PRACTICE AREA

Healthcare Fraud Defense Lawyer, California

Healthcare fraud allegations bring financial and reputational risks. A single accusation can lead to hefty fines, legal costs, and irreversible damage to your brand. In today’s digital age, news spreads rapidly, and even a hint of fraud can lead to a loss of client trust, plummeting stocks, and long-term financial harm.

Business Litigation & Dispute Resolution

Business Organization & Corporate Securities

Employment Law

Entertainment, Publicity & Privacy

Healthcare

Hospitality & Cannabis

Intellectual Property

Real Estate

Technology Law & Social Media

As the American healthcare system continues to rapidly change, Novian & Novian continues to stay one step ahead. Our highly skilled healthcare fraud defense attorneys recognize the diverse legal challenges healthcare providers and businesses face, as they seek to maximize profits in a complex regulatory environment.

Navigating the complex waters of healthcare fraud requires a specialized legal approach and healthcare fraud defense attorneys play a pivotal role in protecting your business.

Healthcare Fraud in California

Healthcare fraud refers to intentional deception or misrepresentation used to obtain money or benefits from a healthcare program, health insurance program, or private insurance companies. In the healthcare industry, fraud allegations often involve billing fraud, submitting false claims for medical services that were never provided, falsifying medical records or patient records, or engaging in illegal kickback arrangements for referrals. In some healthcare fraud cases, prosecutors also investigate conduct such as prescription drug fraud, upcoding procedures to receive higher reimbursements, or submitting claims to Medicare or Medicaid that violate the Anti Kickback Statute or Stark Law.

The financial scale of the problem is significant. According to the Federal Bureau of Investigation, healthcare fraud costs the United States tens of billions of dollars each year, making it one of the largest categories of financial crime investigated by federal agents. The FBI also reports that the federal government has dramatically expanded enforcement efforts in recent years, with specialized task forces dedicated to uncovering fraud schemes involving healthcare providers, medical professionals, and healthcare businesses suspected of attempting to commit fraud against government-funded healthcare programs.

For healthcare providers in California, the legal framework governing health care fraud is complex and involves both federal and state laws. One of the most important statutes is the False Claims Act, which allows the federal government to pursue civil and criminal penalties against individuals or companies that knowingly submit false claims for payment under federal healthcare programs. Under the statute, penalties can include substantial fines and damages that may be double the amount or more of the alleged fraudulent billing, in addition to potential criminal penalties if prosecutors determine the conduct involved intentional fraud.

California also enforces its own healthcare laws targeting fraud involving state-funded programs such as Medi-Cal, the state’s Medicaid program. Allegations involving Medi-Cal fraud charges often arise when investigators believe a medical provider or healthcare professional improperly billed the program for services, falsified medical records, or participated in a broader fraud scheme. These cases can lead to both civil penalties and criminal charges, particularly when investigators believe the provider intentionally committed healthcare fraud.

In our experience as healthcare fraud defense attorneys, many investigations begin quietly before any formal healthcare fraud indictment is filed. A federal healthcare fraud investigation may start with a government subpoena, grand jury subpoena, or civil investigative demand requesting patient records, billing data, and internal documents from a doctor’s office or healthcare practice. At this stage, federal prosecutors and investigators from the Federal Bureau of Investigation or other agencies may already be building a case to determine whether criminal prosecution is appropriate.

The magnitude of the problem is particularly concerning in California. According to the U.S. Department of Health and Human Services Office of Inspector General, federal enforcement efforts targeting healthcare fraud have recovered billions of dollars in fraud-related judgments and settlements annually. These enforcement actions frequently involve complex allegations such as improper referral arrangements, insurance fraud, and fraudulent billing practices by medical providers or healthcare professionals.

At the same time, not every investigation means a provider intentionally committed healthcare fraud. In many healthcare fraud cases, issues arise from coding errors, documentation mistakes, or misunderstandings about evolving billing requirements. However, once a healthcare fraud investigation begins, the legal stakes are high, especially when federal prosecutors pursue healthcare fraud charges, which can carry severe criminal penalties, including imprisonment, large fines, and the loss of a professional license.

We have seen situations where a medical professional or healthcare provider first becomes aware of a potential investigation when federal agents arrive with a search warrant or when the provider receives a grand jury subpoena demanding records related to a healthcare fraud case. At that point, having an experienced healthcare fraud defense lawyer or federal criminal defense lawyer involved early can be critical in protecting both the provider’s legal rights and their healthcare practice.

