Medicare Fraud Defense

Charged with or Under Investigation for Medicare 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 Medicare 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 white-collar 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 CMS investigators without counsel — questions are specifically designed to establish knowledge and intent; in Medicare fraud cases, what you say about your billing practices, your awareness of documentation gaps, 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 and carries its own federal felony exposure entirely independent of the underlying fraud allegations
• Preserve all documentation — patient records, orders, certifications, billing submissions, marketing agreements, referral arrangements, and compliance materials
• Contact experienced federal healthcare fraud counsel immediately — the investigation phase is when the government builds its case, develops cooperating witnesses, and forms its charging theory; early defense can prevent charges from being filed or significantly limit exposure before the government's narrative is locked in

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THE STAKES ARE REAL

Medicare fraud is a high-priority federal enforcement area in California. Multi-agency task forces — FBI, HHS-OIG, DOJ, and state partners — target false claims, upcoding, kickbacks, and billing for unnecessary services, 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 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 fines depend on the conviction, proved loss, applicable authority and sentencing record. The amount is not automatically every billed dollar or a fixed multimillion-dollar figure; compare actual payments, services and credits.
• 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 professional board may require disclosure or consider discipline under its rules. Licensed health professionals should check the exact board and disposition; revocation is not automatic for every Medicare-fraud allegation.
• 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 Medicare Fraud Allegations vs. Strong Defenses:

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WHAT IS MEDICARE FRAUD?

“Medicare fraud” can refer to a federal section 1347 scheme using alleged false pretenses, Anti-Kickback Statute count, civil False Claims Act claim or state insurance charge. The statutes have different elements. Section 1347 covers knowing and willful execution or attempt of a fraudulent health care scheme; it does not require this accused person to submit each allegedly false claim personally. Begin with the actual charging papers and billing period.

• 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 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 Medicare fraud prosecutions

The government must prove knowing and willful conduct — not honest billing errors, good-faith coding disputes, or legitimate clinical judgment. That distinction is the foundation of every Medicare fraud defense.

Key Defenses in Medicare Fraud Cases:

Intent and coding evidence

Review the coverage rule in effect, actual clinical service, claim coding, contemporaneous advice and any audit correction. An honest error or good-faith interpretation may undercut a claimed criminal scheme; a compliance manual alone does not defeat evidence of knowing and willful participation. Section 1347’s scheme element and civil False Claims Act claim-level knowledge must be assessed separately.

Insufficient evidence of falsity

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

Anti-Kickback safe harbors

Employment and personal-services arrangements may fit a regulatory safe harbor if every applicable condition is satisfied. Paying fair market value alone is not a stand-alone safe harbor, and a partial fit does not give safe-harbor protection. An arrangement outside a safe harbor is not automatically illegal; assess remuneration, referrals, actual services and intent under the statute and OIG guidance.

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 MEDICARE FRAUD CASES

Federal Medicare 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 Medicare fraud defense.

Physicians and Other Licensed Providers

A physician may be investigated for orders, certifications or medical-necessity decisions connected to billed services. Compare the patient’s contemporaneous condition, coverage rule and actual decision. Genuine clinical judgment later questioned by an auditor does not itself prove a knowing and willful section 1347 scheme; it also does not defeat separate proof of knowingly false documentation, referral remuneration or another charged fraudulent act. Review the whole role and record rather than treating either a retrospective audit or professional status as conclusive.

Nurses, Therapists, and Allied Health Professionals

A nurse or therapist’s documentation, including any alleged forgery, may be central to a scheme, but a later auditor’s disagreement does not establish knowing and willful criminal participation. Review who made each entry, the underlying service, instructions, edits and any warning. An honestly mistaken note may matter; a person who knowingly joined a scheme cannot rely on job title alone to avoid a section 1347 charge.

Billing Managers and Billing Staff

Submitting claims based on clinical notes does not by itself prove or disprove knowing and willful participation in a section 1347 scheme. Compare the person’s actual access to documentation, correction requests, notices and conduct after any warning. The statute is not limited to a person who personally submitted a false claim, and an employee’s reliance on others is evidence rather than an automatic defense.

Owners, Executives, and Administrators

Business policies, compensation or claim-review decisions can be relevant to an alleged Medicare scheme, but title alone does not prove section 1347’s knowing and willful participation. Review what the person approved, knew, changed or ignored and what contemporaneous records show. A compliance program or advice received may be relevant evidence, but it is not an automatic bar to prosecution. Civil FCA and exclusion rules require separate analysis.

Marketing and Sales Staff

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.

