Attorney for Medicare Fraud Defense in New York City

A Medicare fraud investigation can threaten everything you have built — your medical practice, your professional license, your reputation, and your freedom. Healthcare providers across New York City, from solo practitioners in Queens to large medical groups in Manhattan, are facing increasingly aggressive enforcement from federal and state authorities. If you have received a subpoena, a civil investigative demand, an audit letter, or a visit from federal agents, the decisions you make in the next few days can shape the outcome of your case for years to come.

Our New York City Medicare fraud defense attorneys represent physicians, nurses, pharmacists, durable medical equipment suppliers, home health agencies, laboratories, billing companies, and practice owners at every stage of an investigation or prosecution. We understand both the law and the complex billing systems at the heart of these cases, and we move quickly to protect our clients before charges are ever filed.

What Is Medicare Fraud?

Medicare fraud generally refers to knowingly submitting false or misleading claims to the Medicare program in order to obtain payments that are not legitimately owed. Because Medicare is a federal program, most prosecutions are brought in federal court — and in New York City, that typically means the federal courthouses in Manhattan and Brooklyn, where prosecutors handle some of the most high-profile healthcare fraud cases in the country.

Common allegations in Medicare fraud cases include:

Billing for services never rendered — submitting claims for patient visits, procedures, or tests that did not occur.
Upcoding — billing for a more expensive service or procedure than the one actually performed.
Unbundling — billing separately for services that should be billed together at a lower combined rate.
Medically unnecessary services — ordering tests, equipment, or procedures that are not justified by the patient's condition.
Kickbacks and illegal referrals — paying or receiving anything of value in exchange for patient referrals or orders for Medicare-covered services.
Phantom patients — billing under the identities of deceased individuals or patients who were never treated.
False certifications — certifying that services met Medicare requirements when they did not, such as falsely certifying home health eligibility.
Prescription and pharmacy fraud — billing Medicare Part D for medications that were never dispensed or were diverted.

It is critical to understand that not every billing error is fraud. Medicare's rules are extraordinarily complex, and honest mistakes, ambiguous coding guidance, and disputes over medical judgment are frequently mischaracterized as criminal conduct. A central goal of an experienced defense attorney is demonstrating that a billing discrepancy reflects error or legitimate clinical judgment — not criminal intent.

The Laws Used to Prosecute Medicare Fraud

Prosecutors and regulators rely on a powerful set of statutes in Medicare fraud cases. Understanding which laws are in play helps determine your exposure and your defense strategy.

Federal Health Care Fraud Statute (18 U.S.C. § 1347)

This statute makes it a felony to knowingly execute a scheme to defraud a healthcare benefit program. A conviction carries up to 10 years in federal prison per count — up to 20 years if the fraud results in serious bodily injury, and life imprisonment if it results in death.

The False Claims Act (31 U.S.C. §§ 3729–3733)

The False Claims Act imposes civil liability for knowingly submitting false claims to the government, with penalties including treble damages and substantial per-claim fines. Many Medicare fraud cases begin as whistleblower (qui tam) lawsuits filed under seal by current or former employees, competitors, or business partners. You may be under investigation for months before you ever learn a case exists.

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b)

This criminal statute prohibits offering, paying, soliciting, or receiving anything of value in exchange for referrals of Medicare patients or business. Violations carry up to 10 years in prison per offense, and claims tainted by kickbacks can also trigger False Claims Act liability.

The Stark Law (42 U.S.C. § 1395nn)

The Stark Law prohibits physicians from referring Medicare patients for certain designated health services to entities with which the physician or an immediate family member has a financial relationship, unless an exception applies. Stark violations are strict liability — intent is not required — making compliance review essential.

New York State Charges

New York prosecutors can also pursue related state charges. Article 177 of the New York Penal Law criminalizes health care fraud in five degrees, ranging from a class A misdemeanor to a class B felony, depending on the amount wrongfully obtained. Providers may additionally face charges such as grand larceny, falsifying business records, and offering a false instrument for filing under New York law. State and federal authorities frequently coordinate, and conduct involving both Medicare and Medicaid can draw scrutiny from the New York Attorney General's Medicaid Fraud Control Unit alongside federal investigators.

Who Investigates Medicare Fraud in New York City?

Medicare fraud investigations in New York City are typically led by one or more of the following agencies:

The U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG)
The Federal Bureau of Investigation (FBI)
The U.S. Attorney's Offices serving Manhattan, the Bronx, Brooklyn, Queens, and Staten Island
The Department of Justice Health Care Fraud Strike Force, which maintains an active presence in the New York City area
The Centers for Medicare & Medicaid Services (CMS) and its contractors, including Unified Program Integrity Contractors (UPICs) and Recovery Audit Contractors (RACs)
The New York Attorney General's Office and local district attorneys, where state charges are involved

These agencies use sophisticated data analytics to flag billing patterns that deviate from peer norms. A provider whose billing appears statistically unusual — even for legitimate reasons, such as a specialized patient population — can become a target without ever knowingly doing anything wrong.