Legal Risks and Consequences

California’s healthcare laws are among the most stringent in the country. These laws target a wide range of alleged misconduct, including medicare fraud, medicaid fraud, Medi-Cal fraud charges, improper billing for medical services, violations of the Anti Kickback Statute, and illegal referral arrangements prohibited by the Stark Law. In some cases, prosecutors may also pursue related federal crime allegations such as wire fraud, money laundering, or insurance fraud if investigators believe a healthcare provider intentionally attempted to commit fraud against a health insurance program.

The potential penalties for health care fraud charges are severe and can have life-altering consequences. Depending on the circumstances of the healthcare fraud case, a conviction could result in:

Significant criminal penalties, including large fines under federal statutes
Imprisonment under the federal sentencing guidelines
Restitution payments that may require repayment of alleged fraudulent billing, sometimes double the amount claimed under certain statutes
Civil penalties and lawsuits brought by the federal government or whistleblowers under the False Claims Act
Exclusion from federal healthcare programs, which can effectively prevent a medical provider or healthcare professional from participating in Medicare, Medicaid, or other health care benefits programs
Loss or suspension of a professional license, which may end a career in the healthcare industry

As Andrew Goodman, partner at Novian & Novian, explains: “Healthcare fraud investigations often begin long before a provider realizes they are under scrutiny. Early legal intervention can make a significant difference in how the case develops and may help prevent charges from being filed or reduce the scope of the investigation.”

For example, we once represented a medical provider in Southern California who operated a busy healthcare practice that billed several private insurance companies and federal healthcare programs. The provider received a government subpoena requesting several years of medical records and billing documents as part of a federal healthcare fraud investigation. Investigators believed the provider had committed healthcare fraud through improper billing codes tied to certain treatments.

After carefully reviewing the patient records and billing procedures, our healthcare fraud defense lawyers discovered the issue stemmed from a complex coding error rather than an intentional fraud scheme. By responding strategically to the federal investigation, presenting documentation, and negotiating with federal prosecutors, we were able to resolve the matter without criminal charges being filed. Thus, protecting the provider’s professional license and healthcare business.

This example highlights that not every healthcare fraud investigation involves someone intentionally trying to commit fraud. In some instances, allegations arise from administrative errors, billing misunderstandings, or compliance issues within a healthcare practice. However, once a healthcare fraud investigation begins, the legal stakes are extremely high.

That is why early involvement from an experienced healthcare fraud defense lawyer or federal criminal defense lawyer is so crucial. A skilled fraud defense lawyer can review the allegations, evaluate potential exposure under federal statutes, and develop a strategic fraud defense designed to protect both your healthcare business and your professional future.

Role and Expertise of a Healthcare Fraud Defense Lawyer

Below are some of the key roles a healthcare fraud attorney plays during a healthcare fraud case:

Investigating the Allegations: A healthcare fraud defense lawyer California carefully reviews medical records, patient records, billing data, and insurance claims to determine whether the government can actually prove that a healthcare provider intentionally committed healthcare fraud.
Managing Government Investigations: Experienced healthcare fraud attorneys guide clients through healthcare fraud investigations, including responding to a government subpoena, civil investigative demand, grand jury subpoena, or search warrant issued during a federal healthcare fraud investigation.
Communicating With Federal Prosecutors: A seasoned health care fraud lawyer negotiates directly with federal prosecutors and investigators to clarify allegations, present evidence, and potentially limit exposure to criminal charges or civil penalties.
Defending Clients in Federal Proceedings: If the case progresses to grand jury proceedings or a healthcare fraud indictment, a fraud defense lawyer represents the client throughout the legal process, challenging evidence and protecting them from severe criminal penalties under federal statutes.
Protecting Professional Licenses and Healthcare Practices: Allegations involving medicare fraud, medicaid fraud, or Medi-Cal fraud charges can threaten a provider’s professional license and healthcare business, which is why strong healthcare fraud defense is essential for safeguarding both reputation and career.
Navigating Complex Healthcare Laws: Skilled healthcare fraud defense attorneys understand the complex legal framework governing the healthcare industry, including the False Claims Act, Anti Kickback Statute, Stark Law, and other healthcare laws tied to federal healthcare programs.

Healthcare Fraud Investigations

During a federal healthcare fraud investigation, various steps are taken, such as reviewing the complaint, conducting background analyses, data analysis of claims, interviewing beneficiaries, and reviewing a sample of medical claims.

The definition of the “target” of a federal investigation is that the government believes sufficient evidence exists to convene a grand jury and seek an indictment.

Healthcare fraud investigations often begin due to audits identifying unusual billing patterns (such as double billing, upcoding, billing for services not rendered), whistleblower lawsuits, or patient complaints. These red flags are then turned over to fraud investigators.

