What You Should Expect When Being Investigated for Health Care Fraud

Healthcare fraud charges can stem from allegations of up-coding by a government official to patients saying you billed them for unnecessary procedures. The issues might be reported by anyone from an employee to a third party. Regardless of what causes it, you need to act quickly and seek expert legal counsel. But what happens once the allegations are made? Here’s what you should expect when being investigated for health care fraud.

A Whistleblower Reports Something

As we’ve already said, the whistleblower could be anyone from a client to an employee. They may be mistaken in their belief that duplicate claims were deliberate fraud or gaps in documentation mean you’re billing for services that were not actually rendered. However, government agencies from the FBI to the Office of the Inspector General to the United Postal Service could all get involved in the investigation. They can issue financial penalties for honest mistakes in addition to prosecuting intentional, fraudulent claims.

Get Help

No matter what federal agency investigates the fraud, any case against you will end up in federal court. This is why you must seek out a federal criminal defense attorney licensed to practice in federal court.

Furthermore, it needs to be someone experienced with medical fraud cases. We suggest you check out this Medicare fraud investigation article from Healthcare Fraud Group. They outline the common issues identified rightly or wrongly as Medicare fraud and provide detailed examples of each. They also discuss actions that could result in you being found guilty and the penalties that are incurred when that happens.

Provide the Necessary Documentation

When you receive a letter informing you of the impending investigation, you need to immediately act to preserve evidence. For healthcare providers, this means preserving hardcopy records and ensuring electronic health records are saved but unchanged. You need to maintain records regarding billing, services rendered, and prescriptions written. Any or all of this could be demanded by the feds. You can face consequences for mistakes as well as intentional acts, but you have no defense if you don’t have the documents to back you up.

Collaborate with Your Attorney

There is a fair chance that investigators will interrogate you or your employees. You don’t need to face these investigators alone. You have the right to an attorney present. Your attorney can also manage conversations between the FBI or Medicare Fraud Control Unit, minimizing your interactions with them.

You could have your attorney do an internal investigation. This information is often privileged, but it allows you to find gaps in your processes that may have led to the problems reported to the government. You might still have to pay back the excessive charges with interest. However, if you can prove it was due to mistakes that you’re rectifying, you avoid the damages that literally multiply what you owe the state.

Case Settlements

The worst-case scenarios include loss of your medical license and jail time. The best-case scenarios involve a detailed audit of your records that take up a lot of your time and attention, while the government issues a modest fine. The government normally reports the outcome of their legal action. You can issue your statement or take other steps to repair your reputation.


Healthcare fraud consumes up to 10% of all healthcare expenditures. This is why the government pursues it so aggressively, even when there was no malice on the part of the accused. This is also why you should be prepared to avoid the worst in case you’re accused.