Healthcare fraud is one of the most serious and harshly punished federal crimes. Medicare fraud is a type of healthcare fraud where someone submits false claims to receive federal healthcare payment from Medicare or reimbursements when they are not entitled to them.

If you or a family member are charged with Medicare fraud, hiring a defense attorney immediately is important. Rossen Law Firm specializes in defending against Medicare fraud, and we successfully help our clients achieve their best future. Our attorneys are best equipped to handle your case with their extensive knowledge, trial experience, and thorough arguments to provide the best possible care in South Florida and the country.


Medicare fraud is illegal under the statute 18 U.S.C. § 1347, which states that it is a federal criminal offense to defraud any health care program or obtain, using false or fraudulent pretenses, representations, or promises, any money.

The main element of Medicare fraud cases is that the person who committed the fraud intended to defraud the government. To achieve this, someone can use false means, such as false promises or misrepresentations. Here are some example activities that are illegal under the statute:

  • Billing for services or supplies that were not provided
  • Misrepresenting a diagnosis, services provided, or other facts to justify payment
  • Misrepresenting a beneficiary’s identity
  • Prescribing or giving unnecessary tests, medications, or services
  • Billing for unneeded doctor visits
  • Paying for referrals of Federal healthcare program beneficiaries

The FBI is the primary agency for investigating healthcare fraud for both federal and private insurance programs, very often working in conjunction with the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).

Individuals who often commit healthcare fraud are within the healthcare industry including:

  • Doctors
  • Nurses
  • Pharmacists
  • Medical office administrative staff
  • Medical billing companies
  • Laboratory owners
  • Marketers
  • Insurance brokers
  • Patients

For someone to be found guilty of Medicare fraud, the government must prove each of the following elements beyond a reasonable doubt:

  • First, the defendant knowingly and willfully executed or attempted to execute a scheme or plan to defraud a health care benefit program. Or they knowingly and willfully obtained money or property owned by or under the custody or control of a health care benefit program using materially false or fraudulent pretenses, representations, or promises;
  • Second, the defendant acted with the intent to defraud; and
  • Third, the scheme was executed concerning the delivery or payment for health care benefits, items, or services.

Other federal laws, such as the False Claims Act, Anti-Kickback Statute, and Physician Self-Referral Law (Stark Law), go hand-in-hand with Medicare fraud.

The False Claims Act says that submitting claims for payment to Medicare or Medicaid that you know or should know are false or fraudulent is illegal.

The Anti-Kickback Statute prohibits the knowing and willful payment of “remuneration” to induce or reward patient referrals or generate business involving any item or service payable by the Federal healthcare programs (e.g., drugs, supplies, or healthcare services for Medicare or Medicaid patients.)

Physician Self-Referral Law prohibits physicians from referring patients to receive “designated health services” payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship.

These three laws often overlap with Medicare fraud charges because these offenses can be coupled with Medicare fraud. In other words, committing Medicare fraud usually involves violating these statutes. For example, accepting kickbacks is Medicare fraud and violates the Anti-Kickback Statute.


The harsh penalties for Medicare fraud include expensive fines, restitution, and imprisonment. 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.

Medicare fraud is even more serious because it can be related to other charges with severe penalties, such as wire fraud or money laundering. For example, if someone commits Medicare fraud and does so through emails or phone conversations, they can also be charged with wire fraud.

In addition to the expensive fines and lengthy imprisonment you may face if convicted of Medicare fraud, healthcare fraud convictions can bring extremely harmful collateral consequences, affecting our clients and their loved ones far after the criminal penalties are over.

Here are a few examples of these collateral consequences:

  • 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 are rules established by the U.S. government to provide set policies for convicted felons. Specifically, the sentences outline serious, Class A misdemeanors. When dealing with Medicare fraud cases, the Guidelines also consider the nature of the crime and the offender’s criminal history when dictating recommended sentences.

  • Base Offense Level: The base offense level is typically set at Level 6 or Level 7 (under USSG §2B1.1) for healthcare fraud.
  • Loss Amount: The amount of loss is one of the most significant factors determining sentencing in Medicare fraud cases. The loss amount is the intended loss that resulted from the fraudulent activity. When the amount of loss increases, the offense level does as well. This leads to the length of sentences in Medicare fraud cases increasing.
  • Specific Offense Characteristics: The Sentencing Guidelines also consider particular offense characteristics. These factors include the techniques and means used to commit the offense, whether anyone was harmed, the number of victims involved, and whether the offender used sophisticated methods to carry out these offenses. Each of these factors can increase the offense level.
  • Role in the Offense: The defendant’s role in the offense can impact sentencing. If the defendant held a position as an organizer or leader within the scheme, it could result in the offense level increasing. If the defendant played a more minor role, it could lead to points being subtracted from the offense level.
  • 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.

All these factors can impact the final offense level, which is then used in addition to the defendant’s criminal history to determine the final sentencing range. It is important to note that these Guidelines are not mandatory; the judge has the final say but must consider them in all cases.


Your future and the success of your case depends on your defense attorney. If you are confronted with Medicare fraud charges, it is crucial to immediately seek the counsel of an experienced, intelligent, and seasoned attorney specializing in Medicare fraud defense.

Although each case and defense strategy is unique, there are a few commonly used defenses when tackling Medicare fraud charges. Below are some examples of common defenses:

  • 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. Suppose these third parties provide incorrect information or services that lead to fraudulent billing. In that case, the defense may argue that the healthcare provider reasonably relied on this advice and, thus, did not have the intent 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.

Effectively defending a Medicare fraud case requires a strong knowledge of reimbursement principles. Each case has its unique collection of principles involved, and they continue to become more complicated. Various entities receive payment through different methodologies (e.g., cost-based, charge-based, or fee schedules) and may encounter limitations based on several factors. It is critical to hire a Medicare fraud attorney who is knowledgeable about Medicare reimbursement.


The Rossen Law Firm excels at defending against Medicare charges. Our team of attorneys has extensive knowledge, a strong background, and years of experience in effectively navigating these specific cases. We prioritize our commitment to our clients as we strive to secure the best possible outcomes for them. We pride ourselves in truly understanding our clients and listening to their cases to create the best defense strategies possible.

If you or your family are facing Medicare fraud charges, you deserve the best care to achieve your best future. Hiring an attorney immediately to get the best possible resolutions is also crucial. Contact the Rossen Law Firm today to schedule a free strategy session and learn how we can help you.

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