Miami Healthcare Fraud Lawyers

Strategic and Aggressive Healthcare Fraud Defense

Healthcare fraud is a serious federal offense involving intentionally deceiving a healthcare benefit program for financial gain. Under 18 U.S.C. § 1347, it is illegal to knowingly execute—or attempt to execute—a scheme to defraud a healthcare benefit program or obtain funds or services through false or misleading claims. These cases can involve billing for services not provided, misrepresenting diagnoses, or accepting improper referrals in exchange for compensation.

Because healthcare fraud directly impacts federal programs like Medicare and Medicaid, agencies such as the U.S. Department of Justice (DOJ), the Office of Inspector General (OIG), and the FBI investigate and prosecute these offenses aggressively. Investigations often begin quietly, sometimes triggered by billing audits or whistleblower complaints, and can quickly escalate to criminal charges. A conviction can lead to steep fines, program exclusion, and even imprisonment, making early legal intervention critical.

If you are under investigation or have been charged, you need legal representation from a Miami healthcare fraud lawyer who understands the complexities of healthcare regulations and the strategies used by federal prosecutors. At Hager & Schwartz, P.A., we know that many professionals accused of fraud did not act with criminal intent but were instead caught in a complicated web of administrative errors, evolving compliance rules, or third-party mistakes.

We invite you to contact us for a free and confidential consultation. Let us review your situation and explain how we can protect your rights and defend your future.

Common Types of Healthcare Fraud Allegations

Healthcare fraud cases can take many forms, but most revolve around improper billing practices or the misuse of federal healthcare programs like Medicare and Medicaid. These allegations often involve complex regulations and large volumes of records, making them difficult to navigate without experienced legal guidance.

Violations often involve:

• Medicare and Medicaid fraud refers to deceptive practices intended to obtain unauthorized payments from these federal programs. Conduct may include billing for services not actually provided, misrepresenting a diagnosis to justify unnecessary tests, or using another person’s Medicare or Medicaid ID to receive services.
• Billing fraud is one of the most frequently cited offenses. It includes:
  • Upcoding, which involves billing for a more expensive procedure than what was performed.
  • Phantom billing, which refers to charging for services or treatments that never took place.
  • Double billing, where the same service is billed more than once to the same or different payers.
• False Claims Act violations occur when individuals or organizations knowingly submit—or cause to be submitted—false or misleading claims to federal programs. This law imposes significant penalties and is often used in whistleblower cases where former employees bring attention to unlawful practices.
• Prescription fraud can involve healthcare providers who prescribe medications without medical necessity or individuals who engage in doctor shopping to obtain multiple prescriptions for controlled substances. These cases often intersect with addiction issues or breakdowns in communication between providers and pharmacies.
• Durable Medical Equipment (DME) fraud involves improper billing for items like wheelchairs, braces, or catheters. Allegations typically center on equipment that was not medically necessary, not delivered, or billed at inflated rates. These cases are commonly tied to Medicare and Medicaid reimbursements.
• Drug Diversion cases involve the unauthorized redirection of prescription medications, particularly controlled substances. This conduct may include allegations against medical professionals accused of illegally distributing drugs or failing to monitor their storage and use properly.

These accusations can be intensely stressful, especially when your career, reputation, and freedom are at stake. We can help you review your options and build a strong, personalized defense if you face healthcare fraud allegations.

Key Federal Laws in Healthcare Fraud Cases

Federal healthcare fraud cases often involve complex legal frameworks that regulate how providers interact with patients, billing systems, and government healthcare programs. Understanding these laws is essential when building a strong legal defense.

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) is one of the most frequently cited federal laws in healthcare fraud cases. It prohibits the offer, payment, solicitation, or receipt of anything of value to induce or reward referrals for services covered by federal healthcare programs like Medicare or Medicaid. Even seemingly routine financial arrangements—such as referral bonuses or service discounts—can trigger scrutiny if not correctly structured. Violations are considered criminal offenses and can result in significant penalties, including fines and imprisonment.

