollars annually lost to federal healthcare programs, most commonly Medicare. South Florida is considered one of, if not the most highly targeted region for federal investigators and prosecutors in the healthcare arena. South Florida is responsible for 20% of all false healthcare claims in recent years, prompting federal officials to refer to it as “ground zero” for healthcare fraud. Frauds executed against Medicare, Medicaid, or other government aid programs may be prosecuted via several federal criminal statutes.
The attorneys at the Rossen Law Firm are highly experienced in federal healthcare fraud. Based in South Florida, we are constantly at the forefront of the battle against the government in the highly complex and ever-changing arena of healthcare fraud and compliance. This complex area of law requires an intricate understanding of the legal system and the healthcare industry from a regulatory compliance standpoint. With a dedicated team of attorneys specializing in healthcare fraud and regulatory compliance, the lawyers at the Rossen Law Firm are ready to guide you through the murky waters of federal healthcare investigations and prosecutions.


Healthcare fraud can be committed by doctors, nurses, pharmacists, medical office administrative staff and billing companies, laboratory owners, marketers, insurance brokers, patients, and others accused of intentionally deceiving the healthcare system to receive unlawful benefits or payments. The FBI is the primary agency for investigating health care fraud for federal and private insurance programs, often working in conjunction with the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).

Federal healthcare fraud typically involves deceptive practices that result in unauthorized benefits from health insurance providers, especially those funded by the federal government, such as Medicare and Medicaid. The crime includes overbilling, billing for services not rendered, misrepresenting services provided, and falsifying a patient’s diagnosis to justify tests, surgeries, or other procedures that aren’t medically necessary.

The fraud and abuse laws under the False Claims Act, Anti-Kickback Statute, and Physician Self-Referral Law (Stark Law) often interact in a healthcare fraud case and can significantly influence your potential for prosecution and severe criminal exposure. While “Healthcare Fraud” comes in many different forms and can implicate several different federal statutes, the primary statute for federal healthcare fraud is 18 U.S.C. § 1347. This law makes it illegal to knowingly and willfully execute, or attempt to execute, a scheme or artifice:

  1. To defraud any healthcare benefit program; or
  2. To obtain, using false or fraudulent pretenses, representations, or promises, any money or property owned by, or under the custody or control of, any healthcare benefit program.

To obtain a conviction for healthcare fraud, the government must prove several elements beyond, and to the exclusion of, any and all reasonable doubt. These elements include:

  • Execution of a Scheme or Artifice: The defendant must have executed or attempted to execute a scheme or artifice. This generally means that the defendant took some action toward perpetrating the fraudulent scheme.
  • Intent to Defraud a Healthcare Benefits Program: The defendant must have intended to defraud a healthcare benefit program. This means the defendant’s actions were deliberate, not accidental, or based on a mistake.
  • Use of False Pretenses, Representations, or Promises: The defendant must have used pretenses, representations, or promises to execute the fraudulent scheme. This means that the defendant used deception or lied in some way.
  • Obtaining Money or Property from a Healthcare Benefits Program: The defendant must have executed or attempted to execute the scheme or artifice to obtain money or property from a healthcare benefit program.


The healthcare fraud attorneys at the Rossen Law Firm regularly defend against a variety of types of fraud, as the crime can come in various forms, but common allegations include:

  • “Medically Unnecessary” Services or Testing
  • Upcoding: Billing for more expensive services or procedures than were provided or performed.
  • Duplicate Claims: Submitting multiple claims for the same service rendered.
  • Phantom Billing: Billing for services, tests, or procedures that were never performed.
  • Kickbacks: Receiving unearned compensation from a federal health insurance reimbursement for patient referrals for tests or procedures or medically unnecessary medical equipment or laboratory testing.
  • Durable Medical Equipment (DME) Fraud
  • Genetic Testing Fraud
  • Prescription Fraud
  • Marking and Solicitation Fraud related to healthcare services


The penalties for healthcare fraud are severe. They can include substantial fines, restitution, asset forfeiture, and imprisonment. For example, under the Federal Health Care Fraud statute (18 U.S.C. § 1347), the potential penalties include fines and up to 10 years in prison or up to 20 years if the fraud results in serious bodily injury.

Even worse, the federal government will almost always charge an individual with related offenses that carry severe penalties, including Wire Fraud, Money Laundering, and Conspiracy (by itself or as a conspiracy to commit wire fraud or conspiracy to money laundering, which carries increased penalties).

On top of the penalties that one could face, such as prolonged incarceration and hefty fines, healthcare fraud convictions can bring extremely harmful collateral consequences, affecting our clients and their loved ones far after the criminal penalties are over. Just a few of the severe collateral consequences include:

  • Loss of professional license to practice medicine
  • Loss of professional license to sell medical insurance
  • Loss of ability to prescribe medication, including loss of DEA registration
  • Exclusion from federal health insurance programs
  • Disbandment of medical practice
  • Banishment from operating in the medical education field


The Federal Sentencing Guidelines set out a uniform sentencing policy for individuals and organizations convicted of felonies and serious (Class A) misdemeanors in the United States federal courts system. In healthcare fraud cases, the Sentencing Guidelines consider the nature of the crime and the offender’s criminal history to determine the recommended sentence.

