Urgent: 5 Critical Steps to Take Today If You Are Under Healthcare Fraud Scrutiny

Step One: Halt All Communication with Government Agents Immediately

In my 25 years as a federal prosecutor, I witnessed countless individuals talk their way into indictments simply by trying to "explain" their billing practices to agents from the FBI or HHS-OIG. Under the Fifth Amendment, you have an absolute right to remain silent, and exercising that right cannot be used against you in court. Federal agents are trained to ask open-ended questions designed to elicit admissions or contradictions that can later be used to prove intent under 18 U.S.C. § 1347, the Healthcare Fraud Statute. Even if an agent assures you that you are only a witness, remember that the government can convert a witness into a target based on statements made during that interview. Do not rely on politeness or a desire to appear cooperative—politely state, "I am exercising my right to remain silent and request my attorney," then end the conversation.

Step Two: Preserve All Documents and Implement a Legal Hold

One of the most common mistakes I see is the destruction or alteration of records after a target learns of an investigation, which invites a separate charge under 18 U.S.C. § 1519 for obstruction of justice. Federal law explicitly criminalizes the concealment, alteration, or destruction of records with the intent to impede a federal investigation, and this statute carries up to 20 years in prison. You must immediately issue a written legal hold to all employees, contractors, and IT personnel, directing them to preserve all emails, billing records, patient files, and internal communications related to Medicare, Medicaid, or private insurance claims. Do not rely on verbal instructions—document the hold in writing and confirm receipt by each recipient. Additionally, suspend any automatic deletion policies for emails or electronic records, and ensure that backup tapes or cloud storage are not recycled until your attorney gives explicit approval.

Step Three: Conduct a Privileged Internal Audit of Your Billing Practices

Under the False Claims Act (31 U.S.C. §§ 3729-3733), the government can recover treble damages and impose civil penalties of up to $23,607 per false claim, making even minor billing errors financially devastating. In my experience, healthcare fraud investigations often begin with data mining by the Centers for Medicare & Medicaid Services (CMS), which identifies patterns of upcoding, unbundling, or billing for services not rendered. Your attorney should engage a forensic accountant and a healthcare compliance specialist to review a statistically significant sample of claims, focusing on Evaluation and Management (E/M) code levels, modifier usage, and documentation sufficiency. This review must be conducted under the protection of the attorney-client privilege and the work product doctrine, as defined in Federal Rule of Civil Procedure 26(b)(3), to prevent the government from subpoenaing the results. If the audit reveals overpayments, your attorney can guide you on whether voluntary disclosure to the Department of Justice under the Civil Monetary Penalties Law is appropriate.

Step Four: Identify and Mitigate Potential Qui Tam Whistleblower Exposure

More than 80% of healthcare fraud cases originate from whistleblower complaints filed under the False Claims Act's qui tam provisions, which allow private individuals to sue on behalf of the government and receive 15-30% of any recovery. In my practice, I advise clients to immediately identify any disgruntled former employees, competitors, or current staff who may have access to billing records or compliance concerns. You must review all recent employee terminations, performance issues, and compliance complaints to assess whether a sealed qui tam complaint may already be pending. If you suspect a whistleblower is involved, do not retaliate against that individual—retaliation under 31 U.S.C. § 3730(h) can expose you to double back pay, reinstatement, and additional damages. Instead, work with your attorney to prepare a comprehensive defense narrative that addresses the specific allegations you anticipate, focusing on the absence of knowing intent, which is a required element under the False Claims Act.

If you are under healthcare fraud scrutiny, time is not your ally—every day that passes without legal counsel increases your exposure to federal charges, asset forfeiture, and exclusion from Medicare participation. In my 25 years as a federal prosecutor, I saw too many professionals wait until after a search warrant was executed or an indictment was unsealed to seek representation. Do not make that mistake. Contact our firm immediately for a confidential, privileged consultation where we will assess your specific risk profile, review any correspondence or subpoenas you have received, and develop an aggressive defense strategy tailored to your practice. Your reputation, your license, and your freedom depend on the actions you take today.