Stark Law violations (42 U.S.C. § 1395nn) involve what’s known as “self-referral.” This law prevents physicians from referring Medicare or Medicaid patients to facilities or services where they or their immediate family members have a financial interest unless an exception applies. These designated health services (DHS) include lab tests, imaging services, or physical therapy. Unlike the Anti-Kickback Statute, the Stark Law is a strict liability statute, meaning intent does not have to be proven to impose liability.

The False Claims Act is central to healthcare fraud enforcement, especially in whistleblower-driven investigations. This law allows private individuals (often former employees or contractors) to file lawsuits on behalf of the government when they believe false claims have been submitted for payment. If the government recovers funds, the whistleblower may receive a portion of the amount collected. Providers accused under the False Claims Act may face treble damages and steep civil penalties.

EMTALA—the Emergency Medical Treatment and Active Labor Act—was enacted to prevent hospitals from turning away patients who cannot pay. It requires Medicare-participating hospitals to conduct a medical screening examination and provide stabilizing treatment to any individual seeking care in the emergency room. 

Violations include:

• Failing to perform an adequate screening
• Denying treatment
• Transferring patients without meeting safety standards
• Discriminating based on insurance status

These violations can trigger investigations by the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG), with potential penalties ranging from monetary fines to exclusion from federal healthcare programs.

We deeply understand these statutes and how they are enforced in South Florida and at the federal level. Our legal team works diligently to assess each case, identify potential defenses, and protect clients from the life-changing consequences of a healthcare fraud conviction.

Healthcare Fraud Penalties and Fines

A healthcare fraud conviction can have far-reaching effects on every part of a person’s life—personally, professionally, and financially. Federal authorities take These cases seriously, and the penalties reflect that.

Under federal law, a conviction for healthcare fraud can result in up to 10 years in prison for each offense. If the fraud leads to serious bodily injury, such as administering medically unnecessary treatment, the sentence can increase to up to 20 years. In cases where death occurs as a result of the fraud, the penalty can include any term of years or life imprisonment. 

In addition to prison time, those convicted may face substantial fines, especially in large-scale fraud cases or multiple offenses.

Beyond incarceration, healthcare professionals risk losing their ability to practice. A conviction may lead to the revocation of medical licenses, DEA registration, and professional certifications. Individuals and entities found guilty are often excluded from participating in federal healthcare programs like Medicare and Medicaid, effectively ending their ability to serve publicly insured patients.

The financial toll can also be significant. Under laws like the False Claims Act, defendants may be ordered to pay restitution to the government, civil monetary penalties, and treble damages. In many cases, this can lead to personal bankruptcy, especially when combined with the loss of employment and reputation.

Clients face immense pressure when their freedom, livelihood, and professional standing are on the line. We take a proactive approach to defending against healthcare fraud charges—working to reduce or eliminate the penalties and protect what our clients have built.

How Our Team Builds a Strong Defense

At Hager & Schwartz, P.A., we recognize that healthcare fraud allegations can be legally complex and personally overwhelming. Whether you're a physician, pharmacist, clinic owner, or healthcare organization, your future may be shaped by how these charges are addressed. That’s why we take a strategic, customized approach to every case.

We begin by conducting a thorough review of the facts. Our team carefully examines the government’s evidence, looking for weaknesses, inconsistencies, or violations of your rights during the investigation process. In many cases, what prosecutors view as fraud may stem from billing errors, ambiguous coding practices, or misunderstandings of ever-changing healthcare regulations, not criminal intent.

If you're already under audit or investigation, we can help you navigate the process confidently. We work directly with investigators and federal agencies to protect your rights and prevent the situation from escalating into formal charges. For those already facing prosecution, we know how to manage these cases discreetly, minimizing public exposure and reputational harm wherever possible.

Our defense strategies are tailored to each case's unique circumstances. Healthcare law is highly technical, and success depends on understanding how regulations like the Anti-Kickback Statute, Stark Law, and the False Claims Act are applied in real-world settings. Our experience handling federal healthcare fraud cases enables us to build a defense grounded in legal knowledge and practical insight.

If you’ve been accused or are under investigation for healthcare fraud in Miami, time matters. Contact Hager & Schwartz, P.A. for a confidential consultation. We are ready to help you understand your options.