  • Base Offense Level: For healthcare fraud, the base offense level is typically set at Level 6 or Level 7 (under USSG §2B1.1), depending on the case’s specific details.
  • Loss Amount: One of the most significant factors influencing sentencing in healthcare fraud cases is the amount of loss involved. The loss amount is the intended or actual financial loss that resulted from fraudulent activity. As the amount of loss increases, so does the offense level, which can lead to an increased sentence length.
  • Specific Offense Characteristics: Besides the loss amount, the Guidelines consider other specific offense characteristics. This can include the means and methods used to commit the offense, whether any patients were harmed, the number of victims, and whether the offender used sophisticated means to commit the offense. Each of these characteristics can add to the offense level.
  • Role in the Offense: The defendant’s role in the offense can also influence the sentencing. If the defendant was an organizer or leader of a scheme, additional points could be added to the offense level. Conversely, points may be subtracted if the defendant played a minor role.
  • Acceptance of Responsibility: If the defendant accepts responsibility for the offense, the court can decrease the offense level. This usually requires the defendant to plead guilty.
  • Criminal History: The defendant’s criminal history can impact the sentencing. A defendant with a prior criminal history may face a harsher sentence than a first-time offender.

Each of these factors will be calculated to determine the final offense level, which is then used with the defendant’s criminal history to determine the sentencing range in months. The Guidelines are advisory, not mandatory, meaning the judge has the discretion to sentence the defendant above or below the recommended range under certain circumstances. However, judges must consider the Guidelines in all cases and provide written reasons for departures from the recommended range.

These are just the primary factors that apply, and in the context of healthcare fraud, several other potential factors within the sentencing guidelines may apply to your case. Given the complexity of sentencing in healthcare fraud cases, it’s essential to have the experienced legal counsel of the Rossen Law Firm to navigate these issues.


The Anti-Kickback Statute (AKS) is a federal law that prohibits the exchange (or offer to exchange) of any type of gift, bribe, kickback, or rebate for referrals for services paid for by federal healthcare programs such as Medicare and Medicaid. This law is outlined in 42 U.S.C. § 1320a-7b.

The conspiracy to violate the federal Anti-Kickback Statute is punishable by a maximum potential penalty of five years in prison and a fine of $250,000, or twice the gross profit or loss caused by the offense, whichever is greater.

Additionally, violations of the Anti-Kickback Statute are considered felonies. The penalties can be severe and include:

  • Fines up to $25,000 per violation
  • Imprisonment of up to five years per violation
  • Civil monetary penalties of up to $50,000 per violation plus three times the amount of the kickback
  • Exclusion from federal healthcare programs

Criminal Violations under the Anti-Kickback Statute

Under the AKS, it is a criminal offense to knowingly and willfully solicit, receive, offer, or pay any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or kind, in return for:

  1. Referring an individual to a person for the furnishing, or arranging for the furnishing, of any item or service for which payment may be made, in whole or in part, under a federal healthcare program.
  2. Purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made, in whole or in part, under a federal healthcare program.

The AKS is an “intent-based” law, meaning that a person must have a deliberate intent to induce or reward referrals for services paid for by a federal healthcare program.

It is imperative to note that certain “safe harbors” – practices that are protected even if they may technically violate the AKS – typically include certain types of investment interests, rental agreements, and personal service arrangements. However, the specific requirements for each safe harbor must be strictly met to avoid potential liability. It’s essential to consult with an attorney well-versed in healthcare law when navigating these complex issues related to safe harbors and violations of the AKS.


Defending against a federal healthcare fraud charge requires a deep understanding of the healthcare system, laws, and a well-thought-out strategy. Here are just a few of the common defenses utilized by the healthcare fraud defense attorneys at the Rossen Law Firm:

  • Lack of Intent: Federal healthcare fraud charges require proof that the defendant acted with the intent to defraud. If the defense can show that the defendant lacked this intent, it may result in an acquittal. For example, if the defendant can show they were acting under a genuine misunderstanding or error, this may establish a lack of intent.
  • Insufficient Evidence: The prosecution bears the burden of proving the defendant’s guilt beyond a reasonable doubt. If the defense can show insufficient evidence to meet this standard, the charges may be dropped, or the defendant may be acquitted.
  • Good Faith: Another common defense is to demonstrate that any discrepancies or mistakes were not intentional but due to confusion, misunderstanding, or simple errors in record-keeping. If the defendant believed in good faith that the billing or coding was correct, this could serve as a defense.
  • Reliance on Advice: In some cases, healthcare providers rely on the advice or services of third parties, such as consultants or billing companies, to navigate complex billing procedures. If these third parties provide incorrect information or services that lead to fraudulent billing, the defense may argue that the healthcare provider reasonably relied on this advice and, thus, did not intend to commit fraud.
  • Challenging Calculation of Losses: In healthcare fraud cases, the amount of the alleged loss can significantly impact the severity of penalties. The defense can challenge the method used by the prosecution to calculate these losses.
  • Statute of Limitations: Federal healthcare fraud charges must be brought within a specific time frame, generally five years from when the fraud was committed. If the defense can show that the statute of limitations has expired, the charges must be dismissed.

Successful defense of a Medicare case will often require a sophisticated understanding of the reimbursement principles involved in that case. The reimbursement principles under Medicare have grown increasingly complicated over the years. Different entities are paid under different methodologies (e.g., cost-based, charge-based, or fee schedules) and may be subject to limits based on several factors. Some providers are paid directly, and some are paid by the patient and reimbursed by Medicare. Hiring an attorney who understands the complexities of Medicare reimbursement is crucial.


Given the unique complexity of healthcare fraud cases, it’s essential to have a lawyer with experience in healthcare fraud defense. The healthcare fraud defense attorneys at the Rossen Law Firm will finely tailor our defense strategy to your case’s specific facts and circumstances, taking into account the evidence, the law, and our client’s unique circumstances, whether our client is an individual or a corporation.

If you or your business is under investigation or has been charged with healthcare fraud, contact the Rossen Law Firm immediately for a free strategy session at 754-206-6200.

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