New York City Federal Medicare and Medicaid Fraud Lawyer

Federal healthcare fraud prosecutions are among the most document-heavy, investigation-intensive cases the government brings. By the time agents show up at a medical office or a billing company’s door, prosecutors have often spent months or years building the case, working with the Department of Health and Human Services Office of Inspector General, the FBI, and sometimes the Department of Justice’s Fraud Section simultaneously. For anyone caught in that web, a New York City federal Medicare and Medicaid fraud lawyer is not a precaution, it is a necessity.

Healthcare fraud charges at the federal level carry consequences that go far beyond criminal penalties. Physicians lose their licenses. Executives lose their companies. Providers face exclusion from every federal healthcare program, which for most medical practices is a death sentence. And because the government tends to charge these cases as ongoing schemes rather than isolated billing errors, the sentencing exposure is often staggering. Prosecutors calculate loss amounts that can push even a first-time offender into a sentencing range measured in years rather than months.

New York City is one of the most active federal healthcare fraud enforcement markets in the country. The Southern District of New York and the Eastern District of New York both have substantial histories of prosecuting healthcare providers, billing companies, pharmacies, home health agencies, durable medical equipment suppliers, and healthcare executives. If you have received a subpoena, been contacted by investigators, or learned that you are a target or subject of a federal grand jury inquiry, the time to retain counsel is right now, before your next conversation with anyone from the government.

What Federal Medicare and Medicaid Fraud Prosecutions Actually Look Like in New York

The government does not wake up one day and decide to charge a doctor or a billing manager. Federal healthcare fraud cases are built slowly and deliberately. They begin with data analytics: algorithms that flag billing patterns, unusually high claim volumes, suspicious procedure codes, or statistical outliers compared to peer providers. From there, investigators pull claims data, interview patients, flip cooperating witnesses, execute search warrants, and sometimes run undercover operations. By the time charges are filed, the government believes it has a case it can win.

That does not mean it will. Federal healthcare fraud cases are defensible, and they are defended successfully on a regular basis. But the defense has to be built on the same level of preparation and precision the government brings. That means getting into the billing records, understanding the clinical documentation, identifying where the government’s loss calculations are inflated, and knowing how to attack cooperating witness testimony that has often been shaped by pressure and plea deals.

The charges themselves vary depending on the alleged scheme. Prosecutors in New York federal courts have brought cases under the federal healthcare fraud statute, the False Claims Act, the Anti-Kickback Statute, the Stark Law, wire fraud, mail fraud, and money laundering, sometimes stacking multiple charges in a single indictment. Each charge carries its own elements, its own defenses, and its own sentencing implications.

Common Federal Healthcare Fraud Charges and Schemes

• Billing for Services Not Rendered: One of the most frequently charged categories, involving claims submitted to Medicare or Medicaid for appointments, procedures, or tests that never actually took place, often detected through patient interviews or electronic health record audits.
• Upcoding and Unbundling: Billing for a more expensive procedure than what was performed, or separating services into multiple claims that should have been billed together, both of which inflate reimbursement beyond what the program allows.
• Anti-Kickback Violations: Paying or receiving remuneration in exchange for patient referrals to a particular provider, facility, or supplier covered by a federal healthcare program, a federal crime that can be charged whether or not the underlying services were actually performed.
• Home Health and DME Fraud: Schemes involving fraudulent certifications for home health services or durable medical equipment where the patient did not qualify, the services were not delivered, or the certifying physician had no legitimate relationship with the patient.
• Pharmacy and Prescription Fraud: Billing for prescriptions that were never dispensed, dispensing lower-cost drugs while billing for brand-name equivalents, or participating in schemes where prescriptions are generated without legitimate clinical need.
• Unnecessary Medical Procedures: Performing or ordering tests, surgeries, or treatments that were not medically necessary and billing federal programs for those services, which requires the government to prove both the billing irregularity and the clinical standard of care.
• False Claims Act Exposure: Civil and criminal liability arising from any false statement or fraudulent claim submitted to a federal healthcare program, including cases brought by qui tam relators (whistleblowers) who file suits on behalf of the government and are entitled to a share of any recovery.
• Conspiracy Charges in Multi-Defendant Schemes: Many New York federal healthcare fraud cases are charged as conspiracies involving physicians, practice administrators, billing companies, and marketers, which means each participant can be held accountable for the full scope of the alleged fraud even if their individual role was limited.

Why Jason Goldman Defends Federal Healthcare Fraud Cases

As a federal Medicare and Medicaid fraud attorney in New York City, Jason Goldman brings a background that shapes how he approaches government investigations from the first phone call. He started his career as a Brooklyn prosecutor, rising through the ranks by trying serious felony cases to verdict. That prosecutorial foundation matters in healthcare fraud cases because he understands how federal investigations are structured, how cooperating witnesses are developed, and where the government’s cases tend to be weakest long before they reach a courtroom.

