Hospice Fraud Defense

Charged with or Under Investigation for Hospice Fraud in California?

A hospice or Medicare billing allegation requires a close look at the charged statute, individual conduct, clinical records and claimed loss.

California criminal defense attorney David Chesley has successfully defended hospice fraud investigations and charges — including federal healthcare fraud (18 U.S.C. § 1347), civil False Claims Act matters, Anti-Kickback Statute matters, and related Medi-Cal fraud allegations — in federal and state courts across every county in California. These complex cases 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, or state investigators without counsel — questions are specifically designed to elicit statements establishing knowledge or intent; in hospice fraud cases, what you say about your billing practices, your awareness of patient eligibility, and your understanding of certifications is the prosecution's most important evidence
• Do not destroy, alter, or delete any records, charts, billing data, or communications — document destruction after a government investigation begins constitutes obstruction of justice and carries its own federal felony exposure entirely independent of the underlying fraud allegations
• Preserve all documentation — patient records, physician certifications, clinical notes, billing submissions, marketing agreements, compliance materials, and all communications between staff, billing departments, and referral sources
• Contact experienced federal healthcare fraud counsel immediately — the investigation phase is when the government builds its case; early defense can prevent charges from being filed, limit the scope of the government's theory, and protect individual defendants before cooperating witnesses have given their accounts

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THE STAKES ARE REAL

Hospice fraud is a high-priority federal enforcement target in California. Recent investigations and prosecutions have focused on ineligible patient enrollment, kickback arrangements, upcoding, and falsified documentation — often resulting in multi-million-dollar loss calculations that drive federal sentencing guidelines ranges into years and decades of prison exposure. The federal government pursues these cases with specialist prosecutors, specialist investigators, and the full resources of the federal grand jury system — building cases over years before a single charge is filed.

A conviction can mean:

• Federal health care fraud under 18 U.S.C. section 1347 has a maximum of 10 years ordinarily, up to 20 years if the violation results in serious bodily injury, and any term of years or life if it results in death. Those higher ranges require the specified resulting harm; they are not an automatic penalty for a billing allegation.
• Restitution and criminal fines depend on the conviction, proved loss, applicable authority and sentencing record; not every billed dollar is automatically recoverable as fraud loss.
• The False Claims Act can impose civil liability of up to three times the government’s proved damages plus adjusted per-claim civil penalties for qualifying conduct; three times all billed amounts is not the statutory measure by itself.
• HHS-OIG exclusion from federal health care programs can be mandatory for specified convictions or discretionary on other grounds. Many mandatory exclusions have a five-year minimum, not an automatic lifetime term; repeat qualifying convictions can extend the term and a third may require permanent exclusion. An excluded person generally cannot receive federal program payment for items or services furnished, ordered or prescribed. Reinstatement requires a separate OIG application and approval.
• A physician, nurse or other professional may face board-specific disclosure or discipline; the exact license, offense and disposition matter. A hospice-fraud allegation alone does not automatically revoke every health license.
• After a qualifying federal health care offense conviction, 18 U.S.C. section 982(a)(7) provides for forfeiture of property constituting or derived from gross proceeds traceable to the offense. That is not an automatic forfeiture of every business or personal asset merely because it exists. Trace the claimed proceeds and ownership.

Common Hospice Fraud Allegations vs. Strong Defenses:

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WHAT IS HOSPICE FRAUD?

“Hospice fraud” can describe several theories, including a criminal scheme using alleged false pretenses under section 1347, a kickback allegation, a civil False Claims Act case or a California count. A disagreement about patient eligibility or certification does not itself establish which statute was violated. Identify the filed charge, coverage rule, claim period and each person’s alleged conduct before treating a disputed chart as fraud.

• 18 U.S.C. § 1347 — Federal healthcare fraud: knowingly executing a scheme to defraud a healthcare benefit program
• Anti-Kickback Statute (42 U.S.C. § 1320a-7b) — Prohibiting knowing and willful payment or receipt of remuneration to induce or reward referrals of Medicare or Medi-Cal patients
• The False Claims Act, 31 U.S.C. section 3729, establishes civil liability and potential treble damages and adjusted civil penalties for qualifying knowingly false claims; qui tam actions are civil suits under section 3730. Separate statutes, such as criminal health care fraud under 18 U.S.C. section 1347, have their own elements and punishments.
• California Penal Code § 550 — State insurance fraud, frequently charged alongside federal counts in California hospice prosecutions

Under 18 U.S.C. section 1347, the government must prove a knowing and willful execution or attempt of a health care fraud scheme. The statute is not limited to proving that this person personally submitted a particular false claim. Compare the alleged plan, clinical documentation, billing chronology and person’s actual participation. Honest clinical disagreement or an error can matter to intent, but it does not automatically defeat a supported scheme theory.

