Healthcare Fraud Attorney for Medical Billing and Coding Errors
Medical billing and coding errors can quickly escalate into serious civil or criminal investigations. Healthcare providers who submit claims to Medicare, Medicaid, TRICARE,
or other federal programs face strict compliance requirements under the False Claims Act and other federal statutes.
Even unintentional coding mistakes can trigger audits, repayment demands, civil penalties, and federal criminal investigations.
If your practice is under investigation for billing irregularities, upcoding, or improper documentation, early legal intervention is critical to protecting your license, reputation, and freedom.
Your best hope for a favorable outcome is with an experienced criminal defense attorney at the Hedding Law Firm in Los Angeles. To schedule a consultation, call (866) 986-2092 or use the contact form here.
When Do Coding Errors Become Healthcare Fraud?
Healthcare fraud allegations often begin with routine audits or algorithm-driven reviews by federal enforcement agencies. The government analyzes billing data to identify outliers and suspicious patterns.
Coding errors may lead to fraud allegations when investigators believe a provider:
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Knowingly submitted false claims
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Overbilled government healthcare programs
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Used improper billing codes
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Received payments for services not rendered
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Failed to maintain proper documentation
The key legal issue in criminal cases is intent. Prosecutors must prove that a provider knowingly and willfully submitted false claims. However, under the False Claims Act, civil liability does not always require proof of criminal intent.
Federal Laws That Apply to Coding Errors
Several federal statutes may apply when billing errors are discovered.
False Claims Act
The False Claims Act allows the government to pursue civil penalties for false or fraudulent claims submitted to federal healthcare programs. Violations can result in:
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Treble damages
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Substantial per-claim penalties
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Whistleblower (qui tam) lawsuits
Federal Criminal Healthcare Fraud Statutes
Under 18 U.S.C. § 1347, knowingly executing a scheme to defraud a healthcare benefit program can result in federal criminal prosecution.
Criminal penalties may include:
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Federal prison time
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Significant fines
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Restitution
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Supervised release
Anti-Kickback Statute and Stark Law
Improper referral arrangements, financial relationships, and kickback allegations may accompany coding investigations.
Common Medical Billing and Coding Errors That Trigger Investigations
Healthcare providers face scrutiny for a wide range of billing practices. The most common allegations include:
Upcoding
Billing for a higher level of service than was actually performed.
Unbundling
Separating procedures that should be billed under a single comprehensive code.
Phantom Billing
Submitting claims for services that were never provided.
Duplicate Billing
Charging multiple times for the same procedure or service.
Improper Use of Provider Identifiers
Using a physician's National Provider Identifier for services not personally performed or supervised.
Lack of Documentation
Submitting claims unsupported by adequate medical records.
Medically Unnecessary Services
Billing for procedures or tests lacking clinical justification.
Falsified Diagnoses
Assigning inaccurate diagnosis codes to justify reimbursement.
Even if errors were unintentional, repeated irregularities can raise red flags.
Government Investigations and Audits
Healthcare fraud investigations often involve:
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Medicare Fraud Strike Force audits
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DOJ investigations
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FBI surveillance
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Subpoenas for billing records
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Grand jury proceedings
Federal agencies use sophisticated data analytics to identify providers whose billing patterns deviate from national norms.
If contacted by federal investigators, you should not provide statements without legal counsel present.
Civil vs. Criminal Exposure
Civil Enforcement
Civil enforcement under the False Claims Act may result in:
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Repayment of overbilled amounts
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Treble damages
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Exclusion from federal healthcare programs
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Professional disciplinary action
Criminal Prosecution
If the government alleges intentional fraud, criminal penalties may include:
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Up to 10 years in federal prison per count
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Enhanced penalties if bodily injury resulted
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Significant fines
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Permanent exclusion from Medicare and Medicaid
Early intervention may significantly affect whether a case remains civil or escalates to criminal prosecution.
Defense Strategies in Coding Error Cases
An effective defense requires a detailed review of billing practices, compliance policies, and documentation.
Common defense approaches include:
Lack of Intent
Demonstrating errors were administrative, technical, or based on complex regulatory misunderstandings.
Good Faith Compliance Program
Evidence of active compliance training, audits, and corrective measures may reduce liability.
Prompt Repayment
Voluntary self-disclosure and repayment can mitigate enforcement actions.
Challenging Data Analysis
Statistical sampling and algorithm-based conclusions can be challenged.
Expert Testimony
Coding experts may rebut allegations of intentional misconduct.
Each case requires individualized evaluation.
Why Healthcare Providers Must Act Immediately
Healthcare fraud investigations can escalate quickly.
Consequences may include:
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Freezing of accounts
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Seizure of records
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Suspension from Medicare billing
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Professional license review
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Public reputational harm
A proactive legal strategy is often the difference between regulatory resolution and criminal indictment.
Frequently Asked Questions
Can an honest billing mistake be considered fraud?
Yes. Even unintentional mistakes may trigger civil liability. Criminal charges require proof of intent.
What should I do if I receive a subpoena?
Contact a federal defense attorney immediately. Do not respond without legal guidance.
Can repayment avoid criminal charges?
Repayment may mitigate penalties but does not automatically prevent prosecution.
How do investigators detect billing irregularities?
Federal agencies use data analytics to compare billing patterns against peer benchmarks.
Can I lose my medical license?
Yes. Licensing boards may initiate disciplinary proceedings following fraud allegations.
Protect Your Practice and Professional License
Healthcare fraud allegations involving billing and coding errors are serious matters that require experienced legal representation.
If you are under audit, investigation, or facing allegations of improper billing practices, consult with a federal healthcare fraud defense attorney immediately.
Early case assessment, compliance review, and strategic response can protect your career, your business, and your freedom.
The Hedding Law Firm is here to help. Schedule your consultation today. Our law firm is based in Los Angeles, CA
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