Defending a federal healthcare fraud case requires your defense counsel to convince the government that it will not be able to prove the elements to a jury, which can result in a dismissal.

Common Healthcare Fraud Charges and How They Are Defended

Below are some of the most common allegations and how a healthcare fraud defense lawyer may approach defending them:

Charge Type	Description	Typical Defense Approach	Potential Penalties
False Claims	Allegations that a healthcare provider submitted false claims for payment to a healthcare program, Medicare, Medicaid, or health insurance program for services that were unnecessary or not provided. These cases often involve the False Claims Act.	A healthcare fraud attorney may challenge whether the provider knowingly submitted false information, demonstrate that billing errors or administrative mistakes occurred without intent to commit fraud. Defense may also involve reviewing medical records and billing practices to show compliance with healthcare laws	Civil penalties, restitution, and damages that may be double the amount of the alleged fraud. In serious cases, criminal charges and potential imprisonment under federal sentencing guidelines.
Upcoding	Occurs when a medical provider bills for a more expensive medical service than the one actually provided in order to receive higher reimbursement from Medicare, Medicaid, or private insurance companies.	A healthcare fraud defense lawyer California may demonstrate that coding discrepancies resulted from documentation errors or confusion within billing systems rather than intentional misconduct. Expert review of patient records and coding standards is often critical.	Financial penalties, repayment demands, and potential criminal prosecution if prosecutors believe the provider intentionally inflated billing.
Kickback Schemes	These allegations involve illegal payments or referral incentives in violation of the Anti-Kickback Statute or Stark Law, often tied to patient referrals or services provided within a healthcare practice.	Healthcare fraud defense lawyers may challenge whether the arrangement actually violated federal healthcare laws, or demonstrate that payments were legitimate business transactions rather than illegal referral incentives.	Significant fines, possible imprisonment, exclusion from federal healthcare benefits programs, and loss of a professional license.
Billing Fraud	Broad allegations that a healthcare provider engaged in billing fraud by submitting inaccurate or misleading claims for reimbursement through Medicare, Medicaid, Medi-Cal, or private insurance companies.	A health care fraud attorney often conducts a detailed audit of billing systems and medical records to determine whether the alleged fraud scheme resulted from clerical mistakes, billing software errors, or misinterpretation of regulations.	Large financial penalties, potential civil liabilities, restitution payments, and in severe cases criminal penalties and time in county jail or federal prison.

Novain & Novian – Your Healthcare Fraud Defense Lawyers

Our legal approach to healthcare law emphasizes aggressive, proactive defense strategies. Each defense is tailored to your company’s unique situation, ensuring that financial loss and reputational damage are minimized. We understand the nuances of high-stakes scenarios and craft our defense accordingly.

Proactive Defense Strategies, Prevention and Compliance

A proactive legal approach safeguards the company not just legally, but also financially and reputationally. Companies can avoid the costs associated with lengthy legal battles and the public relations fallout from legal disputes.

An aggressive defense strategy involves thorough preparation, a detailed understanding of the law, and proactive measures to counter potential allegations. Anticipating and addressing issues before they escalate, minimizing the chance of litigation.

Customizing defense tactics to suit the specific context of your business is essential. This could involve deep dives into the company’s operations to identify potential vulnerabilities and tailor a defense strategy that aligns with the company’s specific risks and business model.

How Novian & Novian Can Help You

Our firm approaches every healthcare fraud case with a proactive fraud defense strategy. We work quickly to analyze the allegations, review medical records, and identify weaknesses in the government’s case. By carefully evaluating the facts and applicable federal statutes, our healthcare fraud defense attorneys develop strategies designed to protect your healthcare practice, your professional license, and your future.

No two healthcare fraud cases are the same. That is why our health care fraud attorneys take the time to understand the unique circumstances surrounding each client’s healthcare business and alleged fraud scheme. In many cases, we conduct a detailed review of the company’s billing procedures, patient records, and internal operations. This allows us to identify potential vulnerabilities, clarify misunderstandings related to medical services, and build a defense strategy tailored to the client’s specific legal risks. This personalized approach is particularly important in complex federal healthcare fraud investigations involving government subpoenas, grand jury proceedings, or civil investigative demands.

Healthcare fraud investigations can be overwhelming. At Novian & Novian, we prioritize clear communication and close collaboration with our clients throughout the legal process. Our attorneys provide honest guidance, explain the potential legal risks, and outline practical next steps so clients understand exactly where their case stands.

