New York Healthcare Fraud Lawyer
As a New York Healthcare Fraud Lawyer, George F. Hildebrandt defends medical professionals, healthcare providers, and healthcare business owners facing state and federal healthcare fraud investigations throughout the state. Health care fraud cases threaten your freedom, professional license, and financial security when federal prosecutors pursue criminal charges based on billing disputes, coding errors, or allegations of fraudulent activity. Attorney Hildebrandt provides experienced criminal defense from the moment you receive a target letter through trial, if necessary, protecting your rights and achieving the best possible outcome.
To schedule a free consultation, use the online contact form, call the law firm directly at 315-303-6533, or call toll-free at (800) 672-3523.
Criminal Defense for State and Federal Health Care Fraud Charges in New York State
Healthcare fraud charges move fast and carry serious consequences, which is why George F. Hildebrandt provides aggressive defense for healthcare fraud. New York medical professionals and healthcare business owners need a healthcare fraud attorney who understands both the complex medical billing landscape and federal healthcare fraud laws.
Federal prosecutors treat billing disputes and honest mistakes as deliberate criminal activity that can result in lengthy prison sentences, massive fines, and loss of professional licenses. Attorney George Hildebrandt represents physicians, hospital administrators, pharmacists, and other healthcare providers throughout New York in federal and state fraud investigations.
New York Healthcare Fraud Charges
New York classifies healthcare fraud charges by degree, with penalties tied directly to the total dollar amount allegedly involved.
- Healthcare Fraud 1st Degree NY: Threshold amount over $1 million
- Healthcare Fraud 2nd Degree NY: Threshold amount over $50,000
- Healthcare Fraud 3rd Degree NY: Threshold amount over $10,000
- Healthcare Fraud 4th Degree NY: Threshold amount over $3,000
- Healthcare Fraud 5th Degree NY: Threshold amount over any amount
As the alleged amount increases, the charges and potential penalties become more severe, making early legal defense critical at every level.
Common Cases Central New York Healthcare Fraud Defense Lawyer George Hildebrandt Handles
George F. Hildebrandt defends healthcare providers, medical professionals, and healthcare business owners throughout Central New York facing state and federal healthcare fraud charges. These cases arise from government investigations that can threaten criminal penalties, professional licenses, and continued participation in healthcare programs.
Medicare Fraud and Medicaid Fraud New York
Medicare fraud and Medicaid fraud cases involve false information for services not rendered, Medicare Advantage fraud through manipulated diagnosis codes, Medicare Part D prescription fraud, medically unnecessary services, and Medicaid provider and recipient fraud.
Federal authorities, including the Department of Health and Human Services Office of Inspector General (HHS OIG), the FBI, and Recovery Audit Contractors, investigate billing patterns that suggest fraudulent activity. The federal government pursues criminal prosecution carrying up to 10 years per count and civil liability under the Federal False Claims Act, allowing for treble damages and penalties of $10,781 to $27,894 per false claim. A Medicaid fraud lawyer can challenge these allegations early and work to limit criminal exposure and civil penalties.
Medical Billing Fraud New York: Billing For Services Not Rendered, Phantom Billing, Double Billing, Upcoding, and Unbundling Medical Services
Medical billing fraud includes billing for services not rendered (phantom billing), upcoding to higher reimbursement codes, unbundling services that should be billed together, double-billing multiple insurers, and submitting claims for procedures that never occurred.
Federal prosecutors investigate doctors whose billing patterns differ significantly from those of their peers and allege that providers deliberately manipulated codes to maximize revenue. Healthcare providers face both federal charges carrying up to 10 years per count, and New York state charges with penalties ranging from one to 25 years, depending on the degree.
Prescription Drug Fraud New York
Prescription drug fraud cases involve prescription mill operations dispensing controlled substances without legitimate medical purpose, illegal prescribing outside usual professional practice, pharmacy billing fraud for prescriptions never dispensed, and drug diversion schemes.
The Drug Enforcement Administration investigates doctors, pharmacists, and clinics accused of writing medically unnecessary prescriptions, receiving kickbacks, or billing Medicare Part D for prescriptions never provided. These cases result in criminal charges and consequences that require a proven New York prescription drug fraud defense.
Kickback and Referral Schemes / Stark Law Self-Referral Violations
The Anti-Kickback Statute prohibits paying or receiving anything of value for patient referrals, while the Stark Law prohibits physicians from referring Medicare and Medicaid patients to entities with which they have financial relationships unless specific exceptions apply.
Federal agents investigate illegal patient referrals, payment for referrals through consulting agreements, and financial relationships that don’t meet safe harbor protections. Violations result in criminal liability (up to 10 years and $100,000 per violation), civil penalties, treble damages, and mandatory Medicare and Medicaid exclusion.
