Health Care Fraud Defense

Charged with or Under Investigation for Health Care Fraud in California?

A health-care fraud allegation can involve criminal charges, civil False Claims Act exposure and program-exclusion proceedings; each follows its own elements and outcome rules.

California criminal defense attorney David Chesley has successfully defended health care fraud investigations and charges — including federal healthcare fraud (18 U.S.C. § 1347), False Claims Act violations, Anti-Kickback Statute matters, Medi-Cal fraud, and related offenses — in federal and state courts across every county in California. These complex cases span physicians, hospitals, home health agencies, DME suppliers, pharmacies, labs, behavioral health providers, and more. They often involve parallel criminal, civil, and administrative proceedings. Early intervention during the investigation phase is critical. Build your defense now.

IMMEDIATE STEPS IF UNDER INVESTIGATION OR CHARGED:

• Do not speak with FBI, HHS-OIG, DOJ, DHCS, or state investigators without counsel — questions are specifically designed to establish knowledge and intent; in health care fraud cases, what you say about your billing practices, your awareness of documentation, and your understanding of coverage rules is the prosecution's most important evidence
• Do not destroy, alter, or delete any records, billing data, or communications — document destruction after a government investigation begins constitutes obstruction of justice carrying its own independent federal felony exposure
• Preserve all documentation — patient records, orders, certifications, billing submissions, marketing agreements, referral arrangements, compensation agreements, and compliance materials
• Contact experienced healthcare fraud counsel immediately — the investigation phase is when cooperating witnesses are developed, documents gathered, and charging theories formed; defendants who engage counsel during the investigation phase have dramatically more options than those who wait

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THE STAKES ARE REAL

Health care fraud is a top federal and state enforcement priority in California. Multi-agency task forces — FBI, HHS-OIG, DOJ, and state partners — target false claims, upcoding, kickbacks, and billing for services not rendered, often resulting in multi-million-dollar loss calculations that drive federal sentencing guidelines ranges into years and decades of prison exposure.

A conviction can mean:

• Federal prison: Up to 10 years per count under 18 U.S.C. § 1347 — not more than 20 years if the violation results in serious bodily injury; up to life if death results
• Massive restitution and fines — amounts depend on proved loss, payer payments and the actual criminal order; a civil claim follows separate rules
• A separate civil False Claims Act case can involve up to treble proven government damages plus adjusted per-claim penalties; three times every dollar billed is not the statutory damages formula.
• OIG exclusion can follow specified convictions. A first mandatory exclusion ordinarily has a five-year minimum; longer terms and reinstatement rules depend on the ground and history. Reinstatement requires an application and written approval, not merely passage of time.
• Professional-license reporting and discipline depend on the person’s board, offense and disposition; revocation is not automatic for every licensed worker.
• A forfeiture allegation requires an applicable statute and a traceable property interest; an investigation or charge does not automatically forfeit all business or personal assets.

Common Health Care Fraud Allegations vs. Strong Defenses:

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WHAT IS HEALTH CARE FRAUD?

Health care fraud generally involves the knowing submission of false or fraudulent claims to any healthcare benefit program — Medicare, Medi-Cal, private insurance, or workers' compensation. Key statutes include:

• 18 U.S.C. § 1347 — Federal healthcare fraud: knowingly executing a scheme to defraud any healthcare benefit program
• Anti-Kickback Statute (42 U.S.C. § 1320a-7b) — Prohibiting the knowing and willful payment or receipt of remuneration to induce or reward referrals of patients covered by any federal healthcare program
• False Claims Act (31 U.S.C. § 3729) — Civil liability for specified false claims to the federal government, with qui tam whistleblower provisions allowing private parties to file on the government's behalf
• California Penal Code § 550 — State insurance fraud, frequently charged alongside federal counts in California prosecutions
• Welfare and Institutions Code § 14107 — California Medi-Cal fraud, often charged in coordination with federal prosecutors

A criminal section 1347 allegation requires proof of a knowing and willful scheme; a civil section 3729 claim instead uses actual knowledge, deliberate ignorance or reckless disregard, without a specific intent to defraud requirement. An AKS allegation has its own statutory elements. Compare the actual counts before treating an honest coding dispute as fraud.

