New York City Federal Health Care Fraud Under 18 U.S.C. 1347 Lawyer
Federal health care fraud prosecutions have grown into one of the most aggressive enforcement priorities in the country, and New York City sits at the center of that enforcement activity. The statute at issue, 18 U.S.C. 1347, reaches anyone who knowingly executes or attempts to execute a scheme to defraud a health care benefit program, or to obtain money or property under such a program through false pretenses. That definition is deliberately broad, and federal prosecutors in the Southern and Eastern Districts of New York use it broadly. Physicians, practice administrators, billing specialists, hospital executives, pharmacists, home health agency operators, and medical equipment suppliers have all found themselves targets of grand jury investigations under this statute. The allegation does not require proof that a patient was harmed. It requires only that the government believe you knew what you were doing and that what you were doing was designed to extract money from a federally funded or regulated health care program.
A conviction under 18 U.S.C. 1347 federal health care fraud carries a prison sentence of up to ten years per count, rising to twenty years if the violation caused serious bodily injury to a patient, and potentially life imprisonment if a death resulted. Federal prosecutors routinely stack charges, pairing a health care fraud count with wire fraud, conspiracy, aggravated identity theft, and Anti-Kickback violations. That stacking dramatically multiplies the sentencing exposure a defendant faces. Beyond incarceration, the consequences extend to permanent exclusion from Medicare and Medicaid programs, forfeiture of proceeds the government ties to the scheme, and professional license revocation proceedings before the applicable state licensing board. For a physician or health care professional, the license issue can mean the permanent end of a career even before the criminal case resolves.
These cases move on two tracks simultaneously. Federal agents from the FBI, HHS Office of Inspector General, or the Department of Defense investigate for months or years before an indictment is returned. During that investigation phase, documents are subpoenaed, billing records are analyzed, cooperating witnesses are developed, and the government builds a detailed statistical picture of your practice’s billing patterns against national and regional benchmarks. By the time charges are filed, the government has already constructed its narrative. Understanding this, and engaging qualified federal criminal defense counsel at the earliest possible stage, is what separates those who shape the outcome from those who respond to it.
How Federal Health Care Fraud Cases Are Actually Built in New York
The Southern District of New York, which covers Manhattan, the Bronx, and Westchester, and the Eastern District, which covers Brooklyn, Queens, Staten Island, and Long Island, are among the most active jurisdictions in the country for health care fraud enforcement. Both districts have dedicated Health Care Fraud Units within the U.S. Attorney’s offices, and both coordinate regularly with the HHS-OIG, the FBI, DCIS, and the New York Medicaid Fraud Control Unit. That coordination means investigations touching federal programs often run parallel to state Medicaid fraud investigations, creating dual exposure from the beginning.
The government’s case is almost always constructed through data analysis before any witness is interviewed. Billing patterns are run against statistical norms. A physician who billed a higher percentage of complex office visits than the national average, or a home health agency that showed perfect documentation compliance across thousands of patient files, or a DME supplier whose referral sources were geographically concentrated in unusual ways, may draw the initial flag from a data audit before any human investigator ever looks at the file. From there, agents review claim submissions against clinical records to identify discrepancies, interview patients and former employees, and develop cooperating witnesses, often individuals who were part of the alleged scheme and who are cooperating in exchange for reduced exposure of their own. By the time a target receives a grand jury subpoena, the investigation is typically well advanced. By the time an indictment is unsealed, the government considers its case largely proven.
This architecture of federal prosecution means defense strategy must engage with the government’s evidence at every level: statistical, documentary, and testimonial. A defense attorney who arrives at the indictment stage without having engaged during the investigation may be working against a fully formed prosecutorial theory with no ability to influence how the evidence was gathered or preserved. The opportunity to counter-investigate, to challenge cooperator credibility, to present alternative billing explanations, or to approach the government before charges are filed is most valuable during the pre-indictment window.
What Federal Health Care Fraud Charges Actually Cover
- Upcoding and Phantom Billing: Submitting claims for more complex or expensive procedures than were actually performed, or billing for services that were never provided at all, represents the most common pattern alleged under 18 U.S.C. 1347. Federal prosecutors compare submitted CPT codes against clinical documentation, patient testimony, and office records.