Mr. Goldman has built his reputation on what he describes as controlling the narrative and controlling the outcome. In federal healthcare fraud cases, that means engaging early in the pre-indictment phase when the opportunity to shape what charges are brought, or whether charges are brought at all, is still real. He has been described by the New York Post as “High-Powered” and by WABC’s Sid Rosenberg as “Brilliant,” and his practice has drawn high-profile clients from the worlds of medicine, finance, real estate, and beyond. His representation is selective and elite by design, focused on clients with extraordinary stakes and reputations that cannot survive a careless defense.

Having tried over 25 cases to verdict and developed a practice that spans pre-arrest investigations, trials, and appellate work, Mr. Goldman is equipped to handle every phase of a federal healthcare fraud case. He also taps into a trusted network of forensic experts, private investigators, and public relations professionals when a case demands more than courtroom advocacy alone. For healthcare providers whose professional licenses and institutional standing are on the line alongside their liberty, that full-spectrum approach is often what makes the difference.

What to Do If You Are Under Federal Healthcare Fraud Investigation

The most consequential decisions in a federal healthcare fraud case are made before indictment. If you have received a grand jury subpoena for documents, a Civil Investigative Demand from the Department of Justice, or a contact from an HHS-OIG agent asking for a “voluntary” interview, treat all of it as serious and retain counsel before responding to anything. There is no such thing as a harmless preliminary conversation with a federal investigator when you are already a target.

Document preservation is critical from the moment you learn of any inquiry. Federal obstruction statutes apply broadly, and destroying or altering records after learning of an investigation, even records you would have routinely discarded, can result in independent criminal charges that complicate your situation significantly. Your attorney should help you understand what a litigation hold requires and how to apply it to your electronic health records system, billing software, and email archives.

Federal healthcare fraud cases in New York City are handled primarily in the Southern District of New York, located at 500 Pearl Street in Manhattan, and the Eastern District of New York, based at 225 Cadman Plaza East in Brooklyn. Both districts have active healthcare fraud units and a track record of significant prosecutions. If your case involves Medicaid specifically, the New York State Attorney General’s Medicaid Fraud Control Unit also operates independently and can pursue state charges alongside or separate from any federal action, so the jurisdictional picture may be more complex than it first appears.

One of the most common mistakes providers make is assuming that because they did not intend to defraud anyone, they are safe. Federal healthcare fraud does not always require proof of specific intent to defraud. The government can pursue cases on theories of reckless disregard or deliberate ignorance, meaning that sloppy billing practices supervised by someone who should have known better can still support a prosecution. Billing errors and criminal fraud are different things, but only if the record supports that distinction. Getting counsel involved early means building that record with purpose.

Questions About Federal Healthcare Fraud Cases in New York

What is the difference between a Medicare fraud investigation and a Medicaid fraud investigation?

Medicare is a federal program administered through the Centers for Medicare and Medicaid Services, so Medicare fraud investigations are led by federal agencies like the FBI, HHS-OIG, and DOJ. Medicaid is a joint federal-state program, which means Medicaid fraud can be investigated and prosecuted by both federal authorities and New York State’s Medicaid Fraud Control Unit under the Attorney General’s office. In practice, many New York cases involve both programs and both enforcement bodies, which increases the complexity and the potential exposure considerably.

Can I negotiate with federal prosecutors before charges are filed?

Pre-indictment negotiations are possible and in some cases produce outcomes significantly better than what is achievable after charges are filed. Prosecutors have discretion to decline prosecution, pursue civil rather than criminal liability, or narrow the scope of charges in response to information or arguments defense counsel presents. These conversations require judgment about what to disclose, what to challenge, and how to position the client, and they should never happen without experienced counsel guiding every word.

What are the penalties for federal healthcare fraud in New York?

The federal healthcare fraud statute alone carries a base maximum of ten years per count, with enhanced penalties when the offense results in serious bodily injury or death. False Claims Act violations carry significant civil penalties per claim in addition to treble damages. Anti-Kickback convictions carry separate penalties. Sentencing in these cases is driven heavily by the calculated loss amount under the federal sentencing guidelines, and the government’s loss figures are often aggressively inflated, making legal challenges to those calculations one of the most important aspects of federal healthcare fraud defense.

What happens to my medical license if I am charged with Medicare or Medicaid fraud?

A conviction for healthcare fraud generally triggers mandatory exclusion from federal healthcare programs under federal law, which for most physicians and providers is financially catastrophic. In New York, the Office of the Professions and the applicable licensing board can initiate license revocation or suspension proceedings based on the criminal charge itself, sometimes before any conviction. Defending your license often requires parallel proceedings in front of licensing authorities alongside the criminal case, and both tracks need coordinated strategy.