Key Defenses in Health Care Fraud Cases:

A good-faith coding or clinical explanation can be evidence against a knowing and willful section 1347 scheme. Review the contemporaneous coverage rule, original chart, claim data and the individual’s role; a later disagreement with a billing decision alone does not establish fraud, and reliance on staff alone does not resolve the charge.

Insufficient evidence of falsity

Challenging whether services were actually unnecessary or undocumented — through contemporaneous medical records, treating provider testimony, and independent clinical expert review establishing that services were supported by genuine medical need at the time they were provided.

Check the actual compensation, referral purpose, applicable safe-harbor conditions and any separate Stark rule. A qualifying safe harbor can protect an arrangement, but failure to fit one does not automatically make the arrangement illegal; the Anti-Kickback statute still requires its own knowing and willful elements.

Reliance on advice and compliance records can be relevant to what the accused knew and did. Obtain the actual advice, materials provided to the adviser, billing instructions, dates and follow-up. Their existence does not automatically defeat the government’s proof of a knowing and willful criminal scheme.

Loss amount challenges

Forensic billing review can test whether the government's calculation includes legitimate services, unsupported claim values or flawed sampling. A lower supported loss may affect the advisory guidelines range, but no fixed sentence reduction follows from a disputed figure.

WHO CAN BE CHARGED — INDIVIDUAL LIABILITY IN HEALTH CARE FRAUD CASES

Federal and state health care fraud prosecutions pursue individual criminal liability at every level of the healthcare organization. Understanding what the government must prove for each specific role — and what defenses are available based on that role — is one of the most important early tasks in every health care fraud defense.

Physicians and Licensed Providers

Charged when the government alleges they signed orders, certifications, or prior authorizations without adequate clinical basis, or made medical necessity determinations for billing purposes rather than clinical ones. The most important defense for physicians is that the determination reflected genuine clinical judgment supported by the patient's contemporaneous medical record. A documented, good-faith clinical determination can contest an allegation that a medical-necessity judgment was knowingly false; a different retrospective opinion alone does not establish a criminal scheme. Counsel must still examine any separate billing, referral or kickback allegation, the records available at the time, and the physician's actual role rather than treating one honest judgment as a complete defense to every count.

Nurses, Therapists, and Allied Health Professionals

Charged based on documentation they completed that the government characterizes as falsified or inaccurate. The knowledge element requires proof that they knew their documentation was false — not that it was later found inaccurate by a government reviewer. A clinician who completed documentation based on a genuine patient assessment, with no reason to believe it was supporting fraudulent billing, did not act with the required criminal intent.

Billing Managers and Billing Staff

Charged when the government alleges knowing participation in an unsupported-claims scheme. Reliance on licensed professionals' documentation, ordinary billing procedures and limited clinical access can be relevant evidence, but they do not automatically defeat a criminal charge if communications or conduct show knowing and willful participation or deliberate avoidance of obvious fraud. A separate civil False Claims Act count has its own knowledge standard, including reckless disregard. Examine claim edits, warnings, audits, communications and the employee's actual role; organizational employment alone is insufficient.

Owners, Executives, and Administrators

Charged based on their establishment of business models, compensation structures, and operational policies that allegedly produced fraudulent billing. Individual knowledge is required — general awareness of the business is not sufficient. Compliance work, legal advice and limited knowledge of individual claims can be relevant evidence, but do not automatically exclude an executive who knowingly and willfully directed or joined a broader fraudulent scheme. Examine instructions, warnings, audit findings and any deliberate avoidance; the government must prove the individual's role and required criminal mental state, not mere title or financial benefit.

Marketing and Sales Staff

Charged in kickback cases based on their role in recruiting patients or providers through alleged remuneration arrangements. Staff who implemented arrangements they were told were legally compliant have specific reliance defenses — the knowing and willful element required for AKS violations is the most important defense target for marketing-level defendants.