- Kickback and Referral Fee Arrangements: Paying or receiving remuneration in exchange for patient referrals to facilities or services reimbursed by Medicare or Medicaid triggers both the Anti-Kickback Statute and, frequently, a parallel health care fraud charge under 18 U.S.C. 1347 when the resulting claims are submitted.
- Home Health and DME Fraud: Home health agencies and durable medical equipment suppliers operating in New York are frequent enforcement targets. Allegations typically involve services billed to patients who did not qualify for them medically or did not actually receive them, with physicians allegedly signing orders they never reviewed.
- Pharmacy and Compounding Fraud: Dispensing controlled substances without valid prescriptions, billing for brand-name drugs while dispensing generics, or operating compound pharmacies that pay kickbacks to prescribers have generated significant federal indictments in the New York market.
- Telehealth Fraud: The expansion of telehealth reimbursement created new enforcement focus on services billed as telehealth encounters that were either never conducted, conducted without a legitimate patient relationship, or ordered without any clinical basis, often through third-party marketing schemes.
- Mental Health and Substance Abuse Treatment Billing: Residential treatment facilities and outpatient behavioral health providers have faced 18 U.S.C. 1347 charges for billing group therapy as individual sessions, billing for patients not present, and billing services provided by unlicensed staff as though delivered by licensed clinicians.
- Physician Practice and Hospital Billing Schemes: Corporate health care executives, compliance officers, and practice managers have been charged alongside the treating physicians when the government alleges that billing irregularities were systemic and supervised from within the practice’s management structure.
What to Do If You Believe You Are Under Federal Investigation
The clearest signal that a federal health care fraud investigation has reached you is a subpoena, whether directed to you personally, to your practice, or to your billing company or records custodian. A subpoena from a federal grand jury is not a routine compliance request. It means a federal prosecutor has already presented enough information to a grand jury to justify compelling the production of documents or testimony. If you have received one, or if federal agents have appeared at your office seeking voluntary interviews, or if you have been told by an employee or business partner that they have been contacted by investigators, those are all points at which you need legal representation, not after you have spoken to agents or produced documents without counsel reviewing them first.
Do not make the error of treating a voluntary interview request from federal agents as a benign conversation. Agents conducting health care fraud investigations are trained interviewers who use these sessions to lock in statements that will later be compared against documentary evidence. Inconsistencies between what you say in a voluntary interview and what the billing records show can become the basis for an obstruction charge or a false statements count under 18 U.S.C. 1001, separate from and in addition to whatever health care fraud allegations may be pending. Declining to speak without counsel present is your right, and exercising it is not evidence of guilt.
Federal health care fraud cases in New York are handled in the United States District Court for the Southern District of New York, located at 500 Pearl Street in Manhattan, or the United States District Court for the Eastern District of New York, located at 225 Cadman Plaza East in Brooklyn. Which courthouse handles your case depends on where the conduct allegedly occurred and where the government chose to indict. Both courts operate under Federal Rules of Criminal Procedure, and both are served by U.S. Attorney’s offices with well-resourced health care fraud enforcement units. Understanding which district has jurisdiction, and developing a defense approach calibrated to the specific unit and prosecutors involved, matters from the beginning.
Preserve records and do not destroy, delete, or alter any documents once you have reason to believe you are under investigation. Doing so exposes you to obstruction of justice charges that carry their own substantial sentencing consequences. Separate from what you are obligated to preserve legally, your defense attorney will want to review your billing records, contracts, compliance policies, physician credentialing files, and any communications with billing companies or referral sources to assess where the government’s case is strong and where it has weaknesses worth challenging.
Why Jason Goldman for Federal Health Care Fraud Defense in New York
Jason Goldman began his career as a Brooklyn prosecutor, rising through the ranks by taking serious felony cases to trial. That prosecutorial foundation gives him a specific advantage in federal health care fraud defense: he understands how investigations are constructed, how cooperators are developed and used, and how prosecutors evaluate the strength of their own case before bringing charges. That understanding drives the pre-indictment strategy he pursues for clients who come to him during the investigation stage, where the government has not yet committed to a charging theory and where the opportunity to present exculpatory information or negotiate a resolution before charges are filed still exists.