Durable Medical Equipment (DME) Fraud
DME fraud involves billing for equipment never provided, medically unnecessary equipment, power wheelchairs and scooters, and DME kickback schemes paying physicians for referrals. Federal investigations target suppliers whose billing patterns raise red flags and examine whether suppliers paid kickbacks to generate prescriptions for expensive equipment. Defending DME fraud requires presenting clinical evidence that patients’ conditions justified prescribed equipment and that physicians exercised legitimate medical judgment.
Home Health and Hospice Fraud New York
Home health fraud involves falsifying certifications, billing for unperformed visits, billing unskilled services as skilled care, and patient recruitment kickbacks, while hospice fraud includes falsifying terminal illness certifications, enrolling ineligible patients, billing for non-hospice-appropriate patients, and continuous care fraud.
Federal investigations examine visit records, GPS data, and patient interviews to identify agencies billing for services not provided or ineligible patients. Both carry federal criminal charges, False Claims Act liability, and program exclusion.
Telemedicine Fraud
Telemedicine fraud involves billing for services without establishing legitimate physician-patient relationships, services not actually rendered, telehealth kickback schemes, and COVID-19-related fraud exploiting pandemic regulatory relaxations.
Federal authorities investigate doctors who signed orders after brief or nonexistent patient interactions and telemedicine companies that paid illegal kickbacks. These cases often involve conspiracy and wire fraud charges.
Medical Identity Theft
Medical identity theft involves using stolen patient information to submit fraudulent claims, HIPAA violations when improperly accessing protected health information, and aggravated identity theft charges carrying mandatory consecutive two-year prison sentences.
Federal prosecutors pursue healthcare workers who accessed patient records improperly and providers who purchased patient lists to generate fraudulent billings. The mandatory consecutive sentences for aggravated identity theft significantly increase defendants’ exposure and require experienced identity theft defense in Central New York.
Diagnostic Testing and Laboratory Fraud
Laboratory fraud involves medically unnecessary testing, falsified test results, lab kickback arrangements, and genetic testing fraud exploiting Medicare coverage. Federal investigations target laboratories whose test volumes significantly exceed industry norms and examine whether labs paid illegal kickbacks to generate orders. Prosecutors pursue both laboratories and physicians who ordered unnecessary tests in exchange for kickbacks.
False Diagnosis and Medical Necessity Schemes
False diagnosis schemes involve documenting conditions patients don’t have to justify billing for unnecessary services, tests, or equipment. Federal authorities investigate doctors who exaggerate symptom severity, fabricate diagnoses, or manipulate records to meet coverage criteria for expensive procedures. Criminal prosecution often includes wire fraud and conspiracy charges when multiple staff members participate.
Legal Defense for Medical Professionals in New York Healthcare Fraud Cases
Individual physicians face charges for false claims, illegal kickbacks, or medically unnecessary services, while medical practices face liability for alleged systematic fraud. Hospital fraud allegations include upcoding and billing for unnecessary procedures, with executives facing liability for directing misconduct or ignoring compliance warnings. Nursing homes and home health agencies face charges for upcoding acuity levels, falsifying therapy records or visits, and participating in kickback schemes.
Pharmacies face fraud charges for billing prescriptions never dispensed, compounding fraud, and controlled substance violations. DME suppliers and laboratories face allegations involving equipment never provided or unnecessary testing, while billers and office managers face liability for knowingly submitting false claims, all requiring experienced New York professional license defense alongside criminal defense representation.
How Healthcare Fraud Investigations Work in New York
Whistleblower qui tam actions, data analytics, insurance referrals, and employee or competitor reports commonly trigger federal and state healthcare investigations. Recovery Audit Contractors and other CMS Program Integrity Contractors flag billing anomalies by comparing providers to peer and historical patterns, which can lead to criminal charges.
Federal Investigations
The HHS Office of Inspector General conducts civil and criminal healthcare fraud investigations, working closely with federal prosecutors to pursue both monetary penalties and criminal prosecution. The FBI Healthcare Fraud Unit investigates large-scale fraud schemes using undercover operations, wiretaps, and search warrants to build criminal cases against healthcare providers. The Department of Justice Healthcare Fraud Strike Force operates in multiple cities, coordinating federal agents from multiple agencies to target telemedicine fraud, DME fraud, and other schemes involving millions in alleged fraudulent billing.