Criminal section 1347 liability requires proof of the individual’s knowing and willful role in the charged scheme; a job title or organizational proximity is not enough. The civil False Claims Act uses its separate actual-knowledge, deliberate-ignorance and reckless-disregard definition. Compare each person’s records, statements and responsibilities with the statute actually pleaded.

HOW DAVID CHESLEY DEFENDS HEALTH CARE FRAUD CASES

These cases require simultaneous defense on criminal, civil False Claims Act, and administrative exclusion tracks — while protecting individual defendants from organizational liability and ensuring the government's fraud theory is contested at every level. David Chesley personally handles every health care fraud case statewide — Southern, Central, and Northern California, every county, every major federal district — and is available 24 hours a day, 7 days a week. No hand-offs. No junior associates.

Core defense strategies pursued immediately:

Investigation-phase intervention

The most important defense work happens before charges are filed. Grand jury subpoena responses, employee interview coordination, joint defense arrangements, and presentation of exculpatory evidence to prosecutors — all can begin before charges and continue after an indictment as counsel evaluates discovery, defenses, negotiations and trial options.

Challenging the government's clinical and billing theory

Billing analysis challenged through contemporaneous medical records, treating provider testimony, independent clinical and coding expert review, and the specific coverage rules governing the services at issue.

Individual knowledge element defense

Each person's role, conduct and required mental state should be analyzed independently. Organizational proximity to fraud is insufficient, while instructions, warnings and deliberate avoidance may matter even without proof that the person read a particular false claim.

Loss amount challenge

Independent forensic billing analysis examines the government's methodology, identifies claims incorrectly included in the loss calculation, and challenges overstated figures inflating the guidelines range.

Anti-Kickback and Stark safe harbor analysis

Every compensation arrangement alleged as a kickback or self-referral violation is analyzed against the full safe harbor and exception framework.

Civil FCA and administrative track management

Civil FCA exposure, program exclusion proceedings, and licensing consequences are addressed simultaneously — because decisions in one track directly affect the others.

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YOU HAVE RIGHTS. USE THEM.

A criminal section 1347 count requires proof of its knowing and willful scheme; a separate civil False Claims Act or AKS allegation requires its own elements. Counsel can test those elements with original claim, clinical, referral and payment records. The examples below are possible case paths, not standard results or promises.

• Investigation closed without charges — early intervention presents exculpatory evidence; government declines to charge
• Individual charges defeated — knowledge element not established; defendant's role and actual knowledge insufficient for criminal liability
• Fraud theory successfully challenged — contemporaneous records and expert testimony establish legitimate services and good-faith billing
• Loss amount successfully reduced — forensic analysis demonstrates overstated calculation; guidelines range reduced by years
• Kickback allegations defeated — compensation arrangements fall within AKS safe harbors; corrupt intent not established
• Civil FCA exposure negotiated — civil settlement achieves favorable resolution while preserving criminal defenses
• Exclusion minimized or avoided — resolution structured to limit program exclusion consequences
• License consequences minimized — resolution structured to reduce mandatory reporting and board exposure
• Immigration-safe resolution — charge resolved without conviction constituting crime of moral turpitude or aggravated felony

WHY CLIENTS CHOOSE DAVID CHESLEY

Direct, personal attention — statewide, 24/7

David Chesley personally handles health care fraud defense in federal courts and California state courts across all of California — Los Angeles, San Diego, Orange County, San Francisco, Sacramento, Fresno, San Jose, Riverside, San Bernardino, Ventura, and every other jurisdiction statewide. Available 24 hours a day, 7 days a week — because federal and state agents appear unannounced and the window to respond effectively is measured in minutes.

Straight talk, always

Health care fraud cases range from situations where the government's theory is legally defective, individual knowledge cannot be established, or the loss amount is substantially overstated — to cases where the evidence is substantial and the focus shifts to minimizing guidelines exposure, negotiating cooperation, or preserving the ability to continue practicing. You deserve honest counsel about which situation you are actually in. No false promises. No sugarcoating.