Having tried more than 25 cases to verdict, Mr. Goldman brings courtroom experience that matters in federal court, where health care fraud cases often turn on complex expert testimony about billing standards, clinical documentation, and industry practice norms. He is admitted to practice in both the Southern District of New York and the Eastern District of New York, the two federal courts that handle the vast majority of health care fraud prosecutions arising from conduct in New York City. His practice covers every phase of this litigation, from the initial investigation and grand jury stage through trial and, where necessary, sentencing and appeal. He has been recognized as a New York Super Lawyers Rising Star and is a member of the National Association of Criminal Defense Lawyers and the New York State Association of Criminal Defense Lawyers. The New York Post has called him “High-Powered” and WABC’s Sid Rosenberg has called him “Brilliant,” reflecting a reputation built on results in serious federal and state criminal cases.
Mr. Goldman’s approach extends beyond the courtroom where the circumstances require it. For health care professionals and executives whose cases carry reputational consequences alongside criminal exposure, he draws on his network of crisis communications specialists, public relations professionals, and strategic advisors to manage how a matter is perceived publicly, and when appropriate, to keep clients out of the public narrative altogether during sensitive investigations. This is not window dressing. For a physician whose practice depends on patient trust, or a hospital executive whose board of directors is watching, the public dimension of a federal investigation can determine outcomes that no courtroom victory can fully repair. Addressing both dimensions together, legal and reputational, reflects how he has always approached high-stakes representation.
Questions About Federal Health Care Fraud Charges in New York
What is the difference between a billing error and federal health care fraud under 18 U.S.C. 1347?
The statute requires that the defendant knowingly executed or attempted to execute a scheme to defraud. Innocent billing errors, coding mistakes made by a billing department without the physician’s knowledge, or good-faith disagreements about how a service should be coded do not meet that standard. Federal prosecutors must prove intent. The difficulty is that the government often infers intent from patterns of conduct: a billing error that occurs once looks like a mistake; a billing error that occurs in thousands of claims over years looks, to a prosecutor, like a scheme. Establishing that errors were the result of system failures, inadequate compliance infrastructure, or billing company conduct that the client neither directed nor knew about is a central defense strategy in these cases.
Can I be charged under 18 U.S.C. 1347 even if Medicare or Medicaid ultimately paid nothing on the fraudulent claims?
Yes. The statute covers both executing and attempting to execute a scheme to defraud a health care benefit program. A claim that was submitted fraudulently but caught and denied before payment was made can still support a charge under the attempt language of the statute. The government does not need to prove that the scheme succeeded financially, only that it was knowingly attempted.
What health care programs are covered under 18 U.S.C. 1347?
The statute covers any health care benefit program, which is defined broadly to include Medicare, Medicaid, TRICARE and other military health programs, the Federal Employees Health Benefits Program, and private insurance plans that affect interstate commerce. The broad definition means that schemes targeting private insurers, not just government programs, can fall within the statute’s reach.
What is the role of the HHS Office of Inspector General in these cases?
The HHS-OIG is typically the lead investigative agency in Medicare fraud cases. Its agents conduct audits, analyze billing data, interview witnesses, and execute search warrants. The OIG also has the independent authority to exclude health care providers from participation in Medicare and Medicaid, a consequence that can be imposed administratively, separate from and in addition to any criminal prosecution. An exclusion can be triggered by a conviction, a plea, or even certain civil fraud findings.
If I have already spoken to federal agents without a lawyer, does that destroy my case?
Not necessarily, but it is a serious complication that needs to be addressed strategically. Whatever you said in that conversation is likely memorialized in an agent’s report. Your attorney will want to review what was said, assess whether any statements were inconsistent with the documentary record, and determine whether the government intends to use those statements. In some situations, there are grounds to challenge the admissibility of statements made in circumstances that were not truly voluntary. In others, the focus shifts to mitigating the damage and building around what was disclosed.
Can my medical practice be charged as a corporate entity alongside me personally?
Yes. The government frequently charges both individuals and the entities through which the alleged fraud was committed. A corporate conviction can result in substantial fines, forfeiture, and exclusion of the entity from federal health programs. In practice, this means a physician charged alongside his or her practice faces the prospect of both personal incarceration and the complete destruction of the business structure through which they earn a living.
What happens to my medical license if I am convicted of federal health care fraud?
A federal conviction for health care fraud typically triggers mandatory reporting obligations to the New York State Education Department, which oversees professional licensing. The Office of Professional Discipline can initiate its own proceedings, and a criminal conviction is among the most serious grounds for license revocation. In many cases, the licensing consequences are permanent. Because the criminal and licensing proceedings run on separate tracks, it is possible for someone to resolve the criminal matter and still face license revocation. A defense strategy that accounts for both consequences from the beginning puts the client in the strongest position on both fronts.
