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Charged with or Under Investigation for Medicare Fraud in California?

Federal Prosecutors Treat Medicare Fraud as a Top Priority — Allegations of False Claims, Upcoding, Kickbacks, or Unnecessary Services Can Lead to Years in Federal Prison, Massive Restitution, Permanent Exclusion from Medicare and Medi-Cal, and License Revocation.

California criminal defense attorney David Chesley has successfully defended Medicare fraud investigations and charges — including federal healthcare fraud (18 U.S.C. § 1347), False Claims Act violations, Anti-Kickback Statute matters, and related Medi-Cal fraud allegations — in federal and state courts across every county in California. These complex white-collar cases 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, or CMS investigators without counsel — questions are specifically designed to establish knowledge and intent; in Medicare fraud cases, what you say about your billing practices, your awareness of documentation gaps, 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 and carries its own federal felony exposure entirely independent of the underlying fraud allegations
• Preserve all documentation — patient records, orders, certifications, billing submissions, marketing agreements, referral arrangements, and compliance materials
• Contact experienced federal healthcare fraud counsel immediately — the investigation phase is when the government builds its case, develops cooperating witnesses, and forms its charging theory; early defense can prevent charges from being filed or significantly limit exposure before the government's narrative is locked in

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

THE STAKES ARE REAL

Medicare fraud is a high-priority federal enforcement area in California. Multi-agency task forces — FBI, HHS-OIG, DOJ, and state partners — target false claims, upcoding, kickbacks, and billing for unnecessary services, 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 Medicare and all affected government payers, 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 Medicare Fraud Allegations vs. Strong Defenses:

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WHAT IS MEDICARE FRAUD?

Medicare fraud generally involves the knowing submission of false or fraudulent claims to Medicare. Key federal 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 Medicare or Medi-Cal patients
• 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 Medicare fraud prosecutions

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

Key Defenses in Medicare Fraud Cases:

Lack of intent / good faith

Honest billing errors, reliance on coding experts, genuine clinical decisions, and good-faith interpretation of complex Medicare coverage rules do not equal fraud. The prosecution must prove the defendant knew the claims were false and submitted them intentionally — not that billing decisions were later characterized as incorrect by a government reviewer.

Insufficient evidence of falsity

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

Anti-Kickback safe harbors

Legitimate compensation arrangements that fall within established AKS safe harbors — bona fide employment, personal services, fair market value compensation, and other regulatory exceptions — do not violate the statute 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 designed to ensure accurate billing — defeats the knowing and willful element the prosecution must prove.

Loss amount challenges

The government's loss calculation is frequently overstated — including legitimately rendered services, failing to offset legitimate reimbursements, or using flawed statistical sampling. Reducing the loss amount reduces the sentencing guidelines range, often by years.

WHO CAN BE CHARGED — INDIVIDUAL LIABILITY IN MEDICARE FRAUD CASES

Federal Medicare 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 Medicare fraud defense.

Physicians and Other Licensed Providers

Charged when the government alleges they signed orders, certifications, or prior authorizations without adequate clinical basis, or made medical necessity determinations driven by billing rather than clinical judgment. The most important defense for physicians is that the medical necessity determination, the order, or the certification reflected genuine clinical judgment supported by the patient's contemporaneous medical record. A physician who made a genuine clinical determination — even one that other physicians might have made differently — did not commit fraud. The government's retrospective billing data 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 Medicare 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 for clinical staff requires proof that they knew their documentation was false — not that it was later found to be inaccurate by a government reviewer. A nurse or therapist who completed documentation based on a genuine patient assessment, and who had no reason to believe assessments were being used to support 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, who followed standard billing procedures, and who had no independent ability to verify the clinical accuracy of the underlying records did not act with knowing and willful intent. The government must prove the billing staff member's specific knowledge of the false nature of the claims — not merely that false claims were submitted by the organization.

Owners, Executives, and Administrators

Charged based on their establishment of business models, operational policies, and compensation structures that allegedly produced fraudulent billing. Individual knowledge is required — awareness of the general nature 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. The knowing and willful element — that the marketing employee knew the arrangement violated the Anti-Kickback Statute — is the most important defense target, and staff who implemented arrangements they were told were legally compliant have specific reliance defenses.