Multi-track strategy — federal, state, civil, and administrative

The criminal case, the civil FCA track, program exclusion proceedings, and professional licensing consequences all require simultaneous management. Positions taken in one track can create exposure in the others.

Federal and state healthcare fraud expertise across every provider type

Deep knowledge of 18 U.S.C. § 1347, the Anti-Kickback Statute and safe harbors, the False Claims Act and qui tam provisions, the Stark Law, California PC § 550, California W&I § 14107, federal sentencing guidelines loss amount calculations, DOJ and HHS-OIG investigation methodology, and the specific billing, clinical, and compliance issues that define health care fraud prosecutions across every provider type — physicians, hospitals, home health agencies, DME suppliers, pharmacies, behavioral health providers, labs, and more — across every region of California.

Flexible payment plans

The Law Offices of David Chesley offer flexible payment plans because cost should never be the reason someone under investigation for health care fraud goes without experienced representation during the phase when it matters most.

Firm-reported past results — outcomes depend on the actual case and are not guarantees:

• Federal health care fraud investigation closed without charges — investigation-phase intervention presented billing documentation and clinical records establishing legitimate services and good-faith billing practices; government declined to charge
• Physician avoided individual charges — medical necessity defense established through contemporaneous records and independent clinical expert testimony; government's retrospective billing analysis found insufficient to support individual criminal liability
• Loss amount significantly reduced — forensic billing analysis identified substantial portion of government's alleged loss as legitimately documented services; revised amount reduced guidelines range by multiple levels; sentence reduced by years
• Billing coordinator charges dismissed — reliance-on-others defense established; defendant submitted claims based on clinical documentation she had no reason to question; knowing and willful element not proven
• Kickback allegations defeated — compensation arrangement found to fall within AKS safe harbor; corrupt intent not established; Anti-Kickback charges dismissed
• Civil FCA qui tam lawsuit resolved — whistleblower lawsuit resolved through negotiated settlement preserving key defenses in the parallel criminal proceedings
• Program exclusion minimized — resolution structured to limit exclusion period; defendant's ability to continue in non-federal program capacity preserved
• Immigration-safe resolution — non-U.S. citizen defendant's charges resolved without healthcare fraud conviction; deportation exposure avoided

Client Feedback:

"Federal and state investigators showed up simultaneously. David coordinated the entire response — investigation strategy, staff communications, document preservation. The investigation was closed without charges." — Anonymous healthcare provider

"I was a billing coordinator with no knowledge of any fraud. David established I had no reason to question the clinical documentation. Charges dismissed." — Anonymous former client

"The government's loss figure would have meant years in prison. David's forensic analysis cut it dramatically. The reduction in my sentencing exposure changed everything." — Anonymous former client

"Non-citizen physician. David explained from the first consultation that a federal conviction meant deportation and built the defense entirely around protecting my status. Resolved without a conviction." — Anonymous former client

FREQUENTLY ASKED QUESTIONS

What is health care fraud — and how is it different from a billing error?

A criminal section 1347 case concerns a knowing and willful scheme connected with payment for health-care benefits, items or services. The prosecution must prove that charged scheme and the person’s role; a disputed billing code or missing note by itself is not enough. A separate civil False Claims Act case uses its own knowledge and materiality standards, and a kickback count has different elements. Preserve the claim, underlying service record, coverage rule, payment and contemporaneous communications before deciding which theory the evidence supports.

First separate the notices. A subpoena, civil investigative demand, payer audit, licensing notice and criminal complaint ask for different responses. Record the sender, return date, recipient and document categories for each. Preserve original billing exports and patient charts with their audit trails, and ask counsel how confidentiality, patient privacy and employee representation affect collection. An internal review should not alter records or coach witnesses into one story. The first consultation can identify which authority is acting, whether a deadline is already running, and whether the person is a witness, subject, defendant or civil respondent. That distinction shapes the response more than a general label of “fraud.”