California’s Healthcare Fraud Laws

The most common types of healthcare fraud investigation include billing for unnecessary services, kickback schemes, billing for services not rendered, upcoding, misuse of staff for medical procedures, unbundling, double billing, and misrepresenting non-covered treatments.

Laws under Penal Code 550 PC: relating to healthcare and insurance fraud are designed to combat fraudulent activities in the healthcare system, which can range from individual claimants to third-party businesses.
False Declaration as to Eligibility Code 14014 PC: A person receiving or encouraging another to receive health care, for which he or she was not eligible, based on false declarations may lead to anything from a misdemeanor to six months in county jail and/or $1,000 fine; or a felony from 16 months, 2 or 3 years in county jail.
Fraudulent Claims as to Eligibility Code 14107 PC: If an individual presents a false claim for payment for goods or services, with intent to defraud, or knowingly submit false information, to obtain greater compensation than legally entitled or to obtain authorization to provide goods or services or knowingly engage in a scheme to defraud the Medical program. They may face penalties such as a misdemeanor to six months in county jail and/or a $1,000 fine up to a felony charge of 2, 3, or 5 years in state prison and/or a fine not exceeding three times the amount of fraud or improper reimbursement or value of the scheme. If committed under circumstances likely to cause or that do cause two or more persons great or serious bodily injury, an additional, consecutive term of four years shall be imposed for each person so injured.
Kickbacks, Bribes or Rebates – Solicitation/Offer as to Eligibility Code 14107.2(a),(b): It is unlawful for any person to solicit or receive, or offer or pay any form of remuneration, commit healthcare fraud for kickbacks, bribes, or rebates, in any form (cash or valuable consideration). The referral or promise of referral of an individual to any entity for healthcare services or products, the purchasing, leasing, ordering, or recommending of any goods, services, or merchandise in healthcare for which payment may be made under specific healthcare chapters. The previously mentioned may be punishable by imprisonment in a county jail for no more than one year or imprisonment as per Penal Code Section 1170, or a fine not exceeding $10,000, or both.
California Penal Code Sections 487, 548, 549, 550, and 551: cover different aspects of health insurance fraud, such as the illegal disposal of property for fraudulent claims, illegal referrals for insurance claims, signing insurance documents containing false information, and commissions for insurance-based referrals. To convict someone of healthcare fraud under California Penal Code Section 550, the prosecution must prove that the defendant knew the claim was fraudulent or duplicated and truly intended to commit fraud.

Highlights of Welfare and Institutions Fraud Laws

False Declaration as to Eligibility Code 14014 PC: A person receiving or encouraging another to receive health care, for which he or she was not eligible, based on false declarations may lead to anything from a misdemeanor to six months in county jail and/or $1,000 fine; or a felony from 16 months, 2 or 3 years in county jail.

Fraudulent Claims as to Eligibility Code 14107 PC: If an individual presents a false claim for payment for goods or services, with intent to defraud, or knowingly submit false information, to obtain greater compensation than legally entitled or to obtain authorization to provide goods or services or knowingly engage in a scheme to defraud the Medical program;

They may face penalties such as a misdemeanor to six months in county jail and/or a $1,000 fine up to a felony charge of 2, 3, or 5 years in state prison and/or a fine not exceeding three times the amount of fraud or improper reimbursement or value of the scheme.

If committed under circumstances likely to cause or that do cause two or more persons great or serious bodily injury, an additional, consecutive term of four years shall be imposed for each person so injured.

Kickbacks, Bribes or Rebates – Solicitation/Offer as to Eligibility Code 14107.2(a),(b):

It is unlawful for any person to solicit or receive, or offer or pay any form of remuneration, commit healthcare fraud for kickbacks, bribes, or rebates, in any form (cash or valuable consideration) for:

The referral or promise of referral of an individual to any entity for healthcare services or products, the purchasing, leasing, ordering, or recommending of any goods, services, or merchandise in healthcare for which payment may be made under specific healthcare chapters. The previously mentioned may be punishable by imprisonment in a county jail for no more than one year or imprisonment as per Penal Code Section 1170, or a fine not exceeding $10,000, or both.

California Penal Code Sections 487, 548, 549, 550, and 551 cover different aspects of health insurance fraud, such as the illegal disposal of property for fraudulent claims, illegal referrals for insurance claims, signing insurance documents containing false information, and commissions for insurance-based referrals.

To convict someone of healthcare fraud under California Penal Code Section 550, the prosecution must prove that the defendant knew the claim was fraudulent or duplicated and truly intended to commit fraud.

Contact Novain & Novian as your fraud defense Lawyer.

