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Charged with or Under Investigation for Health Care Fraud in California?

Federal and State Prosecutors Aggressively Target Every Provider Type — Allegations of False Claims, Upcoding, Kickbacks, or Unnecessary Services Can Lead to Federal Prison, Massive Restitution, Permanent Program Exclusion, and License Revocation.

California criminal defense attorney David Chesley has successfully defended health care fraud investigations and charges — including federal healthcare fraud (18 U.S.C. § 1347), False Claims Act violations, Anti-Kickback Statute matters, Medi-Cal fraud, and related offenses — in federal and state courts across every county in California. These complex cases span physicians, hospitals, home health agencies, DME suppliers, pharmacies, labs, behavioral health providers, and more. They often involve parallel criminal, civil, and administrative proceedings. Early intervention during the investigation phase is critical. Build your defense now.

IMMEDIATE STEPS IF UNDER INVESTIGATION OR CHARGED:

• Do not speak with FBI, HHS-OIG, DOJ, DHCS, or state investigators without counsel — questions are specifically designed to establish knowledge and intent; in health care fraud cases, what you say about your billing practices, your awareness of documentation, and your understanding of coverage rules is the prosecution's most important evidence
• Do not destroy, alter, or delete any records, billing data, or communications — document destruction after a government investigation begins constitutes obstruction of justice carrying its own independent federal felony exposure
• Preserve all documentation — patient records, orders, certifications, billing submissions, marketing agreements, referral arrangements, compensation agreements, and compliance materials
• Contact experienced healthcare fraud counsel immediately — the investigation phase is when cooperating witnesses are developed, documents gathered, and charging theories formed; defendants who engage counsel during the investigation phase have dramatically more options than those who wait

Call now for a free, confidential consultation — available 24/7. 📞 (800) 755-5174

THE STAKES ARE REAL

Health care fraud is a top federal and state enforcement priority in California. Multi-agency task forces — FBI, HHS-OIG, DOJ, and state partners — target false claims, upcoding, kickbacks, and billing for services not rendered, often resulting in multi-million-dollar loss calculations that drive federal sentencing guidelines ranges into years and decades of prison exposure.

A conviction can mean:

• Federal prison: Up to 10 years per count under 18 U.S.C. § 1347 — 20 years or more if serious bodily injury results; up to life if death results
• Massive restitution and fines — full repayment to every affected payer, often totaling millions
• Treble damages under the False Claims Act — civil liability of three times the fraudulent billing amount plus per-claim penalties, running independently of the criminal case
• Permanent exclusion from Medicare and Medi-Cal — ending the ability to operate in or be employed by any entity serving federal healthcare program patients
• License revocation — for physicians, nurses, and all licensed healthcare professionals; mandatory reporting triggers board proceedings
• Asset forfeiture — all proceeds traceable to the alleged fraudulent billing, including business and personal assets

Common Health Care Fraud Allegations vs. Strong Defenses:

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WHAT IS HEALTH CARE FRAUD?

Health care fraud generally involves the knowing submission of false or fraudulent claims to any healthcare benefit program — Medicare, Medi-Cal, private insurance, or workers' compensation. Key statutes include:

• 18 U.S.C. § 1347 — Federal healthcare fraud: knowingly executing a scheme to defraud any healthcare benefit program
• Anti-Kickback Statute (42 U.S.C. § 1320a-7b) — Prohibiting the knowing and willful payment or receipt of remuneration to induce or reward referrals of patients covered by any federal healthcare program
• False Claims Act (31 U.S.C. § 3729) — Civil and criminal liability for knowingly submitting false claims to the federal government, with qui tam whistleblower provisions allowing private parties to file on the government's behalf
• California Penal Code § 550 — State insurance fraud, frequently charged alongside federal counts in California prosecutions
• Welfare and Institutions Code § 14107 — California Medi-Cal fraud, often charged in coordination with federal prosecutors

The government must prove knowing and willful conduct — not honest billing errors or good-faith clinical judgment. That distinction is the foundation of every health care fraud defense.