U.S. Attorney’s Office investigations proceed through grand jury subpoenas, target letters notifying subjects they’re under investigation, and eventual criminal indictments if prosecutors determine sufficient evidence exists, requiring immediate New York precharge investigation defense. CMS Program Integrity Contractors, including Recovery Audit Contractors and Zone Program Integrity Contractors, conduct audits and refer cases to law enforcement when patterns suggest criminal intent rather than billing errors.
New York State Investigations
The New York Medicaid Fraud Control Unit investigates and prosecutes healthcare providers who defraud the Medicaid program or abuse or neglect patients in healthcare facilities, often working with federal authorities on cases involving both federal and state programs. The New York Attorney General’s Healthcare Bureau pursues both criminal and civil healthcare fraud cases, using state False Claims Act authority to investigate hospitals, nursing homes, and other providers accused of systemic billing fraud.
The Office of Medicaid Inspector General conducts program integrity audits and investigations, referring cases for criminal prosecution when evidence suggests intentional fraud, and can exclude providers from Medicaid participation even without a criminal conviction. New York State Health Department investigations examine licensing violations and professional misconduct that may occur alongside or independent of criminal fraud allegations, with actions potentially resulting in license suspension or revocation separate from criminal proceedings.
Related Federal Charges in New York Healthcare Fraud Cases
Federal prosecutors often add multiple charges to healthcare fraud cases to increase sentencing exposure. These cases frequently include False Claims Act violations, Anti-Kickback Statute charges, wire and mail fraud, money laundering, RICO, and conspiracy allegations, making early defense planning essential.
False Claims Act Violations
Civil False Claims Act liability imposes penalties of $14,308 to $28,619 per false claim plus treble damages (three times the government’s loss), creating enormous financial exposure even without criminal charges. Criminal False Claims charges apply when prosecutors prove defendants knowingly presented false claims to the government for payment, carrying potential five-year prison sentences and $250,000 fines per count.
Treble damages under the False Claims Act mean defendants pay three times the amount the government lost due to fraud plus per-claim penalties, reaching tens or hundreds of millions of dollars in large healthcare fraud cases, with successful qui tam whistleblowers receiving 15-30% of recoveries.
Anti-Kickback Statute Violations
Safe harbor exceptions protect certain financial arrangements that might otherwise violate the Anti-Kickback Statute if they meet specific criteria for fair market value compensation, employee relationships, or other legitimate business purposes, though arrangements must satisfy every element to receive protection.
The one-purpose test establishes that a person violates the statute if the payment or arrangement had the purpose of inducing or rewarding referrals, even if other legitimate purposes also existed. Federal prosecutors don’t need to prove kickbacks were the sole or primary purpose of financial relationships between healthcare providers and referral sources.
Wire Fraud and Mail Fraud
Healthcare fraud wire fraud charges apply when defendants use electronic communications to transmit false claims or further fraud schemes, carrying 20-year maximum sentences that exceed standard healthcare fraud penalties.
Mail fraud charges arise when defendants use postal services to submit claims or communicate about fraud schemes, providing prosecutors additional charges to stack on top of healthcare fraud counts. Federal authorities routinely charge both wire and mail fraud alongside healthcare fraud to increase potential sentences and pressure defendants to accept plea agreements.
RICO and Money Laundering
Healthcare fraud serves as a predicate act for RICO charges when prosecutors allege an ongoing criminal enterprise engaged in a pattern of fraud, with RICO convictions carrying enhanced penalties and asset forfeiture provisions. Enterprise corruption charges in New York mirror federal RICO, targeting organized healthcare fraud operations involving multiple participants and facilities when fraud constitutes part of a criminal enterprise’s ongoing activities.
Laundering healthcare fraud proceeds triggers separate criminal charges when defendants deposit fraud proceeds in banks, move money between accounts, or spend funds in ways prosecutors claim concealed the illicit source, with each transaction potentially constituting a separate money laundering count requiring experienced money laundering defense in Central New York. Structuring transactions to avoid currency reporting requirements can result in federal charges when healthcare providers make multiple deposits under $10,000 to avoid bank reporting, and can carry separate penalties beyond the underlying fraud charges.
Conspiracy
Conspiracy to commit healthcare fraud charges apply when two or more people agree to defraud healthcare programs, even if the underlying fraud never actually succeeds, with prosecutors using conspiracy charges to hold defendants liable for co-conspirators’ actions.
Conspiracy to violate the Anti-Kickback Statute criminalizes agreements to pay or receive illegal kickbacks for referrals, allowing prosecutors to charge defendants before actual kickback payments occur. Federal conspiracy law makes each member of the conspiracy liable for all acts committed by co-conspirators in furtherance of the agreement, requiring a skilled New York conspiracy defense to challenge the government’s allegations.
