Medicare fraud allegations are serious, complex, and often overwhelming. Whether you are a physician, healthcare administrator, billing specialist, or business owner, being accused of Medicare fraud can put your career, finances, and freedom at risk. These cases are frequently prosecuted aggressively at both the state and federal levels, and even an investigation alone can have lasting consequences.
If you are facing Medicare fraud charges—or believe you may be under investigation—it is critical to understand what these allegations involve and why experienced legal representation matters.
What Is Medicare Fraud?
Medicare fraud generally involves knowingly submitting false or misleading information to the Medicare program in order to receive payment. Because Medicare is a federal program, many of these cases fall under federal criminal law, though Missouri state charges can also apply depending on the circumstances.
Common allegations of Medicare fraud include:
- Billing for services that were never provided
- Upcoding or unbundling services to increase reimbursement
- Submitting claims for medically unnecessary procedures
- Accepting or paying illegal kickbacks for patient referrals
- Using false diagnoses to justify treatments
- Identity theft involving Medicare beneficiaries
Even administrative errors or misunderstandings can escalate into criminal allegations if prosecutors believe there was intent to deceive.
Who Is Investigated for Medicare Fraud?
Medicare fraud cases do not only target doctors. Investigations frequently involve:
- Physicians and surgeons
- Nurses and nurse practitioners
- Medical billing companies
- Durable medical equipment (DME) suppliers
- Home healthcare agencies
- Physical therapy clinics
- Practice administrators and office managers
In many cases, individuals are shocked to learn they are under investigation until federal agents appear with subpoenas or search warrants.
How Medicare Fraud Investigations Begin
Medicare fraud investigations often start quietly. They may be triggered by:
- Data analytics flagging abnormal billing patterns
- Whistleblower complaints (often former employees)
- Routine audits that uncover discrepancies
- Referrals from insurance companies or state agencies
Federal agencies such as the Department of Justice (DOJ), FBI, HHS Office of Inspector General (OIG), and Centers for Medicare & Medicaid Services (CMS) frequently work together on these cases.
By the time charges are filed, prosecutors may already have spent months—or years—building their case.
Potential Penalties for Medicare Fraud
The penalties for Medicare fraud can be severe, especially when charged federally. Depending on the scope of the allegations, consequences may include:
- Significant prison time
- Substantial fines and restitution
- Asset forfeiture
- Loss of professional licenses
- Exclusion from Medicare and Medicaid programs
- Permanent damage to professional reputation
Each count of healthcare fraud can carry its own penalties, meaning exposure can increase quickly in multi-count indictments.
Medicare Fraud Is Not Always Clear-Cut
From a defense perspective, Medicare fraud cases are rarely as simple as prosecutors claim. Healthcare billing is complex, regulations change frequently, and many providers rely on third-party billing services.
Common defense issues include:
- Lack of intent to defraud
- Errors caused by billing staff or software
- Misinterpretation of Medicare regulations
- Insufficient or misleading evidence
- Constitutional issues related to searches and seizures
A strong criminal defense strategy focuses on challenging the government’s assumptions, methods, and proof.
Why Early Legal Representation Matters
One of the biggest mistakes individuals make in Medicare fraud cases is waiting too long to involve a criminal defense attorney. Statements made during audits or “informal” interviews can later be used against you.
An experienced defense attorney can:
- Communicate with investigators on your behalf
- Protect your constitutional rights
- Assess whether charges are likely or avoidable
- Develop a defense strategy before formal charges are filed
- Work toward reduced charges or case dismissal when possible
Early intervention can make a significant difference in the outcome of a case.
Medicare Fraud Defense in Missouri and Federal Court
Medicare fraud cases often involve federal court, which has different rules, procedures, and sentencing guidelines than state court. Having an attorney who understands both systems is essential.
At Rogers, Sevastianos & Bante, our criminal defense team has experience handling serious, high-stakes cases and understands how aggressively these matters are prosecuted. We approach each case with careful preparation, attention to detail, and a clear understanding of what is at stake for our clients.
You can learn more about our criminal defense approach here:
https://rsblawfirm.com/criminal-defense/
If You Are Under Investigation, Do Not Wait
If you have received a subpoena, audit notice, or inquiry related to Medicare billing—or if you believe an investigation may be underway—now is the time to act. Medicare fraud allegations can move quickly, and delays can limit your options.
Speaking with a defense attorney does not mean you are guilty. It means you are taking your situation seriously and protecting your future.
Contact Rogers, Sevastianos & Bante Today
Medicare fraud cases require a strategic, informed defense. The sooner you involve legal counsel, the better positioned you are to protect your rights, your career, and your freedom.
If you are facing Medicare fraud allegations in Missouri or federal court, contact Rogers, Sevastianos & Bante to discuss your situation.
Disclaimer: The information in this blog is for general informational purposes only and does not constitute legal advice. Every legal situation is unique, and you should consult an attorney for personalized guidance on your specific circumstances.