The Critical Principle for All Individual Defendants

Individual criminal liability under section 1347 requires proof of knowing and willful participation in the charged scheme, not merely employment at a practice where claims are disputed. The civil False Claims Act uses a different knowledge standard that can include deliberate ignorance or reckless disregard. Compare access, instructions, records, warnings and actual actions for each person; neither title nor a compliance program automatically decides the case.

HOW DAVID CHESLEY DEFENDS MEDICARE 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 fraud theory is contested at every level. David Chesley personally handles every Medicare 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 work

Counsel can review a subpoena, preserve billing and clinical data, coordinate employee interviews and present relevant records when appropriate before or after a charging decision. Indictment changes procedure but does not categorically close the ability to contest evidence, negotiate or narrow a theory. Confirm the actual deadlines and avoid altering records.

Challenging the government's fraud theory

Billing analysis challenged through contemporaneous medical records, treating provider testimony, independent clinical and coding expert review, and the specific Medicare coverage rules governing the services at issue — establishing that billing reflected legitimate services, genuine clinical determinations, and good-faith compliance with complex coverage requirements.

Individual knowledge element defense

Each defendant's specific role, actual knowledge, and specific conduct is analyzed independently to determine whether the government can establish knowing and willful conduct — because individual liability requires more than organizational proximity to fraud.

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 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, Medicare exclusion proceedings, and professional licensing consequences are addressed simultaneously with the criminal defense — because decisions in one track directly affect the others.

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YOU HAVE RIGHTS. USE THEM.

For a charge under 18 U.S.C. section 1347, the government must prove knowing and willful execution or attempt of a scheme to defraud a health care benefit program or obtain its money or property by false pretenses in connection with health care. A coding mistake or good-faith clinical decision may bear on intent; no single claim-level error alone establishes a scheme, and a defendant need not personally press “submit” for every alleged claim. Compare the statute and person’s actual role with the records.

• Investigation closed without charges — early intervention presents exculpatory billing and clinical 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, genuine medical necessity, and good-faith billing
• Loss amount successfully reduced — forensic analysis demonstrates government's calculation overstated; guidelines range reduced by years
• The firm reports a favorable kickback resolution involving a compensation arrangement. Whether an applicable safe harbor protects it requires every condition; absence of safe-harbor protection is not automatic guilt.
• Civil FCA exposure negotiated — civil settlement achieves favorable resolution while preserving defenses in the criminal case
• Exclusion minimized or avoided — resolution structured to limit Medicare exclusion consequences
• License consequences minimized — resolution structured to reduce mandatory reporting and licensing board exposure
• Reported case disposition — the firm describes a result without a health care fraud conviction. The exact immigration classification depends on the full record, loss, sentence and the person’s history; no universal safety conclusion follows. See the charged felony or misdemeanor and any distinct offense before advising on a plea.

WHY CLIENTS CHOOSE DAVID CHESLEY

Direct, personal attention — statewide, 24/7

David Chesley personally handles Medicare 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.

Straight talk, always

Medicare 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 — criminal, civil, and administrative

The criminal case, the civil FCA track, and the Medicare exclusion proceedings all require simultaneous management. Positions taken in one track can create exposure in the others — and the overall strategy must account for every track from the first consultation.

Federal healthcare fraud expertise

Deep knowledge of the federal Medicare billing and coverage framework, Anti-Kickback Statute and safe harbors, False Claims Act and qui tam provisions, federal healthcare fraud sentencing guidelines loss amount calculations, Medicare Fraud Strike Force investigation methodology, and the specific billing and clinical documentation issues that define every Medicare 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 Medicare fraud goes without experienced representation during the phase when it matters most.

Representative Results:

• Federal Medicare fraud investigation closed without charges — investigation-phase intervention presented billing documentation and clinical records establishing legitimate services; government declined to charge
• Physician avoided individual charges — medical necessity defense established through contemporaneous records and independent clinical expert testimony; government's retrospective 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
• The firm reports that a marketing compensation allegation was dismissed after the arrangement was reviewed. A safe harbor requires all its conditions; failure to fit one does not by itself prove an AKS violation.
• Civil FCA qui tam lawsuit resolved — whistleblower lawsuit resolved through negotiated settlement that preserved key defenses in the parallel criminal proceedings
• Medicare exclusion minimized — resolution structured to limit exclusion period; defendant's ability to continue in non-Medicare clinical capacity preserved
• Reported noncitizen disposition — the firm describes a resolution without a health care fraud conviction. Removal exposure and future applications require individual review of the complete record; this account is not a universal immigration finding.