Key Defenses in Health Care Fraud Cases:

Lack of intent / good faith

Honest mistakes, reliance on billing experts, or genuine clinical decisions do not equal fraud. The prosecution must prove the defendant knew the claims were false — not that billing decisions were later characterized as incorrect by a government reviewer applying hindsight.

Insufficient evidence of falsity

Challenging whether services were actually unnecessary or undocumented — through contemporaneous medical records, treating provider testimony, and independent clinical expert review establishing that services were supported by genuine medical need at the time they were provided.

Anti-Kickback / Stark safe harbors

Legitimate compensation and referral arrangements falling within established regulatory safe harbors and exceptions do not violate these statutes regardless of the government's characterization.

Reliance on experts and compliance systems

Following the advice of compliance officers, billing specialists, or coding experts — and implementing compliance programs — defeats the knowing and willful element the prosecution must prove.

Loss amount challenges

Forensic billing review frequently demonstrates that the government's calculations are significantly overstated — reducing the guidelines range, often by years.

WHO CAN BE CHARGED — INDIVIDUAL LIABILITY IN HEALTH CARE FRAUD CASES

Federal and state health care fraud prosecutions pursue individual criminal liability at every level of the healthcare organization. Understanding what the government must prove for each specific role — and what defenses are available based on that role — is one of the most important early tasks in every health care fraud defense.

Physicians and Licensed Providers

Charged when the government alleges they signed orders, certifications, or prior authorizations without adequate clinical basis, or made medical necessity determinations for billing purposes rather than clinical ones. The most important defense for physicians is that the determination reflected genuine clinical judgment supported by the patient's contemporaneous medical record. A physician who made an honest clinical determination — even one other physicians might have made differently — did not commit fraud. The government's retrospective billing analysis does not establish that individual clinical decisions were fraudulent at the time they were made — and that distinction is the most important battleground in physician-level health care fraud cases.

Nurses, Therapists, and Allied Health Professionals

Charged based on documentation they completed that the government characterizes as falsified or inaccurate. The knowledge element requires proof that they knew their documentation was false — not that it was later found inaccurate by a government reviewer. A clinician who completed documentation based on a genuine patient assessment, with no reason to believe it was supporting fraudulent billing, did not act with the required criminal intent.

Billing Managers and Billing Staff

Charged when the government alleges they submitted claims they knew or should have known were unsupported. The reliance-on-others defense is the most important defense for billing-level defendants: a billing coordinator who submitted claims based on clinical documentation provided by licensed professionals, followed standard billing procedures, and had no independent ability to verify clinical accuracy did not act with knowing and willful intent. The government must prove the billing staff member's specific knowledge — not merely that false claims were submitted by the organization.

Owners, Executives, and Administrators

Charged based on their establishment of business models, compensation structures, and operational policies that allegedly produced fraudulent billing. Individual knowledge is required — general awareness of the business is not sufficient. Executives who implemented compliance programs, relied on advice of counsel, and had no specific knowledge that individual claims were false have specific defenses that distinguish their exposure from those who designed or directed the fraud.

Marketing and Sales Staff

Charged in kickback cases based on their role in recruiting patients or providers through alleged remuneration arrangements. Staff who implemented arrangements they were told were legally compliant have specific reliance defenses — the knowing and willful element required for AKS violations is the most important defense target for marketing-level defendants.

The Critical Principle for All Individual Defendants

Individual criminal liability requires proof that the specific defendant acted with knowledge that the claims were false or with deliberate indifference to their falsity — not proof that false claims were submitted somewhere in the organization. Each defendant's specific role, specific knowledge, and specific conduct is analyzed independently — and the government's burden to prove knowledge as to each defendant is the foundation of every individual liability defense.