Penalty for Insurance Fraud in New York
Healthcare fraud convictions carry severe penalties at both federal and state levels, including prison time, substantial fines, mandatory restitution, asset forfeiture, and professional consequences that effectively end medical careers. Federal sentences range from 10 years per count to life imprisonment, depending on whether fraud resulted in serious bodily injury or death, while New York State penalties range from one year to 25 years based on the fraud amount.
Civil penalties can reach tens or hundreds of millions of dollars through False Claims Act treble damages, and professional licensing boards impose discipline, including license revocation and program exclusion, that prevents providers from treating Medicare and Medicaid patients.
Federal Sentencing for Healthcare Fraud
Federal healthcare fraud convictions under 18 U.S.C. § 1347 carry up to 10 years per count, increasing to 20 years if serious bodily injury results and up to life if death results, with judges imposing consecutive sentences for multiple counts. Fines reach up to $250,000 per count, though courts can impose higher amounts based on the defendant’s gain or the victims’ loss.
Restitution requires defendants to repay the full amount of Medicare, Medicaid, or other victims lost due to fraud, which can reach millions of dollars, and remains enforceable for life. Asset forfeiture allows the government to seize property purchased with fraud proceeds or used to facilitate schemes, including homes, vehicles, bank accounts, and business assets.
New York State Penalties
Degree | Maximum Sentence (In Years) |
First Degree | 25 |
Second Degree | 15 |
Third Degree | 7 |
Fourth Degree | 4 |
Fifth Degree | 1 |
* Plus Restitution and Fines
Civil Penalties
Violation Type | Civil Penalty / Consequences |
False Claims Act (FCA) | Per false claim ~ $10,781 – $27,894 (adjusted for inflation) + treble damages (three times government loss) + restitution; qui tam whistleblower share 15 –30 % of recovery. |
Anti‑Kickback Statute (AKS) | Up to $100,000 per violation + up to 3× remuneration amount; possible program exclusion. |
Stark Law (Physician Self‑Referral) | Carry civil monetary penalties up to $15,000 for each illegalservice reffered; denial of payment for services, refund of amounts collected for prohibited referrals, treble damages on claims later found false, and potential exclusion. |
Civil Monetary Penalties Law (CMPL) | Civil fines range from $20,000 to $100,000, depending on the conduct; program exclusion is also possible. |
Professional Consequences
Medical license revocation by state boards can permanently end physicians’ careers even without a criminal conviction, proceeding separately from criminal matters with lower proof standards. DEA registration loss prevents prescribing controlled substances and occurs automatically when state medical licenses are revoked.
The Medicare and Medicaid exclusion by HHS OIG prohibits medical providers from participating in federal healthcare programs for a minimum of five years, with many facing permanent exclusion and the collateral consequences of a conviction extending far beyond the courtroom. State licensing board actions include suspension, probation, practice restrictions, and mandatory compliance programs that damage professional reputations and limit practice opportunities.
Defenses to Healthcare Fraud Charges in New York
Lack of intent to defraud defeats charges requiring knowing submission of false claims, good faith reliance on counsel provides a defense when attorneys advised challenged practices, and good faith billing disputes demonstrate honest mistakes rather than fraud. Medically necessary documentation establishes legitimate medical judgment, safe harbor compliance demonstrates arrangements meet anti-kickback exceptions, and Stark Law exception applicability proves referrals fit within Congressional exceptions.
Insufficient evidence of knowledge undermines the government’s proof, challenging search and seizures can exclude illegally obtained evidence, challenging whistleblower credibility attacks exaggerated allegations, and statistical sampling challenges question extrapolation methods.
Why You Need a New York Healthcare Fraud Defense Lawyer
Health care fraud investigations move quickly from civil audits to criminal cases, and statements to investigators become evidence against you. Federal agents conduct interviews designed to obtain admissions and build conspiracy cases, making it critical to understand your right to remain silent before speaking with authorities.
A Syracuse grand jury lawyer can help navigate the complexities of federal grand jury proceedings and target letters that provide a brief window to negotiate before indictment. Attorney Hildebrandt’s proactive approach involves responding to subpoenas, representing clients in interviews, and negotiating to avoid charges when possible.
Contact Central New York Health Care Fraud Attorney George Hildebrandt to Schedule a Free Consultation
Contact George F. Hildebrandt, Attorney at Law, today for a free and confidential consultation to discuss your criminal case and begin building your defense. Attorney Hildebrandt has successfully defended healthcare clients against federal and state fraud charges throughout New York.
Call 315-303-6533, toll-free at (800) 672-3523, or use the online form to speak with a Central New York healthcare fraud lawyer today.