Types of Criminal Defense Cases Protass Law PLLC Handles
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Understanding Health Care and Insurance Fraud

Health care fraud refers to misrepresenting the medical services performed or provided to gain reimbursements from insurers and government health care programs, like Medicare, Medicaid, Tricare, and others. Consequently, the Department of Justice and the Department of Health and Human Service’s Office of Inspector General aggressively pursue these cases. Because of the considerable resources devoted to health care and insurance fraud, even unintentional billing errors and oversights can sometimes lead to damning allegations for legitimate health care professionals.

If you have been formally charged or are actively being investigated for health care fraud in New York, you need a highly-skilled NYC criminal defense attorney, who can rapidly evaluate your situation and work to address the issue. Talk to Protass Law PLLC before it’s too late. Call 212.455.0335 or submit a request online to schedule a free and confidential consultation.

Types of Health Care & Insurance Fraud

Health care and insurance fraud can be committed by or against physicians or other health-care professionals. It may also involve an individual or medical service provider that benefits financially from fraudulent activities related to an array of activities.

Some of the most common actions that constitute health care fraud include:

  • Double/Over Billing, Phantom Billing, Upcoding, and Unbundling
  • Kickbacks, Bribes, and Rebates
  • Physician Self-Referrals
  • False and Fraudulent Claims
  • Billing for Unnecessary Services, Supplies, and Equipment
  • Billing for Services, Supplies, or Equipment Not Provided
  • Prescription Drug Fraud
  • Falsifying Patient Records
  • Inaccurately Reporting Test Results
  • Fraudulent Physician Certifications
  • Improper Election Statements for Hospice Care

Health Care Fraud Investigations

The U.S. Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI) often collaborate with other state and federal entities to investigate accusations of health care fraud.

For example, the FBI’s Complex Financial Crime Program may work with the following agencies and groups to gather evidence and prosecute health care offenders:

  • Health and Human Services – Office of Inspector General (HHS – OIG)
  • Food and Drug Administration (FDA)
  • Drug Enforcement Administration (DEA)
  • Defense Criminal Investigative Service (DCIS)
  • Office of Personnel Management – Office of Inspector General (OPM – OIG)
  • Internal Revenue Service – Criminal Investigation (IRS – CI)
  • Medicaid Fraud Control Units
  • Medicare Fraud Control Units
  • National Health Care Anti-Fraud Association
  • National Insurance Crime Bureau
  • Other state and local agencies
  • Private insurance investigative units

These agencies, investigative units, and private groups build cases by gathering information from patients, health insurance companies, and other sources. Law enforcement may even try to elicit statements from you or ask other medical providers and patients for information. You may initially be tempted to cooperate with government officials, who may suggest that they are trying to exonerate you, but keep in mind that is not their primary concern. Their goal is to gather information that supports the bringing of charges.

If you are under investigation, you have a right to an attorney. Whether you’re dealing with a criminal investigation or inquiry from your state licensing authority, you should contact an experienced health care fraud defense attorney who can walk you through the process and make sure your rights are respected.

Once attorney Protass has the chance to assess your situation, we will quickly make contact with the investigators or attorneys involved. After we ascertain the full scope of their investigation, we will focus on securing the best possible result in light of the facts involved. This may include negotiations or advocating for your interests in an administrative hearing or court. In any fraud case, our primary mission will always be to resolve the matter without the filing of charges, preventing a criminal conviction, or avoiding civil liability, but we will also apply every possible resource, so you can continue practicing medicine or running your business.

Civil vs. Criminal Health Care Fraud Charges

Under federal law, the government can investigate healthcare fraud civilly, criminally, or in some cases both. Frequently, the direction is unclear at the beginning of a case because the mere receipt of a subpoena or interview request does not always indicate whether a case is being pursued civilly or criminally. This uncertainty makes it essential to work with an attorney who will strive to protect you either way.


Here, the government believes that the parties involved perpetrated a fraud, but was not deliberate and willful enough to justify criminal prosecution. Instead, the government will generally demand restitution in addition to a civil penalty.


This involves an official criminal investigation regarding suspected fraud. As in most criminal cases, the objective will be to prosecute the offender, secure a criminal conviction, and apply penalties set by law, up to and including incarceration.

Since most health care fraud investigations start without a clear indication as to whether they are criminal or civil, it is vital to consult with a veteran attorney, who knows the system and what to look for. For instance, specific document requests following the issuance of a subpoena can be indicative of where the case is going.

Some signs of a criminal health care fraud case are:

  • Grand Jury Subpoena
  • Executing Search and or Seizure Warrants
  • Freezing Your Assets
  • A Criminal Prosecutor Being Assigned
  • Certain Documents Being Requested

Don’t Take Unnecessary Risks—Contact Protass Law PLLC

Attorney Harlan Protass brings over two decades of state and federal legal experience to the table with a proved track record of success in all manner of health care fraud cases. If you need guidance or advice about a potential issue or if you are facing a federal investigation, we can intervene and make sure you meet as few consequences as possible.

Speak personally with a veteran health care fraud lawyer at Protass Law PLLC today. Call 212.455.0335 or complete our online form to schedule a free and confidential consultation.