HOW DAVID CHESLEY DEFENDS HEALTH CARE FRAUD CASES

These cases require simultaneous defense on criminal, civil False Claims Act, and administrative exclusion tracks — while protecting individual defendants from organizational liability and ensuring the government's fraud theory is contested at every level. David Chesley personally handles every health care fraud case statewide — Southern, Central, and Northern California, every county, every major federal district — and is available 24 hours a day, 7 days a week. No hand-offs. No junior associates.

Core defense strategies pursued immediately:

Investigation-phase intervention

The most important defense work happens before charges are filed. Grand jury subpoena responses, employee interview coordination, joint defense arrangements, and presentation of exculpatory evidence to prosecutors — all pursued immediately, because the window to influence the charging theory closes at indictment.

Challenging the government's clinical and billing theory

Billing analysis challenged through contemporaneous medical records, treating provider testimony, independent clinical and coding expert review, and the specific coverage rules governing the services at issue.

Individual knowledge element defense

Each defendant's specific role, actual knowledge, and conduct is analyzed independently — because individual liability requires more than organizational proximity to fraud.

Loss amount challenge

Independent forensic billing analysis examines the government's methodology, identifies claims incorrectly included in the loss calculation, and challenges overstated figures inflating the guidelines range.

Anti-Kickback and Stark safe harbor analysis

Every compensation arrangement alleged as a kickback or self-referral violation is analyzed against the full safe harbor and exception framework.

Civil FCA and administrative track management

Civil FCA exposure, program exclusion proceedings, and licensing consequences are addressed simultaneously — because decisions in one track directly affect the others.

Free, confidential case review — available 24/7, no obligation. 📞 (800) 755-5174 | 📧 calllog@chesleylawyers.com

YOU HAVE RIGHTS. USE THEM.

The government must prove knowing and willful submission of false claims — not good-faith decisions, coding disputes, or honest billing errors. Many health care fraud cases resolve significantly better than defendants initially face:

• Investigation closed without charges — early intervention presents exculpatory evidence; government declines to charge
• Individual charges defeated — knowledge element not established; defendant's role and actual knowledge insufficient for criminal liability
• Fraud theory successfully challenged — contemporaneous records and expert testimony establish legitimate services and good-faith billing
• Loss amount successfully reduced — forensic analysis demonstrates overstated calculation; guidelines range reduced by years
• Kickback allegations defeated — compensation arrangements fall within AKS safe harbors; corrupt intent not established
• Civil FCA exposure negotiated — civil settlement achieves favorable resolution while preserving criminal defenses
• Exclusion minimized or avoided — resolution structured to limit program exclusion consequences
• License consequences minimized — resolution structured to reduce mandatory reporting and board exposure
• Immigration-safe resolution — charge resolved without conviction constituting crime of moral turpitude or aggravated felony

WHY CLIENTS CHOOSE DAVID CHESLEY

Direct, personal attention — statewide, 24/7

David Chesley personally handles health care fraud defense in federal courts and California state courts across all of California — Los Angeles, San Diego, Orange County, San Francisco, Sacramento, Fresno, San Jose, Riverside, San Bernardino, Ventura, and every other jurisdiction statewide. Available 24 hours a day, 7 days a week — because federal and state agents appear unannounced and the window to respond effectively is measured in minutes.

Straight talk, always

Health care fraud cases range from situations where the government's theory is legally defective, individual knowledge cannot be established, or the loss amount is substantially overstated — to cases where the evidence is substantial and the focus shifts to minimizing guidelines exposure, negotiating cooperation, or preserving the ability to continue practicing. You deserve honest counsel about which situation you are actually in. No false promises. No sugarcoating.

Multi-track strategy — federal, state, civil, and administrative

The criminal case, the civil FCA track, program exclusion proceedings, and professional licensing consequences all require simultaneous management. Positions taken in one track can create exposure in the others.

Federal and state healthcare fraud expertise across every provider type

Deep knowledge of 18 U.S.C. § 1347, the Anti-Kickback Statute and safe harbors, the False Claims Act and qui tam provisions, the Stark Law, California PC § 550, California W&I § 14107, federal sentencing guidelines loss amount calculations, DOJ and HHS-OIG investigation methodology, and the specific billing, clinical, and compliance issues that define health care fraud prosecutions across every provider type — physicians, hospitals, home health agencies, DME suppliers, pharmacies, behavioral health providers, labs, and more — across every region of California.

