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What Should I Do If I’ve Been Accused of Healthcare Fraud?

By Los Angeles Criminal Defense Attorney on September 30, 2024

Being accused of healthcare fraud is a serious and life-altering event. Whether the accusation comes in the form of a federal indictment, a subpoena, or even a quiet investigation, your professional license, livelihood, and freedom may all be at risk. Healthcare fraud cases are aggressively prosecuted, and they may involve massive amounts of evidence, including billing records, insurance claims, and internal communications.

Werksman Jackson & Quinn LLP, is a nationally recognized healthcare fraud defense firm in Los Angeles. With decades of experience defending clients in white-collar crime cases, we offer immediate, strategic, and powerful legal defense to protect your career, your reputation, and your future.

Why Early Intervention Matters

Time is critical in healthcare fraud investigations. Early legal representation gives you the best chance to:

• Avoid charges before they are filed
• Control the narrative before investigators draw conclusions
• Preserve favorable evidence that may be lost over time
• Avoid mistakes that could harm your defense, such as speaking with investigators or destroying documents

At Werksman Jackson & Quinn LLP, we know how to act quickly, confidentially, and strategically to protect you from the moment an investigation begins.

What Is Healthcare Fraud?

Healthcare fraud refers to deceptive practices used to obtain unauthorized benefits from government or private healthcare programs. These cases frequently involve allegations that the accused knowingly submitted or facilitated the submission of false or misleading claims in order to receive unlawful reimbursement.

Common Allegations in Healthcare Fraud Cases:

• Knowingly presenting a false claim for the payment of a loss or injury: Billing for services that were never performed or exaggerating the complexity of services.
• Intentionally submitting a claim for a healthcare benefit not utilized by the claimant: Submitting claims for phantom patients or for services never received.
• Knowingly submitting a false claim for payment on behalf of any workers’ compensation health benefits: Filing fraudulent documentation or inflating the cost of treatment related to workers’ compensation claims.
• Presenting multiple claims for the same healthcare benefit with intent to defraud: Duplicate billing to multiple insurers or government programs for a single treatment.

These types of accusations can be brought against doctors, nurses, pharmacists, healthcare companies, billing managers, and others connected to the healthcare system.

What Are the Penalties for Healthcare Fraud?

The penalties for healthcare fraud vary depending on the nature and scale of the offense but are often extremely harsh:

• Federal Prison: Up to 10 years per count; 20 years if the fraud resulted in serious bodily injury; life imprisonment if it resulted in death.
• Fines: Can reach hundreds of thousands or even millions of dollars.
• Restitution: Mandatory repayment of the alleged fraudulent gains.
• Asset Forfeiture: Seizure of bank accounts, homes, vehicles, and other assets tied to the alleged scheme.
• Loss of Medical License: Healthcare providers can lose the ability to practice medicine or bill federal healthcare programs like Medicare.
• Civil Penalties: In addition to criminal charges, defendants can face civil lawsuits under the False Claims Act or other regulatory statutes.

Who Prosecutes Healthcare Fraud?

Healthcare fraud cases are often pursued by a range of federal and state agencies working in collaboration, including:

• U.S. Department of Justice (DOJ)
• Federal Bureau of Investigation (FBI)
• Office of Inspector General (OIG) for Health and Human Services
• Centers for Medicare & Medicaid Services (CMS)
• California Department of Insurance
• State Attorney General’s Office

These agencies are supported by task forces like the Medicare Fraud Strike Force, and they use sophisticated investigative tools including audits, data analytics, and whistleblower tips.

What Should You Do If You’re Facing Charges?

If you have any reason to believe you are under investigation, it’s time to find a good Los Angeles healthcare fraud defense lawyer and follow their legal advice.

Stay Silent and Seek Legal Help Immediately

Do not speak to investigators, law enforcement, or regulatory agencies without legal counsel. Anything you say can be used against you. Even innocent comments can be misinterpreted or taken out of context.

Preserve and Gather Evidence

Secure all relevant documents and digital records, including billing statements, emails, internal communications, and patient files. Preserve backups and do not alter any materials.

Do Not Contact Potential Witnesses

Avoid speaking with co-workers, patients, or others involved in the case. This could be seen as witness tampering or obstruction of justice.

Retain a Law Firm Experienced in Healthcare Fraud Defense

Not all criminal defense attorneys have experience with federal healthcare fraud. Choose a firm with the experience and resources to go up against government prosecutors.