How does the government calculate the amount of loss in a federal health care fraud case, and why does it matter?
Loss amount is a critical variable under the Federal Sentencing Guidelines because it directly drives the recommended sentencing range. The government calculates loss based on the total amount of claims submitted or paid that it attributes to the alleged fraud. Defendants frequently dispute these calculations, arguing that the government has attributed legitimate claims to the scheme, used improper comparators, or failed to credit services that were actually rendered. Challenging the loss calculation is one of the most consequential fights in federal health care fraud sentencing, because even a modest reduction in the attributed loss figure can translate into years off the recommended sentence.
Is it possible to resolve a federal health care fraud investigation before charges are filed?
In some cases, yes. The pre-indictment period represents the greatest window of opportunity to engage with the government, present exculpatory information, challenge the government’s theory of the case, and explore whether a civil settlement or deferred prosecution arrangement might resolve the matter without a criminal conviction. Not all cases are amenable to pre-indictment resolution, and the government will not negotiate away a case it considers strong simply because defense counsel has made contact. However, experienced federal criminal defense counsel who understands how the SDNY and EDNY Health Care Fraud Units evaluate cases can sometimes create opportunities at this stage that do not exist after an indictment has been returned and the government has publicly committed to its theory.
What role do cooperating witnesses typically play in federal health care fraud prosecutions?
Cooperating witnesses, often former employees, billing staff, or co-conspirators who have entered into cooperation agreements with the government, frequently provide the testimonial backbone of these cases. They can describe internal conversations, explain how billing decisions were made, and offer firsthand accounts of conduct the government cannot prove through documents alone. Challenging cooperator credibility, exposing the benefit they received in exchange for their cooperation, identifying inconsistencies between their statements and the documentary record, and cross-examining them effectively at trial are among the most important skills a federal health care fraud defense attorney brings to these cases.
Federal Health Care Fraud Defense Across New York City and the Surrounding Region
The Law Offices of Jason Goldman represents clients in federal health care fraud matters throughout New York City and the broader region served by the Southern and Eastern Districts of New York. In Manhattan, that includes clients with practices and businesses in Midtown, the Financial District, the Upper East Side, Washington Heights, and Harlem, neighborhoods where health care providers of every size and specialty operate within reach of federal enforcement. The firm also represents clients in the Bronx, across its medical corridor and community health networks, as well as in Brooklyn, from Bay Ridge through Crown Heights, Flatbush, and East New York. In Queens, the firm serves clients in Flushing, Jamaica, Astoria, Forest Hills, and the surrounding communities where immigrant-serving medical practices have drawn particular enforcement attention. Staten Island clients, particularly those in the home health and behavioral health sectors, are also within the firm’s regular representation footprint.
Beyond the five boroughs, federal health care fraud cases arising from conduct on Long Island, in Nassau and Suffolk counties, are handled in the Eastern District of New York as well, and the firm represents clients from Garden City, Hempstead, Great Neck, Hauppauge, and across Long Island’s health care provider community. Westchester County providers, operating from White Plains, Yonkers, Mount Vernon, and the surrounding suburbs, are within the Southern District’s jurisdiction. The firm also handles matters for clients throughout New Jersey who are charged in connection with federally regulated programs, drawing on Mr. Goldman’s bar admission in that state. When cases arise elsewhere in the country and require the firm’s specific capabilities, pro hac vice admission allows representation in federal courts nationwide.
New York City Federal Health Care Fraud Attorney Ready to Engage
Federal health care fraud charges carry consequences that extend well beyond the criminal case itself, reaching into your professional license, your financial assets, your reputation, and your ability to work in your chosen field for the rest of your career. The decisions made in the earliest stages of an investigation, before charges are filed and before the government’s narrative has hardened into an indictment, are often the ones that determine how the entire matter resolves. A New York City federal health care fraud attorney who understands how these cases are built by federal prosecutors in the SDNY and EDNY, and who has both the trial experience to take a case to verdict and the strategic judgment to know when another path serves the client better, is what this moment calls for.
If you are facing a federal health care fraud investigation or prosecution under 18 U.S.C. 1347, contact The Law Offices of Jason Goldman to discuss your situation and understand your options before making any further decisions about how to proceed.