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 individual defendant is the foundation of every individual liability defense.

HOW DAVID CHESLEY DEFENDS MEDICARE FRAUD CASES

These cases require simultaneous defense on criminal, civil False Claims Act, and administrative exclusion tracks — while protecting individual defendants from organizational liability, managing coordinated defense of multiple defendants, and ensuring the government's fraud theory is contested at every level. David Chesley personally handles every Medicare 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 billing and clinical evidence to prosecutors — all pursued immediately upon retention, because the window to influence the charging theory closes at indictment.

Challenging the government's fraud theory

Billing analysis challenged through contemporaneous medical records, treating provider testimony, independent clinical and coding expert review, and the specific Medicare coverage rules governing the services at issue — establishing that billing reflected legitimate services, genuine clinical determinations, and good-faith compliance with complex coverage requirements.

Individual knowledge element defense

Each defendant's specific role, actual knowledge, and specific conduct is analyzed independently to determine whether the government can establish knowing and willful conduct — 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 safe harbor analysis

Every compensation arrangement alleged as a kickback is analyzed against the AKS safe harbor framework to determine whether a legitimate structural defense exists.

Civil FCA and administrative track management

Civil False Claims Act exposure, Medicare exclusion proceedings, and professional licensing consequences are addressed simultaneously with the criminal defense — 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 Medicare fraud cases resolve significantly better than defendants initially face:

• Investigation closed without charges — early intervention presents exculpatory billing and clinical 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, genuine medical necessity, and good-faith billing
• Loss amount successfully reduced — forensic analysis demonstrates government's calculation overstated; 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 defenses in the criminal case
• Exclusion minimized or avoided — resolution structured to limit Medicare exclusion consequences
• License consequences minimized — resolution structured to reduce mandatory reporting and licensing 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 Medicare fraud defense in federal courts and California 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 agents appear unannounced and the window to respond effectively to initial government contact is measured in minutes.

Straight talk, always

Medicare 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 — criminal, civil, and administrative

The criminal case, the civil FCA track, and the Medicare exclusion proceedings all require simultaneous management. Positions taken in one track can create exposure in the others — and the overall strategy must account for every track from the first consultation.

Federal healthcare fraud expertise

Deep knowledge of the federal Medicare billing and coverage framework, Anti-Kickback Statute and safe harbors, False Claims Act and qui tam provisions, federal healthcare fraud sentencing guidelines loss amount calculations, Medicare Fraud Strike Force investigation methodology, and the specific billing and clinical documentation issues that define every Medicare fraud prosecution — 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 Medicare fraud goes without experienced representation during the phase when it matters most.

Representative Results:

• Federal Medicare fraud investigation closed without charges — investigation-phase intervention presented billing documentation and clinical records establishing legitimate services; government declined to charge
• Physician avoided individual charges — medical necessity defense established through contemporaneous records and independent clinical expert testimony; government's retrospective 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 — marketing 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 that preserved key defenses in the parallel criminal proceedings
• Medicare exclusion minimized — resolution structured to limit exclusion period; defendant's ability to continue in non-Medicare clinical capacity preserved
• Immigration-safe resolution — non-U.S. citizen defendant's charges resolved without healthcare fraud conviction; deportation exposure avoided

Client Feedback:

"Federal agents appeared without warning. David coordinated the entire response — the investigation, our staff's communications, the document preservation. The investigation was closed without charges." — Anonymous medical practice owner

"I was a billing manager 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 over a decade in prison. David's forensic analysis cut it dramatically. The reduction in my sentencing exposure changed everything." — Anonymous former client

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

FREQUENTLY ASKED QUESTIONS

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

Medicare fraud involves the knowing and willful submission of false or fraudulent claims — claims the submitter knew were inaccurate, unsupported 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 the defendant's 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 Medicare coverage rules are not fraud — and that distinction is the foundation of every Medicare fraud defense.