Flexible payment plans

The Law Offices of David Chesley offer flexible payment plans because cost should never be the reason someone under investigation for health care fraud goes without experienced representation during the phase when it matters most.

Representative Results:

• Federal health care fraud investigation closed without charges — investigation-phase intervention presented billing documentation and clinical records establishing legitimate services and good-faith billing practices; government declined to charge
• Physician avoided individual charges — medical necessity defense established through contemporaneous records and independent clinical expert testimony; government's retrospective billing analysis found insufficient to support individual criminal liability
• Loss amount significantly reduced — forensic billing analysis identified substantial portion of government's alleged loss as legitimately documented services; revised amount reduced guidelines range by multiple levels; sentence reduced by years
• Billing coordinator charges dismissed — reliance-on-others defense established; defendant submitted claims based on clinical documentation she had no reason to question; knowing and willful element not proven
• Kickback allegations defeated — compensation arrangement found to fall within AKS safe harbor; corrupt intent not established; Anti-Kickback charges dismissed
• Civil FCA qui tam lawsuit resolved — whistleblower lawsuit resolved through negotiated settlement preserving key defenses in the parallel criminal proceedings
• Program exclusion minimized — resolution structured to limit exclusion period; defendant's ability to continue in non-federal program capacity preserved
• Immigration-safe resolution — non-U.S. citizen defendant's charges resolved without healthcare fraud conviction; deportation exposure avoided

Client Feedback:

"Federal and state investigators showed up simultaneously. David coordinated the entire response — investigation strategy, staff communications, document preservation. The investigation was closed without charges." — Anonymous healthcare provider

"I was a billing coordinator with no knowledge of any fraud. David established I had no reason to question the clinical documentation. Charges dismissed." — Anonymous former client

"The government's loss figure would have meant years in prison. David's forensic analysis cut it dramatically. The reduction in my sentencing exposure changed everything." — Anonymous former client

"Non-citizen physician. David explained from the first consultation that a federal conviction meant deportation and built the defense entirely around protecting my status. Resolved without a conviction." — Anonymous former client

FREQUENTLY ASKED QUESTIONS

What is health care fraud — and how is it different from a billing error?

Health care fraud involves the knowing and willful submission of false or fraudulent claims to any healthcare benefit program — claims the submitter knew were inaccurate, not supported by documentation, or not for services actually rendered. A billing error — an honest coding mistake, a documentation gap, an inadvertent submission that did not meet technical requirements — is not fraud. The critical distinction is knowledge and intent: the prosecution must prove the defendant knew the claims were false and submitted them intentionally. Good-faith coding decisions, honest clinical judgment, and genuine interpretation of complex coverage rules are not fraud — and that distinction is the foundation of every health care fraud defense.

Who can be charged — is it just the owners?

No — health care fraud charges are filed against individuals at every level of the healthcare organization. Physicians, clinical staff, billing coordinators, marketing employees, and executives are all charged individually. But each defendant's criminal liability requires proof of their specific knowledge of the fraud — not merely that they worked for an organization that submitted false claims. Each defendant's specific role, specific knowledge, and specific conduct is analyzed and defended independently.

How do federal sentencing guidelines work — and why does the loss amount matter so much?

Federal sentencing guidelines for health care fraud use the loss amount — the total value of the fraudulent billing alleged — as the primary driver of the sentencing range. Each loss tier adds offense levels that translate directly into months and years of additional recommended sentence. The difference between a $500,000 loss and a $1.5 million loss can mean 2 to 3 additional years. The difference between $1.5 million and $3.5 million adds more years still. Cases involving losses in the tens of millions produce guideline ranges measured in decades — and each tier crossed adds mandatory years that cannot be avoided through probation or suspended sentence in most circumstances. Government loss calculations are frequently overstated — including claims for legitimately rendered services, failing to offset legitimate reimbursements, and using statistical extrapolation methodologies that inflate the fraud rate. An independent forensic billing analysis that moves the loss amount from one guidelines tier to a lower one can reduce the recommended sentence by years — and in cases involving very large alleged losses, by a decade or more. Loss amount challenge is pursued from the first day of representation in every case where sentencing guideline enhancements are alleged.