Key Defenses in Hospice Fraud Cases:

Clinical judgment and intent

A patient’s prognosis can be uncertain, and contemporaneous certifications, face-to-face encounters and care notes may explain a decision later challenged by an auditor. Compare the actual coverage standard at the time with the record the clinician saw. Under section 1347, the question is knowing and willful participation in a scheme; a later disagreement does not prove that state of mind, but it is also not an automatic defense if records were knowingly fabricated.

Insufficient evidence of ineligibility

Challenging whether patients were truly ineligible at the time of certification — through contemporaneous clinical records, treating physician testimony, and independent expert analysis of the patient's prognosis at the time certifications were made.

Anti-Kickback safe harbors

Legitimate compensation arrangements — bona fide employment arrangements, personal services arrangements meeting regulatory requirements, and other structures falling within established safe harbors — do not violate the AKS regardless of the government's characterization.

Advice and compliance records

A compliance program or advice from a billing specialist or counsel may be evidence about the person’s knowledge and intent. It does not automatically defeat section 1347 when the evidence otherwise proves knowing and willful participation. Review what advice was sought, what facts were disclosed, what was actually recommended, and whether later conduct followed it. Distinguish a criminal scheme allegation from a civil False Claims Act knowledge issue.

Loss amount review

The government’s proposed amount should be tested against underlying claims, actual services, payments and any supported credits or extrapolation. A corrected figure may affect an advisory federal guideline calculation, restitution or civil damages under their different rules, but it does not necessarily reduce the final sentence, and no fixed number of years follows. Ask for the claim-level method and identify each disputed assumption.

WHO CAN BE CHARGED — INDIVIDUAL LIABILITY IN HOSPICE FRAUD CASES

Federal hospice fraud prosecutions do not stop at the organizational level. Individual criminal charges are filed against defendants at every level of the hospice operation — and understanding what the government must prove for each role, and what defenses are available based on that specific role, is one of the most important early tasks in every hospice fraud defense.

Physicians and nurse practitioners

A hospice certification should be examined against the patient’s contemporaneous condition, prognosis, encounter and coverage rule. An honest medical judgment later disputed by an auditor does not by itself prove section 1347’s knowing and willful scheme. It also does not immunize a clinician from evidence of knowingly false certification, deliberate record alteration, a referral payment or participation in a different fraudulent act. Identify what this person actually knew and did rather than making every clinical disagreement decisive.

Clinical directors and directors of nursing

A supervisory role can make clinical records and policy decisions relevant, but section 1347 requires proof of knowing and willful participation in the alleged scheme, not merely responsibility for staff. Compare actual access to eligibility reviews, instructions, complaints, corrections and patient charts, including any alleged forged documentation. A retrospective reviewer’s disagreement with a certification is not by itself proof of criminal intent; neither does a delegation automatically defeat evidence that a director joined the plan.

Billing managers and coordinators

A person may be investigated because they submitted or corrected claims, but their role must be distinguished from clinical certification and business policy decisions. Under section 1347, the government must prove knowing and willful participation in a charged health care fraud scheme; “should have known” alone describes neither the statutory criminal mental state nor a complete defense. Compare actual access to notes, error notices, instructions and any edits or warnings. Civil False Claims Act knowledge is a separate issue.

An owner or executive may be investigated for a billing scheme tied to business policies, compensation or referrals, but title alone does not establish the knowing and willful conduct required for 18 U.S.C. section 1347. Review what that person actually knew, approved or caused, including claims data, clinical records, messages, audit findings and advice received. A compliance program or consultation with counsel can be relevant evidence but does not automatically defeat an otherwise proved criminal theory. Civil False Claims Act and exclusion questions have different standards.

Marketing and referral arrangements

Marketing work or referral compensation may be relevant to an Anti-Kickback Statute count, but the government must prove the statutory knowing and willful remuneration-for-referrals theory as to the person charged. Under 42 U.S.C. section 1320a-7b(h), actual knowledge of the statute or specific intent to violate it is not required. Review what was paid, for what work, who directed it, and any written agreement or legal advice. A representation that an arrangement was compliant is evidence to examine, not an automatic defense.