The Legal Process for Healthcare Fraud Cases

• Investigation Phase: This can include audits, subpoenas, search warrants, and interviews. You may receive a target letter indicating you’re under investigation.
• Charging Phase: Charges may come through a criminal complaint or a federal grand jury indictment.
• Pre-Trial Proceedings: These include arraignment, bail hearings, motions to suppress evidence, and other pretrial motions.
• Trial: If the case goes to trial, the prosecution must prove its case beyond a reasonable doubt. The defense has the opportunity to cross-examine witnesses, challenge evidence, and present counterarguments.
• Sentencing or Acquittal: If convicted, sentencing will follow. If acquitted, the charges are dismissed.

Effective Legal Defense Strategies

Each case is unique, but the there are several powerful defense tactics that your attorney may use.

Lack of Intent

Prosecutors must prove that you knowingly and willfully committed fraud. If your actions were the result of confusion, misunderstanding, or an honest mistake, the intent element may not be met.

Lack of Knowledge

You may not have been aware that fraudulent claims were being submitted, especially in large healthcare organizations with multiple billing layers.

Insufficient Evidence

The government must prove each element of the offense beyond a reasonable doubt. If they lack clear documentation or witness credibility, the case may fall apart.

Mistaken Identity

Errors in documentation or use of provider numbers by unauthorized persons can lead to charges against the wrong individual.

Honest Mistake or Clerical Error

Billing errors happen frequently in the complex healthcare system. Clerical or coding mistakes without intent to defraud do not constitute criminal conduct.

Flawed Evidence

If the prosecution relies on weak, incomplete, or illegally obtained evidence, the defense can move to exclude it from the case.

Challenging the Prosecution’s Proof

We scrutinize billing records, audits, and digital data for inconsistencies and alternative explanations. Our team often works with forensic accountants and billing experts to undermine the prosecution’s narrative.

Inconsistencies in the Prosecution’s Case

Contradictory witness statements, incomplete records, and unsupported conclusions are all areas we attack in court to raise reasonable doubt.

Unlawful Evidence Collection

If investigators violated your Fourth or Fifth Amendment rights during the investigation, such as conducting an illegal search or coercing a confession, we will file motions to suppress that evidence.

Unreliable Witnesses Against You

Government witnesses, such as whistleblowers or co-defendants seeking lighter sentences, often have credibility issues or personal motivations. We carefully cross-examine and investigate their testimony for weaknesses.

Why Choose Us Over Other Los Angeles Healthcare Fraud Defense Lawyers

• Founded in 1994, we have decades of experience handling complex federal and state criminal defense cases.
• Mark J. Werksman, a former Deputy District Attorney and former Assistant United States Attorney, brings nearly 40 years of trial experience.
• Alan Jackson, former Assistant Head Deputy of the Major Crimes Division of the L.A. County District Attorney’s Office, has tried some of California’s most closely watched criminal cases.
• Kelly Quinn brings a strategic approach to healthcare fraud defense by identifying legal flaws, constitutional violations, and evidentiary weaknesses that can be used to counter complex government cases.
• AV Preeminent Rated by Martindale-Hubbell, reflecting the highest level of professional excellence.
• Recognized by Super Lawyers based on peer reviews and independent research.
• Team-based approach: You don’t just get one attorney; you get an entire firm fighting for your case.
• Proven results: We have successfully convinced prosecutors to decline filing charges and won acquittals in federal court.

Case Results

No Convictions in Workers’ Fraud Case

Mark Werksman of Werksman Jackson & Quinn LLP halted the Los Angeles District Attorney’s Office in its tracks by preventing a conviction in a four-week workers’ compensation insurance fraud trial. The firm’s 63-year-old client—a successful payroll service provider in the Inland Empire—was accused of orchestrating a $3 million fraud by allegedly failing to secure workers’ compensation coverage for her business clients.

After a lengthy trial featuring 37 prosecution witnesses, the jury deliberated for three days before deadlocking, resulting in a mistrial. The hung jury meant prosecutors were unable to secure a conviction—a critical outcome for the defense.

Werksman credited the result to the firm’s aggressive, detailed approach to dismantling the government’s case. “While a hung jury is not the perfect outcome, our job is to prevent a conviction—and we achieved that goal,” Werksman said. The defense team meticulously reviewed and rebutted hundreds of thousands of pages of discovery, exposing weaknesses in the prosecution’s theory and presenting a clear, compelling counter-narrative to the jury.

This case highlights the firm’s strength in handling complex financial crime cases and underscores Werksman Jackson & Quinn LLP’s ability to protect clients when everything is at stake.