What is the False Claims Act — and how does it affect my case?

The False Claims Act (31 U.S.C. § 3729) creates civil liability for submitting false or fraudulent claims to the federal government — and in health care fraud cases, the civil FCA exposure frequently dwarfs the criminal penalties. The FCA allows the government to recover treble damages — three times the total amount of the false claims — plus per-claim civil penalties of $13,000 to $27,000 for each individual false claim submitted. A healthcare provider that submitted billing across thousands of patients over several years faces civil FCA liability that can be measured in hundreds of millions of dollars, entirely independent of and in addition to the criminal case. The FCA's qui tam provision allows private whistleblowers — including former employees, disgruntled staff, or competitors with inside knowledge — to file FCA lawsuits on behalf of the government under seal, giving the government the opportunity to investigate and intervene. Whistleblowers share in any recovery — typically 15 to 25 percent — and a qui tam filing frequently triggers the criminal investigation in the first place. The civil FCA track runs simultaneously with the criminal case, and managing both tracks without creating additional exposure in either — how a civil resolution affects the criminal defense, whether civil cooperation produces benefits in the criminal case — is one of the most important strategic questions in every health care fraud defense, analyzed from the very first consultation.

What is the Anti-Kickback Statute — and what safe harbors protect legitimate arrangements?

The Anti-Kickback Statute (42 U.S.C. § 1320a-7b) prohibits the knowing and willful payment or receipt of remuneration to induce or reward referrals of patients covered by any federal healthcare program. AKS violations require knowing and willful conduct — a specific corrupt intent. The statute provides safe harbors for bona fide employment arrangements, personal services arrangements, fair market value compensation, and other legitimate structures. Arrangements falling within a safe harbor do not violate the AKS regardless of the government's characterization — and every arrangement alleged as a kickback is analyzed against the full safe harbor framework from the first day of representation.

What is the difference between federal and state health care fraud charges — can I face both?

Yes — many California health care fraud prosecutions involve both federal charges under 18 U.S.C. § 1347 and state charges under PC § 550 or W&I § 14107. Federal charges are prosecuted by the U.S. Attorney's Office and carry federal sentencing guidelines exposure. State charges are prosecuted by the California Department of Justice or county district attorneys and carry California state prison exposure. Both prosecutions can proceed simultaneously — and the defense strategy must account for both tracks, because concessions made in one can affect the other. David Chesley handles both federal and state health care fraud defense across every county in California and in every federal district.

What is program exclusion — and how serious is it?

Exclusion from Medicare and Medi-Cal means the individual or organization cannot participate in any federal healthcare program — cannot treat covered patients, cannot bill those programs, and cannot be employed by any entity that bills them. For healthcare professionals in California — where the majority of patients are covered by Medicare or Medi-Cal — exclusion effectively ends the ability to practice in most clinical settings. Mandatory exclusion applies automatically upon conviction for certain healthcare fraud offenses. Minimizing or avoiding exclusion through the structure of the resolution is a critical component of every health care fraud defense strategy.

What if a former employee filed a qui tam lawsuit?

A qui tam lawsuit is a False Claims Act suit filed by a private whistleblower on behalf of the federal government. The whistleblower files under seal, giving the government the opportunity to investigate and decide whether to intervene. If the government intervenes and the case is successful, the whistleblower shares in the recovery — typically 15 to 25 percent. A qui tam filing frequently triggers the criminal investigation, and the whistleblower's allegations often form the foundation of the government's charging theory. Understanding the specific allegations, who filed the lawsuit, their motivations, and how the civil and criminal tracks interact is essential from the very first consultation.

