In today’s regulatory environment, even well-intentioned billing errors or documentation mistakes can lead to devastating consequences. Healthcare fraud allegations are among the most aggressively investigated and prosecuted white-collar crimes—especially when federal funds are involved. If you’re a medical professional, clinic owner, or administrator in California facing these accusations, your career, license, and freedom may be on the line.
At Simmons Wagner, LLP, we defend Southern California clients—including doctors, nurses, billing managers, and healthcare business owners—against state and federal healthcare fraud charges. Here’s what you need to know if you’ve been targeted.
What Is Healthcare Fraud?
Healthcare fraud occurs when a person or entity deliberately submits false or misleading information to obtain unauthorized benefits or payments from insurance companies or government programs such as Medicare, Medi-Cal, or Tricare.
Common examples include:
- Billing for services not provided
- Upcoding or unbundling procedures
- Falsifying diagnoses or medical records
- Kickbacks or referral fee arrangements
- Phantom billing or duplicate claims
- Prescribing unnecessary tests or medications for financial gain
Because many of these activities involve electronic billing and interstate communications, they often result in federal charges—particularly under statutes like the False Claims Act and Health Care Fraud Statute (18 U.S.C. §1347).
Who Gets Targeted?
While large-scale fraud rings make headlines, many charges are brought against solo practitioners, small practices, and billing departments that simply don’t have robust compliance procedures in place. You may be targeted even if you:
- Outsourced billing to a third-party service
- Relied on templates or codes suggested by software
- Received bonuses tied to productivity or ordering
Whistleblowers (under the qui tam provisions of the False Claims Act), patient complaints, and audit red flags can all trigger investigations.
State vs. Federal Charges: What’s the Difference?
In California, healthcare fraud may be prosecuted under:
- California Penal Code §550 for false claims to private insurers
- Welfare & Institutions Code §14107 for Medi-Cal fraud
- Federal law (18 U.S.C. §§1347, 1349, etc.) for fraud involving federal programs
Federal cases tend to carry steeper penalties and involve longer investigations, often led by agencies such as the FBI, HHS-OIG, and DOJ. Convictions can lead to:
- Up to 10 years in federal prison per count (more if serious injury results)
- Massive fines and restitution
- Loss of medical licenses or DEA registration
- Exclusion from Medicare/Medi-Cal participation
- Immigration consequences for non-citizens
How to Defend a Healthcare Fraud Case
No two cases are alike, but strong defenses often include:
- Lack of intent: Mistakes in billing or documentation—without fraudulent purpose—are not crimes.
- Delegation of responsibility: You relied in good faith on trained billing professionals.
- Insufficient evidence: The government must prove beyond a reasonable doubt that you knowingly defrauded the system.
- Challenging expert witnesses or audit methods: Many cases rely on disputed medical necessity or interpretation of billing codes.
At Simmons Wagner, LLP, we bring in experienced forensic accountants, billing experts, and medical consultants to challenge the government’s narrative and build a strategic defense.
What to Do If You’re Under Investigation
If you’ve received a subpoena, target letter, or audit request—or if agents have shown up at your clinic—do not talk to investigators without legal counsel. Even offhand comments can be twisted into admissions.
Instead:
- Contact a white-collar defense attorney with healthcare fraud experience.
- Preserve all communications, billing records, and patient files.
- Refrain from altering or deleting any documentation.
- Do not speak to staff, colleagues, or vendors about the investigation without legal guidance.
Talk to a Defense Team That Understands Your Industry
Your practice, reputation, and future deserve more than a one-size-fits-all defense. At Simmons Wagner, LLP, we understand the medical and regulatory complexities of healthcare fraud cases—and we fight back with precision, discretion, and experience.
Call Simmons Wagner, LLP at (949) 439-5857 today for a confidential consultation. The sooner you act, the better we can protect your license, your livelihood, and your name.