Individual conduct matters

A section 1347 case requires proof of this defendant’s knowing and willful execution or attempted execution of the alleged scheme; title or proximity to disputed claims alone is not enough. False Claims Act civil liability has its own knowledge standard, which includes deliberate ignorance or reckless disregard. Identify who set policies, certified care, changed records, submitted claims and received notices before treating organizational conduct as an individual criminal act.

HOW DAVID CHESLEY DEFENDS HOSPICE FRAUD CASES

These cases require simultaneous defense on criminal, civil False Claims Act, and administrative exclusion tracks — while protecting individual defendants from organizational liability, managing coordinated defense of multiple defendants, and ensuring the government's characterization of clinical decisions as fraud is contested at every level. David Chesley personally handles every hospice 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. The attorney you hire is the attorney fighting for you.

Core defense strategies pursued immediately:

Investigation-phase intervention

The most important defense work in any federal healthcare fraud case happens before charges are filed. Grand jury subpoena responses, employee interview coordination, joint defense arrangements, and presentation of exculpatory clinical evidence to prosecutors before the charging theory is locked in — all pursued immediately upon retention.

Challenging the government's clinical theory

The government's retrospective billing analysis is challenged through contemporaneous clinical records, treating physician testimony, and independent expert review establishing that certifications reflected genuine clinical judgment at the time they were made.

Individual knowledge element defense

For each person, compare what they knew, directed, approved or attempted with the alleged health care fraud scheme. Section 1347 requires knowing and willful participation; deliberate ignorance or reckless disregard is a separate civil False Claims Act knowledge standard. Organizational proximity alone is not guilt, but an employee title or delegation is not an automatic defense.

Loss amount challenge

Independent forensic billing analysis examines the government's methodology, identifies patients with legitimate clinical eligibility incorrectly included in the loss calculation, and challenges overstated figures that are inflating the guideline range.

Anti-Kickback safe harbor analysis

Every compensation arrangement alleged as a kickback is analyzed against the AKS safe harbor framework to determine whether a legitimate structural defense exists.

Civil FCA and administrative track management

Civil False Claims Act exposure and Medicare exclusion proceedings are addressed simultaneously with the criminal defense — because decisions made in one proceeding directly affect the others.

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YOU HAVE RIGHTS. USE THEM.

The government must prove the mental state and conduct of the specific charged offense. Section 1347 concerns knowing and willful participation in a fraudulent scheme or attempt, not proof that every hospice certification or claim was individually false. Civil False Claims Act liability requires its own knowing false-claim showing. Clinical judgment, eligibility criteria and contemporaneous notes should be reviewed against the charged theory.

• Investigation closed without charges — early intervention presents exculpatory clinical evidence; government declines to charge
• Individual charges defeated — knowledge element not established; defendant's role insufficient for criminal liability
• Clinical certifications defended — contemporaneous records and expert testimony establish good-faith judgment
• Loss amount successfully reduced — forensic analysis demonstrates government's calculation is overstated; guideline range reduced by years
• The firm reports a kickback allegation resolved after an arrangement’s terms were reviewed. A safe harbor protects only when all its conditions apply; missing one does not automatically make the arrangement unlawful. The actual record and charged theory control.
• Civil FCA exposure negotiated — civil settlement preserves defenses in the criminal case
• Exclusion avoided or minimized — resolution structured to limit Medicare and Medi-Cal exclusion consequences
• License consequences minimized — resolution structured to reduce mandatory reporting and board exposure

WHY CLIENTS CHOOSE DAVID CHESLEY

Direct, personal attention — statewide, 24/7

David Chesley personally handles hospice fraud defense in federal courts and California 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 agents appear unannounced and the window to respond effectively to initial government contact is measured in minutes, not days.

Straight talk, always

Hospice fraud cases range from situations where the government's clinical theory is legally defective, the individual defendant's 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 resolving the case to preserve the ability to continue practicing. You deserve honest counsel about which situation you are actually in. No false promises. No sugarcoating.

Multi-track strategy addressing criminal, civil, and administrative exposure

Criminal, civil False Claims Act and OIG exclusion matters can arise at different times and under different standards. The firm describes coordinating them when more than one track exists. A statement or disposition in one may affect another, but a criminal inquiry does not prove that a qui tam case and exclusion proceeding have already begun. Identify the actual notices, parties and deadlines first.

Federal healthcare fraud expertise — clinical, regulatory, and legal

Deep knowledge of the federal Medicare hospice benefit regulatory framework, eligibility certification requirements, the Anti-Kickback Statute and safe harbors, the False Claims Act and qui tam provisions, federal healthcare fraud sentencing guidelines loss amount calculations, HHS-OIG investigation methodology, and the specific clinical and billing issues that define every hospice fraud prosecution — 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 hospice fraud goes without experienced representation during the phase when it matters most.