Will a conviction affect my professional license?

A federal or state health care fraud conviction triggers mandatory reporting to the California Medical Board, Board of Registered Nursing, Board of Pharmacy, or other relevant licensing board — and creates substantial risk of license revocation or suspension. For most licensed healthcare professionals, a felony health care fraud conviction produces both criminal consequences and career-ending licensing consequences simultaneously. License consequences are analyzed from the first consultation in every case involving licensed professionals.

Can a conviction affect my immigration status?

Seriously and potentially permanently. Federal health care fraud convictions are crimes of moral turpitude and potentially aggravated felonies under federal immigration law — triggering mandatory deportation, detention, removal, and permanent bars to naturalization for non-U.S. citizens. Immigration consequences must be analyzed from the very first consultation for any non-U.S. citizen facing a health care fraud investigation or charge.

Do you handle cases throughout California?

Yes — in every federal district and every county superior court across all of California, from Los Angeles and San Diego in the south to San Francisco and Sacramento in the north, and every jurisdiction in between.

Are payment plans available?

Yes. The Law Offices of David Chesley offers flexible payment plans because cost should never be the reason someone under investigation for or charged with health care fraud goes without experienced legal representation during the phase when it matters most. Call to discuss options during your free consultation.

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FREE CONSULTATION — CALL NOW — 24/7

Health care fraud investigations move quickly and involve multiple agencies — and every day without experienced defense counsel is a day the investigation advances on both federal and state tracks without anyone protecting the defendant's rights or presenting the exculpatory billing and clinical evidence that might prevent charges from being filed. Every day employees are approached and interviewed by federal and state agents without coordinated defense guidance is a day statements are made — by billing staff, clinical employees, and marketing personnel — that will be used to build the case against individual defendants who may have had no idea those conversations were occurring or what was being said on their behalf. Every day the government's loss calculation sits unchallenged in the investigation file is a day the overstated figure that may be inflating the guidelines range by years becomes more embedded in the prosecution's charging theory — and the forensic billing analysis that could challenge it and move the loss amount to a lower guidelines tier becomes harder to conduct as records age, the government's narrative calcifies, and the window to influence the charging document closes before any defense attorney has had the opportunity to present the alternative calculation that could reduce the sentence by years. Every day a qui tam whistleblower lawsuit moves forward without coordinated civil and criminal defense strategy is a day the civil and criminal tracks develop independently in ways that may conflict and create additional exposure in both.

Don't wait for charges to be filed. Don't assume the investigation will resolve itself. And don't speak to federal or state agents without experienced counsel. If you have received a subpoena, if investigators have appeared at your practice or your home, if you have been contacted by the FBI, HHS-OIG, DOJ, or DHCS, if a former employee has filed a qui tam lawsuit, or if you have been formally charged with health care fraud or related offenses, call now.

The Law Offices of David Chesley offer a free, confidential consultation available 24 hours a day, 7 days a week. No judgment. No pressure. Clear, honest guidance on your specific situation across every track — criminal, civil, and administrative.

Flexible payment plans available.

David Chesley handles health care fraud defense in federal courts and criminal courts across all of California — Los Angeles County, Orange County, San Diego County, Riverside County, San Bernardino County, Ventura County, Santa Barbara County, Kern County, Fresno County, Sacramento County, Alameda County, Santa Clara County, San Francisco County, Contra Costa County, San Joaquin County, Stanislaus County, Monterey County, and every other jurisdiction statewide.

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📞 (800) 755-5174 📧 calllog@chesleylawyers.com 🌐 www.chesleylawyers.com

"Health care fraud prosecutions are complex matters involving billing practices, clinical judgment, and federal sentencing guidelines. The government must prove knowing and willful submission of false claims — not honest errors or good-faith decisions. My commitment is to defend every element aggressively on every track — criminal, civil, and administrative — while protecting your freedom, license, and future." — David Chesley, California Criminal Defense Attorney