What Clients Are Saying About Us

Fantastic defense attorney- Alex B. (5-Star Avvo Review)

Fantastic defense attorney. Alan Jackson is an incredibly skilled and seasoned attorney. He has passion for his clients and the law and you would be a fool not to hire him.

Highly recommend!!! -Anonymous (5-Star Avvo Review)

Best attorney to help with my case! He will fight for you all the way. I trusted him with my case and his team to assist me. Will go above and beyond to win and defend you. Highly recommend!!!

Speak With a Trusted Los Angeles Healthcare Fraud Defense Attorney

If you’re under investigation or facing charges for healthcare fraud in California, don’t wait. The earlier we can intervene, the more options we may have to fight the allegations and protect your rights.

Contact Werksman Jackson & Quinn LLP at (213) 688-0460 to schedule a consultation right away.

We’re the legal team you want by your side when everything is on the line.

Healthcare Fraud Defense FAQs

What is healthcare fraud?

Healthcare fraud involves knowingly submitting false or misleading information to obtain unauthorized payments from public or private healthcare programs, such as Medicare, Medi-Cal, or workers’ compensation insurance.

What are common examples of healthcare fraud?

Examples include billing for services not rendered, upcoding procedures to increase reimbursement, submitting duplicate claims, falsifying medical records, or accepting kickbacks for patient referrals.

Who investigates and prosecutes healthcare fraud?

Healthcare fraud cases are often prosecuted by the U.S. Attorney’s Office and investigated by federal agencies such as the FBI, HHS-OIG, DOJ, and state agencies like the California Department of Insurance or the Attorney General’s Office.

What should I do if I’m contacted by federal investigators?

Do not speak with investigators without legal representation. Contact Werksman Jackson & Quinn LLP immediately at (213) 688-0460.

Can I go to prison for healthcare fraud?

Yes. A conviction can result in up to 10–20 years in federal prison, depending on the severity of the alleged fraud and whether it caused harm to patients.

Can healthcare fraud charges affect my medical license?

Absolutely. A criminal charge or conviction can lead to license suspension or permanent revocation, as well as exclusion from Medicare and other federal programs.

What legal defenses are available in healthcare fraud cases?

Common defenses include lack of intent, clerical or billing errors, lack of knowledge, insufficient evidence, or unlawful evidence collection by investigators.

Will I automatically be charged if I made a billing mistake?

No. Not all billing errors are fraud. The prosecution must prove that you intentionally submitted false claims with the purpose of defrauding a healthcare program.

What is the legal process for a healthcare fraud case?

Most cases begin with an investigation, followed by formal charges, pretrial motions, and possibly a trial. Werksman Jackson & Quinn LLP handles every stage, from early intervention to trial and appeal if necessary.

How can Werksman Jackson & Quinn LLP help me?

Our attorneys bring decades of experience, trial-tested strategies, and expert forensic support to the table. We will aggressively challenge the government’s case, protect your professional future, and fight for the best possible result.

About Werksman Jackson & Quinn LLP

Werksman Jackson & Quinn LLP is one of California’s premier criminal defense firms, known for handling high-stakes, high-profile cases with discretion, precision, and force. Based in Los Angeles and founded in 1994, the firm defends individuals and organizations facing serious criminal allegations, including white-collar crimes, healthcare fraud, securities fraud, violent felonies, and complex federal prosecutions.

Mark J. Werksman, a founding partner, brings nearly four decades of experience in criminal law. As a former Deputy District Attorney and former Assistant U.S. Attorney, he offers deep insight into both sides of the courtroom and has successfully defended clients in some of California’s most challenging and closely watched cases.

Alan Jackson, also a partner, is a nationally recognized trial lawyer and the former Assistant Head Deputy in the Major Crimes Division of the Los Angeles County District Attorney’s Office. His courtroom experience, media-savvy strategies, and ability to manage complex, sensitive trials make him one of the most sought-after criminal defense attorneys in the state.

Kelly Quinn, a Certified Specialist in Appellate Law, adds a critical layer of depth to the firm’s legal strategy. She focuses on high-level appellate issues and complex trial litigation, particularly in white-collar and regulatory cases, where identifying legal error and constitutional violations is essential.

The firm operates as a united front; every client benefits from a collaborative defense team with decades of experience, strategic foresight, and a commitment to results. When your freedom and reputation are on the line, Werksman Jackson & Quinn LLP is the team you want behind you.