Representative Results:

• Federal investigation closed without charges — investigation-phase intervention presented clinical documentation and expert analysis establishing certifications were supported by contemporaneous patient records; government declined to charge
• Physician avoided charges and license revocation — strong medical necessity and good-faith clinical judgment defense established; clinical expert testimony contradicted government's retrospective analysis; case resolved favorably
• Loss amount significantly reduced — forensic billing analysis demonstrated government's calculation included patients with legitimate clinical eligibility; revised amount reduced guideline range by multiple levels; sentence reduced significantly
• Individual billing coordinator charges dismissed — knowledge element not established; defendant relied on clinical staff determinations and had no basis to question certifications; government could not prove knowing submission of false claims
• Kickback allegation defeated — medical director compensation arrangement found to fall within AKS personal services safe harbor; Anti-Kickback charge not sustained
• Civil FCA exposure negotiated — civil settlement achieved that resolved government's False Claims Act claims while preserving key defenses in the parallel criminal proceedings

Client Feedback:

"Federal agents showed up at my hospice unannounced. I called David immediately. He managed every aspect of the investigation response, coordinated with our staff, and prevented charges from being filed. Having counsel immediately was the difference." — Anonymous hospice administrator

"As a physician, I faced serious allegations over certifications I made in good faith based on my clinical assessment. David brought in clinical experts, established that my judgment was supported by the contemporaneous records, and the charges were resolved favorably." — Anonymous physician

"The loss amount the government was using would have meant years in federal prison. David's forensic accounting analysis showed they were significantly overstating it. The reduction in the guideline range changed everything." — Anonymous former client

"Non-citizen healthcare administrator. David knew immediately that a federal conviction meant deportation and built the entire defense around avoiding that outcome. Resolved without a conviction." — Anonymous former client

FREQUENTLY ASKED QUESTIONS

What should I do if contacted by federal agents?

Do not speak with them or produce any documents without experienced defense counsel present. Federal agents conducting hospice fraud investigations are trained interviewers who ask questions specifically designed to elicit statements establishing knowledge, intent, or awareness of billing irregularities — and statements made without counsel present are among the most damaging evidence in federal healthcare fraud prosecutions. Call experienced counsel immediately — before responding to any agent contact, before producing any documents, and before discussing the investigation with anyone inside or outside the organization.

Can I be charged even if I didn't personally submit the claims?

Yes. A person need not personally submit a claim to face a section 1347 charge, but their title or proximity to a disputed bill is not enough. The prosecution must prove knowing and willful execution or attempt of the charged fraud scheme. Civil False Claims Act exposure uses a separate knowledge test. Examine the person’s actual directions, certifications, access to records, communications and response to warnings before inferring participation.

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

The False Claims Act is a civil statute. For a qualifying knowing false claim it allows up to three times the government’s proved damages plus adjusted per-claim penalties; a private relator may file a qui tam suit under section 3730. The civil damages measure is not automatically every billed dollar or the criminal section 1347 sentence. A settlement, investigation or exclusion notice may proceed on its own facts and timeline.

For hospice eligibility, compare the physician certification and narrative with the patient’s condition at that time, not only a later survival date. Preserve the face-to-face encounter record, recertification sequence, notes about decline or stabilization, care-plan changes and any documentation correction. An enrollment can be challenged without every service being fictitious; the defense should identify which claim and period the government disputes and whether its proposed loss assumes that all care lacked value. A director’s review, a billing employee’s transmission and a clinician’s certification are distinct acts that should be attributed to the right person. This evidence chart helps evaluate the criminal scheme theory, any civil damages claim and the practical effect of an exclusion notice without treating them as one automatic result.

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

Sentencing may involve a disputed loss calculation, and the billed face amount is not necessarily the final figure. Compare identified claims with actual services, payments, dates and the alleged fraudulent portion. Guidelines, statutory penalties, restitution and any civil False Claims Act damages are distinct calculations. Obtain the government’s methodology and underlying claim data before accepting a multi-million-dollar estimate; the court decides any disputed sentencing facts under the applicable rules.

What is the Anti-Kickback Statute — and what are the safe harbors?