If my billing company submitted the fraudulent claims, am I still liable?

Providers cannot simply point to a third-party billing company and walk away from liability. The government regularly charges the physician or provider as the responsible party on the theory that they signed off on or should have reviewed the claims, had a duty to ensure accurate billing, and benefited from the fraudulent submissions. Whether this theory holds up in a specific case depends on the facts, the structure of the billing arrangement, and the evidence of what the provider actually knew or approved.

What is a qui tam lawsuit and how does it affect my situation?

A qui tam lawsuit is filed by a private individual, typically a current or former employee, competitor, or patient, under the False Claims Act on the government’s behalf. These relators can file in secret, meaning the lawsuit may be pending for months or years before a provider learns of it. When the government chooses to intervene in a qui tam case, the relator shares in any recovery. Qui tam suits are increasingly common in New York and are one of the ways federal healthcare fraud investigations get started without any prior notice to the target.

How does the government calculate the loss amount in a healthcare fraud case?

The government typically calculates loss as the total amount billed to federal programs under the alleged scheme, which can dramatically overstate actual harm because it does not always account for services that were legitimately performed or for what would have been reimbursed absent the alleged fraud. Challenging the loss calculation is a critical part of federal healthcare fraud defense because loss amount drives the sentencing guidelines range. Defense experts who can analyze billing records and construct an alternative, credible loss figure often have a material impact on outcomes.

Can civil and criminal healthcare fraud cases be pending at the same time?

Yes, and this is common in complex New York federal healthcare fraud matters. The Department of Justice can pursue both a criminal indictment and a civil False Claims Act action arising from the same conduct simultaneously. This creates significant strategic tension because positions taken in the civil proceeding can be used in the criminal case and vice versa. Fifth Amendment considerations apply across both tracks, and coordinating the defense across parallel proceedings requires careful planning from early in the case.

What should I say if a federal agent calls me asking to set up an interview?

You should say that you will have your attorney contact them. Nothing more. Voluntary interviews with federal investigators are not neutral conversations. Anything you say can be used against you, and agents are trained to ask questions in ways that invite incriminating answers or that can later be characterized as false statements if your recollection differs from the record. You have no legal obligation to speak with investigators outside the grand jury context, and even grand jury subpoenas for testimony come with rights that counsel can help you exercise.

Is it possible to avoid exclusion from Medicare and Medicaid even after a conviction?

Mandatory exclusion applies to certain categories of convictions under federal law and generally cannot be waived. However, the scope of exclusion, the length of the exclusion period, and the conditions under which reinstatement may be sought depend on the specific conviction. Permissive exclusions, which apply to a broader range of conduct, involve a separate administrative process with more discretion. In some cases, negotiating the specific charges to which a client pleads can have a direct impact on whether mandatory exclusion applies, which is one reason plea negotiations in healthcare fraud cases require attention to consequences far beyond the criminal sentence itself.

Federal Healthcare Fraud Representation Across New York City and Beyond

The Law Offices of Jason Goldman represents clients facing federal Medicare and Medicaid fraud investigations and prosecutions throughout New York City and the surrounding region. In Manhattan, the firm serves clients in Midtown, the Financial District, the Upper East Side, Harlem, Washington Heights, Chelsea, and TriBeCa. In Brooklyn, representation extends to clients in Flatbush, Crown Heights, Borough Park, Sunset Park, Williamsburg, and Bensonhurst, communities where home health agencies, pharmacies, and medical practices have historically drawn federal scrutiny. In the Bronx, the firm represents providers and executives in Fordham, Mott Haven, Pelham Bay, and Riverdale. Queens clients from Flushing, Jamaica, Jackson Heights, Astoria, and Forest Hills have also sought the firm’s representation in high-stakes healthcare investigations. Staten Island providers in St. George and Tottenville are within the firm’s geographic reach as well.

Beyond the five boroughs, Mr. Goldman is admitted in both the Southern and Eastern Districts of New York and handles federal matters that extend into Nassau County, Suffolk County, Westchester County, and Rockland County. The firm is also available for pro hac vice admission in federal courts throughout the country when the circumstances of a case require it.

Speak With a New York City Federal Healthcare Fraud Attorney

A federal healthcare fraud investigation will not resolve itself and will not get easier to defend the longer it runs without experienced counsel guiding the response. Whether you are a physician, a practice administrator, a billing company executive, a pharmacist, or a home health agency operator, the decisions made in the earliest stages of a government inquiry shape every outcome that follows. Jason Goldman is a New York City federal healthcare fraud attorney who has spent his career representing clients whose futures depend on getting the defense right from the start. His practice is built on preparation, discretion, and the kind of courtroom credibility that prosecutors and judges take seriously. Reach out to the Law Offices of Jason Goldman today to discuss your situation in a confidential consultation.