Client Feedback:

"Federal agents appeared without warning. David coordinated the entire response — the investigation, our staff's communications, the document preservation. The investigation was closed without charges." — Anonymous medical practice owner

"I was a billing manager 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 over a decade in prison. David's forensic analysis cut it dramatically. The reduction in my sentencing exposure changed everything." — Anonymous former client

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

FREQUENTLY ASKED QUESTIONS

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

Section 1347 addresses knowing and willful execution or attempted execution of a fraudulent health care scheme, not merely the submission of an inaccurate claim. Billing errors, missing documentation and coverage disputes require analysis of the alleged plan and defendant’s actual intent. A person may participate without pressing “submit,” while an unsupported claim alone does not prove every element of a criminal charge. Civil False Claims Act claims have a different legal test.

Who can be charged — is it just the practice owners?

No. An owner, clinician, billing worker or marketing employee may face investigation depending on their actual role. Section 1347 requires knowing and willful participation in an alleged fraudulent scheme or attempt, not just employment or submission of one disputed claim. Other statutes, including the civil False Claims Act and Anti-Kickback Statute, have different elements. Identify each filed count and what the person knew, directed or did before evaluating exposure.

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

A sentencing loss figure can be disputed; the alleged total billed value is not automatically the final criminal loss, restitution amount or civil FCA damages. Compare claims, payments, actual services and the government’s method before discussing a guideline range. Statutory maxima, any resulting-harm finding and the person’s role are separate questions. Counsel should obtain the detailed claim data and explain any disputed calculation to the court.

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

The False Claims Act is civil. For a qualifying knowing false claim, section 3729 permits up to three times the government’s proved damages plus adjusted per-claim penalties; qui tam procedure is under section 3730. That measure is not simply the total amount billed and does not itself set a criminal sentence or exclusion term. Examine the actual claims, payments and alleged false statements.

For a Medicare billing dispute, separate services never delivered from services delivered but allegedly miscoded or medically unnecessary. Match the date of service and beneficiary with orders, encounter notes, the code submitted, any modifier, remittance advice and later corrected claim. Identify who chose the code, who transmitted the bill and who received a coverage warning. A disputed audit sample should be checked against the underlying claim universe before assuming it establishes the same defect in every payment period. Clinical disagreement, documentation defects and a deliberate scheme are different questions; the criminal statute requires the latter’s knowing and willful participation by the accused. This record may also help test civil damages and whether an exclusion notice applies to a person or entity.

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

The Anti-Kickback Statute, 42 U.S.C. section 1320a-7b(b), prohibits knowing and willful remuneration to induce or reward federally reimbursable referrals. Section 1320a-7b(h) does not require actual knowledge of the statute or specific intent to violate it. A regulatory safe harbor protects an arrangement only if every condition of that harbor is met; fair-market-value compensation alone is not a stand-alone exemption. Failure to meet a safe harbor is not automatic illegality, either. Compare the agreement, actual services, compensation, referral relationship and intent with the applicable statute and OIG rules.

What is Medicare exclusion — and how serious is it?

HHS-OIG exclusion generally prevents federal program payment for items or services furnished, ordered or prescribed by an excluded person or entity; it is not a literal ban on treating every patient. Some convictions require exclusion, other grounds are discretionary, and many mandatory periods begin at five years rather than lasting forever. Reinstatement requires a separate application and approval. Review the actual notice, authority, term and role before deciding what work remains possible.

What if a former employee filed a qui tam lawsuit — what does that mean?

A qui tam lawsuit is a False Claims Act suit filed by a private whistleblower — frequently a former employee, a disgruntled staff member, or a competitor — 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 of the government's total recovery. A qui tam lawsuit frequently triggers the criminal investigation, and the whistleblower's allegations often form the foundation of the government's charging theory. Understanding the specific allegations in the qui tam complaint, who filed it, what their motivations are, and how the civil and criminal tracks interact is essential from the very first consultation.

Will a conviction affect my medical or professional license?

A Medicare-fraud conviction can lead to profession-specific board reporting or discipline. A universal career-ending result does not follow from every charge. Identify the precise license, board rule, conviction and exclusion notice before negotiating a disposition.

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.

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 Medicare 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

Medicare 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 and interviewed by federal agents without coordinated defense guidance is a day statements are made — by billing staff, clinical employees, and marketing personnel inside the organization — 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 and the government's narrative about total harm calcifies into an indictment. Every day a qui tam whistleblower lawsuit moves forward without coordinated civil and criminal defense 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 agents without experienced counsel. If you have received a subpoena, if federal agents have appeared at your practice or your home, if you have been contacted by the FBI, HHS-OIG, or CMS, if a former employee has filed a qui tam lawsuit, or if you have been formally charged with Medicare fraud or related federal 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 Medicare 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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"Medicare 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

For a criminal charge under section 1347, the prosecution must prove knowing and willful execution or attempted execution of the alleged health care fraud scheme; personal submission of each false claim is not the statutory test. A civil False Claims Act claim has different requirements.