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) prohibits the knowing and willful payment or receipt of remuneration to induce or reward referrals of patients covered by Medicare or Medi-Cal. In hospice cases, the most common AKS allegations involve medical director fee arrangements alleged to be remuneration for referrals rather than legitimate compensation for services, facility staff payment arrangements providing services to nursing home staff in exchange for referral access, and marketing arrangements involving gifts or other benefits to referral sources. AKS violations require knowing and willful conduct — a specific corrupt intent that must be proven beyond a reasonable doubt. The statute provides safe harbors for bona fide employment arrangements, personal services arrangements meeting specific criteria, and other legitimate compensation structures — and arrangements falling within a safe harbor do not violate the AKS regardless of the government's characterization. Every compensation arrangement alleged as a kickback is analyzed against the safe harbor framework to determine whether a legitimate defense exists.

What is Medicare exclusion — and how serious is it?

HHS-OIG exclusion affects federal program payment for items or services furnished, ordered or prescribed by an excluded person or entity. It does not literally bar all treatment of patients. Some convictions require exclusion and other grounds are discretionary; many mandatory periods start at five years, and reinstatement requires application and approval. Examine the actual authority, notice and term before describing a hospice operator’s or clinician’s future role.

Will a conviction affect my medical or professional license?

A hospice-fraud conviction may create board-specific reporting or discipline questions. A physician or nurse should check the applicable board, precise disposition and exclusion status before assuming automatic license revocation or suspension.

Can a conviction affect my immigration status?

A federal health care fraud conviction can raise immigration or citizenship issues for a noncitizen, but the result depends on the precise conviction, statutory elements, loss, sentence and person’s immigration history. Do not assume every billing-related conviction triggers mandatory deportation, detention or a permanent naturalization bar. A qualified immigration lawyer should review any proposed plea or program before a decision. Related immigration guidance.

Match each alleged claim to the actual care record

Start with the exact billing period, claim identifier, code, amount requested and amount paid. Then trace the relevant order, certification, encounter note, service log, coverage rule and any later correction. A reviewer’s retrospective conclusion may differ from what the clinician knew when care was given; conversely, a copied note or backdated certification may raise a separate question. Preserve original audit trails and version history rather than only a final PDF. Identify who entered, approved and transmitted each record and what that person could see. This comparison helps separate a coding mistake, disputed clinical judgment, a civil false-claim question and a criminal scheme theory. The accused person should not assume that every claim in a government spreadsheet was fraudulent or that one valid service answers every allegation.

Keep the criminal, civil and administrative records distinct

A section 1347 charge, civil False Claims Act demand and OIG exclusion notice can arrive on different schedules and require different responses. A criminal subpoena does not establish a conviction; an exclusion notice has its own asserted authority and term. Identify each caption, deadline, target person or entity and requested records. The same billing data may be relevant across tracks, but a settlement or licensing decision in one does not automatically resolve the others. Counsel can compare proposed statements, document production and dispositions for their effects across proceedings, including any board-specific reporting or federal program payment restriction.

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 hospice fraud goes without experienced legal representation during the phase of the case when counsel matters most. Call to discuss options during your free consultation.

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FREE CONSULTATION — CALL NOW — 24/7

Hospice fraud investigations move quickly and involve multiple agencies — and every day without experienced defense counsel is a day the investigation advances without anyone protecting the defendant's rights or presenting the exculpatory evidence that might prevent charges from being filed. Every day employees are approached, interviewed, and questioned without coordinated defense guidance is a day statements are made — by clinical staff, billing coordinators, marketing employees, and others inside the organization — that will be used to build the case against individual defendants who had no idea those conversations were happening or what was being said. Every day the government's loss calculation sits unchallenged in the investigation file is a day the overstated figure that may be inflating the guideline range by years becomes more embedded in the prosecution's theory — and the forensic billing analysis that could challenge it and reduce it becomes harder to conduct as records age and the government's narrative about the total harm calcifies. And every day a qui tam whistleblower lawsuit moves forward without a defense attorney coordinating the civil and criminal response is a day the civil and criminal tracks develop in ways that may conflict with each other 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 agents without experienced counsel. If you have received a subpoena, if federal agents have appeared at your hospice or your home, if you have been contacted by the FBI or HHS-OIG, if a former employee has filed a qui tam lawsuit, or if you have been formally charged, 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 hospice 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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"Hospice fraud cases are complex matters involving clinical judgment, regulatory compliance, and federal sentencing guidelines. The government must prove knowing falsehoods — not good-faith decisions or honest billing errors. 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

In a criminal section 1347 case, the charged element is knowing and willful execution or attempted execution of a fraudulent health care scheme. Civil False Claims Act allegations have a separate claim-level knowledge standard. The actual count, not a billing label, controls the proof.