Impact of Fraud, Waste, and Abuse (FWA)

FWA in healthcare can significantly increase costs in the healthcare system. Common examples of FWA include billing for services not received or rendered, inflated billing, accepting kickbacks for patient referrals, and billing for non-existent prescriptions or prescription drug fraud. These practices can lead to substantial financial losses in the healthcare industry.

Recent Examples of Healthcare Fraud Cases

Southern California Enforcement Action: In 2019, a healthcare fraud enforcement action resulted in charges against 25 defendants in Southern California. The defendants, including 14 doctors and medical professionals, were allegedly involved in healthcare fraud schemes that fraudulently sought over $150 million from Medicare and Medicaid programs, as well as private insurers and union health benefit plans.

Pacific Hospital Scheme: In a 2022 large-scale fraud case, George William Hammer, the former chief financial officer of Pacific Hospital’s physician management arm, agreed to plead guilty to tax charges related to the fraudulent classification of illegal kickbacks. This was part of a broader spinal surgery kickback scheme that involved several individuals, including chiropractors and orthopedic surgeons, who received illegal kickbacks to refer patients for spinal surgeries at Pacific Hospital. The scheme resulted in claims totaling more than $950 million over a 15-year period.

If convicted, healthcare fraud can lead to severe penalties. A skilled attorney works to mitigate these penalties, which could include fines, restitution, or even imprisonment.

Your Business Deserves Elite Defense

The right legal team can make all the difference in your healthcare fraud defense. Proactively safeguarding your business with Novian & Novian, where our expertise in the healthcare industry is your peace of mind.

Healthcare Fraud FAQ

Below are answers to common questions we hear from clients dealing with health care fraud charges, federal investigations, or concerns about potential criminal prosecution:

How Can a Healthcare Fraud Defense Lawyer Help Me?

A skilled healthcare fraud defense lawyer or federal criminal defense lawyer can review the allegations, analyze medical records, and develop a strategic fraud defense to challenge the government’s case. In many healthcare fraud cases, early intervention by experienced healthcare fraud attorneys can help protect your professional license, respond to a government subpoena, and potentially prevent formal criminal charges.

What Should I Do if I Am Under Investigation for Healthcare Fraud?

If you believe you are the target of a federal healthcare fraud investigation, it is important to contact a healthcare fraud attorney immediately before speaking with federal agents or responding to a government subpoena. An experienced health care fraud lawyer can guide you through the process, protect your rights, and help you respond strategically to requests for medical records or other evidence.

What Penalties Could I Face If Convicted of Healthcare Fraud?

A conviction for healthcare fraud can lead to serious criminal penalties, including substantial fines, restitution, and imprisonment under federal sentencing guidelines. In addition, healthcare providers may face exclusion from federal healthcare programs, loss of their professional license, and significant civil penalties.

How Long Does a Healthcare Fraud Case Typically Take?

The timeline for a healthcare fraud case can vary depending on the complexity of the alleged fraud scheme, the amount of evidence involved, and whether the case proceeds to grand jury proceedings or trial. Many healthcare fraud investigations conducted by the federal government can take months or even years before reaching a final resolution.

What is a Healthcare Fraud Indictment?

A healthcare fraud indictment is a formal accusation made by a grand jury against an individual or entity, alleging involvement in healthcare fraud. This legal document formally charges the accused with specific criminal activities related to healthcare fraud, such as billing for services not rendered, upcoding, or receiving kickbacks.

What if Someone Intentionally Filed False Claims to be Reimbursed By an Insurance Provider?

Having a healthcare fraud defense lawyer with experience in FCA ensures your rights are protected. The False Claims Act (FCA) is one of the most well-known healthcare fraud statutes. It prohibits the submission of “false or fraudulent” claims for payment to any federal benefits program. In most cases, the FCA is invoked in billing discrepancies with Medicaid, Medicare, or Tricare. If you have had a false claim charged against you, contact us today.

What is An Anti-kickback Statute?

The Anti-Kickback Statute (AKS) is a federal criminal law that prohibits the exchange of any form of remuneration in order to induce or reward patient referrals or the generation of business involving any item or service payable by federal healthcare programs, like Medicare or Medicaid.

Legal Disclaimer: The information provided on this page is for general informational purposes only and does not constitute legal advice. Healthcare fraud laws and federal criminal statutes are complex, and the outcome of any case depends on the specific facts and circumstances involved. If you are facing healthcare fraud charges or are under investigation, you should consult a qualified healthcare fraud defense lawyer or federal criminal defense lawyer for advice regarding your particular situation.