Build a claim-level chronology. For each disputed claim, record the service date, payer, submitted code, coverage rule in effect, clinical note, person who approved the service, amount billed and amount actually paid. A payer’s denial or a later coding disagreement does not by itself prove a knowing scheme; equally, a signed chart alone does not establish medical necessity or payment entitlement. Compare the original submission with corrections, refunds and communications about warnings. If a proposed loss figure combines legitimately paid services with questioned claims, counsel can ask which amounts satisfy the charged theory and how the calculation was made.

Keep program and licensing decisions distinct. A criminal disposition may trigger OIG’s mandatory-exclusion categories, while another ground may be permissive. A notice of intent, final exclusion and reinstatement application are different stages; a license board has its own rules. Before accepting a plea or civil settlement, identify the precise conviction language, the provider enrollment and license at stake, any current OIG notice and the person’s work duties. The answer may affect whether they can bill, order, prescribe or work for an entity participating in federal programs. Get qualified program and licensing advice alongside criminal defense rather than assuming one negotiated charge resolves every track.

Who can be charged — is it just the owners?

No — health care fraud charges are filed against individuals at every level of the healthcare organization. Physicians, clinical staff, billing coordinators, marketing employees, and executives are all charged individually. But organizational employment alone does not establish a criminal section 1347 violation. The government must prove each accused person's knowing and willful participation in the charged scheme; instructions, warnings or deliberate avoidance may matter even without personal review of every claim. The separate civil False Claims Act standard should not be imported into that criminal count.

How do federal sentencing guidelines work — and why does the loss amount matter so much?

Federal fraud guidelines can consider supported loss, but they are advisory, not mandatory extra prison years at each dollar tier. Reconcile disputed claims with services provided, payer payment, coverage rules and original clinical records. Statutory limits, other guideline adjustments and case-specific sentencing factors also matter. A lower proved loss can affect the advisory range, but no fixed reduction in years follows from a single disputed figure.

What is the False Claims Act — and how does it affect my case?

Section 3729 creates civil liability for specified false claims to the federal government, including up to treble damages and a per-claim civil penalty adjusted by regulation. A qui tam relator may sue under seal; the government can investigate and choose whether to intervene. A criminal charge under section 1347 or the Anti-Kickback statute is separate. The claimed loss, number of claims, damages, materiality and knowledge standard need review from original billing and payment records; neither a headline claim total nor a civil filing proves a criminal offense.

What is the Anti-Kickback Statute — and what safe harbors protect legitimate arrangements?

The Anti-Kickback Statute addresses knowing and willful remuneration to induce or reward federal-program business. Review who paid or received it, the referral purpose, contract, actual services and any applicable safe harbor. OIG says failure to meet a safe harbor is not automatically a violation; fitting one can provide protection if all conditions are satisfied. A civil Stark exception and an AKS safe harbor are different inquiries.

What is the difference between federal and state health care fraud charges — can I face both?

Yes — many California health care fraud prosecutions involve both federal charges under 18 U.S.C. § 1347 and state charges under PC § 550 or W&I § 14107. Federal charges are prosecuted by the U.S. Attorney's Office and carry federal sentencing guidelines exposure. State charges are prosecuted by the California Department of Justice or county district attorneys and carry California state prison exposure. Both prosecutions can proceed simultaneously — and the defense strategy must account for both tracks, because concessions made in one can affect the other. David Chesley handles both federal and state health care fraud defense across every county in California and in every federal district.

What is program exclusion — and how serious is it?

OIG can impose mandatory or permissive exclusion depending on the Medicare-fraud conviction and statutory ground. A first mandatory exclusion ordinarily has a five-year minimum, not a universal lifetime ban. The notice specifies its term; reinstatement is a separate application requiring written approval. Licensure and employment questions require the actual board and role.

What if a former employee filed a qui tam lawsuit?

A qui tam lawsuit is a False Claims Act suit filed by a private whistleblower on behalf of the federal government. The whistleblower files under seal, giving the government the opportunity to investigate and decide whether to intervene. If the government intervenes and the case is successful, the whistleblower shares in the recovery — typically 15 to 25 percent. A qui tam filing may lead to a separate criminal investigation, but neither that investigation nor a criminal charge automatically follows. Compare the allegations with the actual civil and criminal records. Understanding the specific allegations, who filed the lawsuit, their motivations, and how the civil and criminal tracks interact is essential from the very first consultation.