Penalties and Collateral Consequences

The consequences of a Medicare fraud conviction or civil judgment extend far beyond the courtroom:

Imprisonment — federal sentences are driven by the amount of alleged loss, which prosecutors often calculate aggressively.
Fines and restitution — criminal fines, treble civil damages, and full restitution of alleged overpayments.
Exclusion from federal healthcare programs — mandatory exclusion from Medicare and Medicaid following certain convictions, which is career-ending for most providers.
Professional license discipline — referral to the New York State Office of Professional Medical Conduct or the Office of the Professions, with potential suspension or revocation.
Loss of hospital privileges and insurance panel participation.
Asset forfeiture and account freezes, which can occur before any conviction.

How We Defend Medicare Fraud Cases

Every case demands a strategy tailored to the facts, but our defense work commonly includes:

Early Intervention

The pre-indictment phase is often the most important. By engaging with prosecutors and agents early, we can sometimes persuade the government that no crime occurred, narrow the scope of the investigation, or resolve the matter civilly rather than criminally — before charges are filed and before the case becomes public.

Challenging Intent

Nearly every criminal healthcare fraud statute requires proof that you acted knowingly and willfully. We build the record showing good-faith reliance on billing staff, coding consultants, compliance programs, ambiguous CMS guidance, or legitimate medical judgment — all of which can negate criminal intent.

Attacking the Loss Calculation

Government loss figures are often inflated by extrapolating from small claim samples or by assuming every claim in a category was false. We retain independent billing and statistical experts to challenge these methodologies, which can dramatically reduce both sentencing exposure and restitution.

Suppressing Improperly Obtained Evidence

Search warrants, subpoenas, and interviews must comply with constitutional requirements. Where agents overreached, we move to suppress evidence and statements.

Negotiated Resolutions

Where appropriate, we negotiate civil settlements, corporate integrity agreements, deferred prosecution arrangements, or reduced charges that preserve our client's license and ability to practice.

What to Do If You Are Under Investigation

If you suspect or know that you are under investigation for Medicare fraud in New York City, take these steps immediately:

Do not speak with investigators without counsel. Agents are trained to obtain damaging statements, and even truthful answers can be misconstrued. Politely decline to answer questions and state that your attorney will be in contact.
Do not destroy or alter any records. Deleting emails, shredding files, or amending charts after the fact can lead to obstruction charges that are often easier to prove than the underlying fraud.
Preserve all documents — billing records, patient charts, correspondence, and compliance materials.
Do not discuss the investigation with employees, colleagues, or business partners. Any of them could become a witness, and your statements are not protected.
Identify what triggered the inquiry. An audit letter, a records subpoena, or employee interviews each signal different stages and types of investigation.
Retain experienced defense counsel immediately. Early legal involvement preserves options that disappear once charges are filed.

Why Choose Our New York City Firm

Medicare fraud defense is not a practice area for generalists. These cases require fluency in CPT and ICD coding, Medicare reimbursement rules, statistical sampling, and the procedures of federal and New York state courts. Our attorneys bring:

Substantial experience defending healthcare providers in federal courts throughout New York City
Established working relationships with prosecutors and agents that facilitate productive pre-indictment dialogue
A network of billing, coding, statistical, and medical experts
Coordinated defense of parallel proceedings — criminal, civil, administrative, and professional licensing — so no front of your case is left unguarded
Absolute discretion, protecting your reputation while we work toward a quiet resolution whenever possible

Frequently Asked Questions

I received a letter from a Medicare contractor requesting records. Is this serious?

It can be. Routine audits sometimes evolve into fraud referrals, and your written responses can be used against you later. Have counsel review any records request before you respond.

Can I be prosecuted for my biller's mistakes?

The government must generally prove you knowingly participated in or willfully ignored the fraud. Genuine reliance on a billing company or staff can be a strong defense, but prosecutors will probe whether you turned a blind eye to red flags.

Will I lose my license if I'm charged?

Charges alone do not automatically result in license loss, but New York licensing authorities monitor criminal cases involving providers. We coordinate your criminal defense with licensing counsel strategy from day one.

Can a Medicare fraud case be resolved without criminal charges?

Yes. Many investigations are resolved through civil settlements, repayment agreements, or declinations — especially when defense counsel engages early and presents persuasive evidence of good faith.

Speak With a New York City Medicare Fraud Defense Lawyer Today

Time is the most valuable asset in a Medicare fraud case, and it works against you the moment an investigation begins. Whether you have received a subpoena, learned of a whistleblower lawsuit, been visited by agents, or simply suspect that your billing is under scrutiny, contact our New York City office now for a confidential consultation. We will assess your exposure, take immediate steps to protect you, and build the strongest possible defense of your practice, your license, and your future.

You can contact us by phone at 212-233-1233 or by email at [email protected].