Healthcare Fraud Attorney in Miami, FL
A request for billing records or a visit from federal agents can leave you unsure whether you are a witness or a suspect. If you are under investigation or have been charged with healthcare fraud, we can help you understand the allegation and respond before you make decisions that affect your defense.
These cases may involve a physician, clinic owner, billing employee, or someone accused of arranging referrals. Your role matters. At The Edelstein Firm, we examine the records behind the claims and the evidence of what you knew. Our fraud defense practice includes help during an investigation and after charges have been filed.
If Investigators Contact You or Request Records
An inquiry may begin with an audit, an interview request, or a subpoena for records. Sometimes the first contact is a search warrant. A demand for documents does not, by itself, tell you whether prosecutors intend to charge you.
Before agreeing to a voluntary interview, speak with a defense lawyer. Do not guess at answers or try to reconstruct billing decisions from memory. Counsel can assess your position and address contact with investigators.
A subpoena requires prompt attention. We can review its scope and deadline, assess privilege and patient-privacy issues, and determine whether there is a basis to seek more time or challenge part of the demand. Do not ignore it. If agents execute a search warrant, do not interfere; contact counsel promptly and keep the paperwork they provide.
If your employer has a lawyer, clarify whom that lawyer represents. The organization’s interests may differ from your own, and you may need separate counsel.
Healthcare fraud investigations may involve the Federal Bureau of Investigation (FBI), the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG), and other federal or state agencies, depending on the allegations. Federal prosecutions are handled by the U.S. Department of Justice, including U.S. Attorney’s Offices.
A criminal investigation may run alongside a civil False Claims Act case or a licensing matter. Those proceedings have different rules. Your response should account for each proceeding that affects you.
Records That Can Matter to Your Defense
A billing total rarely tells the whole story. The underlying records may show what care was provided, how a claim was coded, and who made or approved a decision. Depending on the allegation, relevant material may include:
- Patient and treatment records: orders, progress notes, test results, schedules, and records showing why care was provided.
- Billing files: claims, coding instructions, payment notices, denials, corrections, and payer guidance in effect at the time.
- Communications and training: emails, messages, written policies, and advice about the billing practice in question.
- Access and audit records: logs showing who created, changed, reviewed, or submitted an entry.
- Business and payment records: contracts, referral arrangements, invoices, and bank records relevant to the alleged transactions.
Preserve original records, including electronic audit trails. Do not delete or backdate entries. Get advice about what must be retained and how to provide it lawfully; do not access files you are not authorized to obtain. Before sending patient information to our office, ask how it should be provided.
Types of Healthcare Fraud Cases
Healthcare fraud allegations can involve public or private health insurance plans and may lead to state charges or federal crimes. Under 18 U.S.C. § 1347, federal prosecutors must prove that the defendant knowingly and willfully carried out, or attempted to carry out, a scheme to defraud a healthcare benefit program or obtain its money or property through false pretenses in connection with healthcare benefits, items, or services. An honest billing mistake, by itself, does not establish this offense.
For an explanation of Florida charges involving false insurance claims and the penalties that may apply, see our insurance fraud page.
If the allegations concern false statements about income, household circumstances, or other facts used to qualify for Medicaid or other government assistance, see our page on benefits fraud and public assistance fraud.
Common Healthcare Fraud Schemes
- Billing for services not rendered
- Billing for services not medically necessary
- Double-billing for services provided
- Upcoding (e.g., billing for a more highly reimbursed service or product than the one provided)
- Unbundling (e.g., billing separately for groups of laboratory tests performed together to get a higher reimbursement)
- Fraudulent cost reporting by institutional providers
Allegations involving misuse of a patient’s identifying information may also lead to aggravated identity theft charges. Under the Supreme Court’s decision in Dubin v. United States, including a patient’s name in a fraudulent bill does not automatically establish that offense.
When prosecutors allege that several people knowingly agreed to carry out healthcare fraud, they may also bring federal conspiracy charges. A person may face those charges even without personally submitting the false claims.
Transactions involving proceeds from fraudulent healthcare claims may also lead to federal money laundering charges. Those charges require proof beyond the underlying billing fraud, including the knowledge and transaction requirements of the statute charged.
Kickbacks
The federal Anti-Kickback Statute prohibits knowingly and willfully offering or paying anything of value to induce referrals or purchases of items or services payable by a federal healthcare program. It also prohibits knowingly and willfully soliciting or receiving such payments in return for that business. The law reaches more than cash payments. Whether an arrangement violates the statute depends on the facts, the parties’ intent, and any applicable statutory exception or regulatory safe harbor.
Other Fraudulent Healthcare Schemes
Healthcare fraud investigations may also involve false claims about staff qualifications or supervision, deceptive billing for unapproved drugs or devices, or phony health insurance companies or employee benefit plans. A licensing, supervision, or regulatory violation does not, by itself, establish criminal healthcare fraud under 18 U.S.C. § 1347.
How We Examine the Government’s Case
The defense should address the conduct the government alleges and the proof required for each charge. A list of unusual claims or a large payment total leaves important questions unanswered.
What Made the Claim False?
We compare the allegation with the treatment and billing records. Was the service provided? Does the record support the code used? If medical necessity is disputed, the clinical facts and the rules in effect at the time need close review. A billing or medical specialist may be needed to assess those issues.
What Did You Know, and What Was Your Role?
We examine who supplied the information and who controlled the billing decisions. Instructions, training, and communications may bear on whether you acted in good faith or knowingly joined a scheme. Reliance on another person does not automatically resolve the case; the facts must support that explanation.
Does the Evidence Support Each Charge?
Healthcare fraud, conspiracy, kickbacks, and money laundering have different requirements. We assess each charge separately, including the alleged agreement or transaction. We also review how records and statements were obtained and whether there are grounds to challenge their use.
What Can Be Addressed Before Trial?
During an investigation, counsel can assess whether to present records or other information to prosecutors and how to do so without creating needless risk. After charges are filed, defense work includes reviewing discovery, preparing motions, and evaluating trial and negotiated options. If sentencing becomes an issue, disputed loss calculations and your role may require separate work. The course depends on the evidence and your goals.
Discuss Your Healthcare Fraud Case
Attorney David Edelstein has practiced law since July 1995 and is AV Preeminent® rated. You can review our criminal defense case results for examples of the firm’s work.
When you contact us, explain your role in the business and what prompted the inquiry. Have any subpoena, investigator’s letter, or charging document available, along with the next deadline or court date. We can discuss the criminal-defense issues and identify any related matters that may require other counsel.
CALL US NOW for a CONFIDENTIAL CONSULTATION at (305) 538-4545, or simply take a moment to fill out our confidential and secure intake form.* The additional details you provide will greatly assist us in responding to your inquiry.
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