Will a conviction affect my professional license?

Board reporting, discipline and potential exclusion depend on the exact conviction, professional license and governing board or OIG rule. Obtain the licensing application and board notice requirements before resolving a case; neither automatic revocation nor an employment bar follows from every conviction.

Can a conviction affect my immigration status?

A noncitizen’s immigration exposure depends on the precise offense of conviction, loss findings, sentence and immigration history. Neither a fraud label nor a felony label alone establishes automatic detention, removal or a permanent citizenship bar. Qualified immigration counsel should review a proposed plea and the complete record before a decision.

Do you handle cases throughout California?

Yes — in every federal district and every county superior court across all of California, from Los Angeles and San Diego in the south to San Francisco and Sacramento in the north, and every jurisdiction in between.

Are payment plans available?

Yes. The Law Offices of David Chesley offers flexible payment plans because cost should never be the reason someone under investigation for or charged with health care fraud goes without experienced legal representation during the phase when it matters most. Call to discuss options during your free consultation.

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FREE CONSULTATION — CALL NOW — 24/7

Health care fraud investigations move quickly and involve multiple agencies — and every day without experienced defense counsel is a day the investigation advances on both federal and state tracks without anyone protecting the defendant's rights or presenting the exculpatory billing and clinical evidence that might prevent charges from being filed. Every day employees are approached and interviewed by federal and state agents without coordinated defense guidance is a day statements are made — by billing staff, clinical employees, and marketing personnel — that will be used to build the case against individual defendants who may have had no idea those conversations were occurring or what was being said on their behalf. Every day the government's loss calculation sits unchallenged in the investigation file is a day the overstated figure that may be inflating the guidelines range by years becomes more embedded in the prosecution's charging theory — and the forensic billing analysis that could challenge it and move the loss amount to a lower guidelines tier becomes harder to conduct as records age, the government's narrative calcifies, and the window to influence the charging document closes before any defense attorney has had the opportunity to present the alternative calculation that could reduce the sentence by years. Every day a qui tam whistleblower lawsuit moves forward without coordinated civil and criminal defense strategy is a day the civil and criminal tracks develop independently in ways that may conflict and create additional exposure in both.

Don't wait for charges to be filed. Don't assume the investigation will resolve itself. And don't speak to federal or state agents without experienced counsel. If you have received a subpoena, if investigators have appeared at your practice or your home, if you have been contacted by the FBI, HHS-OIG, DOJ, or DHCS, if a former employee has filed a qui tam lawsuit, or if you have been formally charged with health care fraud or related offenses, call now.

The Law Offices of David Chesley offer a free, confidential consultation available 24 hours a day, 7 days a week. No judgment. No pressure. Clear, honest guidance on your specific situation across every track — criminal, civil, and administrative.

Flexible payment plans available.

David Chesley handles health care fraud defense in federal courts and criminal courts across all of California — Los Angeles County, Orange County, San Diego County, Riverside County, San Bernardino County, Ventura County, Santa Barbara County, Kern County, Fresno County, Sacramento County, Alameda County, Santa Clara County, San Francisco County, Contra Costa County, San Joaquin County, Stanislaus County, Monterey County, and every other jurisdiction statewide.

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"Health care fraud prosecutions are complex matters involving billing practices, clinical judgment, and federal sentencing guidelines. The government must prove knowing and willful submission of false claims — not honest errors or good-faith decisions. My commitment is to defend every element aggressively on every track — criminal, civil, and administrative — while protecting your freedom, license, and future." — David Chesley, California Criminal Defense Attorney

That firm-published statement describes a defense position. Section 1347 requires a knowing and willful health-care fraud scheme, not necessarily that the accused personally submitted a particular false claim. Civil False Claims Act and Anti-Kickback allegations have distinct elements.