Who can be charged — is it just the practice owners?

No — federal Medicare fraud charges are filed against individuals at every level of the healthcare organization. Physicians who signed orders without adequate clinical basis, clinical staff who completed documentation the government characterizes as falsified, billing staff who submitted claims, marketing employees who participated in kickback arrangements, and owners and executives who established the billing practices are all charged individually. But each individual 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 healthcare fraud use the loss amount — the total value of the fraudulent billing alleged — as the primary driver of the sentencing range. Each loss tier in the guidelines 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. This is why challenging the government's loss calculation is one of the most important and most frequently successful strategies in every federal Medicare fraud case. Government loss calculations are frequently overstated — including claims for legitimately rendered services that should not be counted as fraudulent loss, failing to offset legitimate reimbursement amounts, and using statistical extrapolation methodologies that inflate the fraud rate beyond what the actual clinical records support. 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. This analysis is pursued from the first day of representation in every Medicare fraud 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 Medicare 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 for thousands of improper claims over several years faces civil FCA liability 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 and share in any recovery, sometimes triggering the government's criminal investigation in the first place. The civil FCA track runs simultaneously with the criminal case — but decisions made in one track can directly affect the other. How a civil resolution affects the criminal defense, whether civil cooperation produces benefits in the criminal case, and how to manage both tracks without creating additional exposure in either are among the most important strategic questions in every Medicare fraud defense, and they are analyzed from the very first consultation.

What is the Anti-Kickback Statute — and what safe harbors are available?

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 Medicare or Medi-Cal. In Medicare fraud cases, common AKS allegations involve referral fee arrangements with physicians, marketing arrangements involving gifts or meals to referral sources, and compensation arrangements with facilities in exchange for patient access. AKS violations require knowing and willful conduct — a specific corrupt intent that must be proven beyond a reasonable doubt. The statute provides safe harbors for bona fide employment arrangements, personal services arrangements meeting specific criteria, 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 safe harbor framework from the first day of representation.

What is Medicare exclusion — and how serious is it?

Exclusion from Medicare and Medi-Cal means the individual or organization cannot participate in federal healthcare programs — cannot treat Medicare or Medi-Cal 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 Medicare fraud defense strategy.

What if a former employee filed a qui tam lawsuit — what does that mean?

A qui tam lawsuit is a False Claims Act suit filed by a private whistleblower — frequently a former employee, a disgruntled staff member, or a competitor — 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 of the government's total recovery. A qui tam lawsuit frequently triggers the criminal investigation, and the whistleblower's allegations often form the foundation of the government's charging theory. Understanding the specific allegations in the qui tam complaint, who filed it, what their motivations are, and how the civil and criminal tracks interact is essential from the very first consultation.

Will a conviction affect my medical or professional license?

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

Can a conviction affect my immigration status?

Seriously and potentially permanently. Federal healthcare 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. For any non-U.S. citizen under investigation for or charged with Medicare fraud, immigration consequences must be analyzed from the very first consultation.

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 Medicare fraud goes without experienced legal representation during the phase when it matters most. Call to discuss options during your free consultation.

More questions? We are available 24/7 — free consultation, no obligation, no pressure. 📞 (800) 755-5174

FREE CONSULTATION — CALL NOW — 24/7

Medicare fraud investigations move quickly and involve multiple agencies — and every day without experienced defense counsel is a day the investigation advances without anyone protecting the defendant's rights or presenting the exculpatory evidence that might prevent charges from being filed. Every day employees are approached and interviewed by federal agents without coordinated defense guidance is a day statements are made — by billing staff, clinical employees, and marketing personnel inside the organization — 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 and the government's narrative about total harm calcifies into an indictment. Every day a qui tam whistleblower lawsuit moves forward without coordinated civil and criminal defense 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 agents without experienced counsel. If you have received a subpoena, if federal agents have appeared at your practice or your home, if you have been contacted by the FBI, HHS-OIG, or CMS, if a former employee has filed a qui tam lawsuit, or if you have been formally charged with Medicare fraud or related federal 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 Medicare 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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"Medicare 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