Healthcare Fraud Defense in New York

Federal healthcare fraud under 18 U.S.C. § 1347 carries a maximum of ten years per count — twenty if serious bodily injury results, life if death results. The investigation usually begins with a civil audit (UPIC/ZPIC), a CMS overpayment determination, or a qui tam complaint, and migrates to the US Attorney's Office only when the dollar volume justifies it.

The Audit-to-Indictment Pipeline

• UPIC/ZPIC audits. The Unified Program Integrity Contractor pulls a sample of claims, calls the records, and extrapolates the error rate across the universe of paid claims. Defense work focuses on the sampling methodology, the medical-necessity standard applied, and the documentation underlying each contested claim.
• OIG subpoenas. HHS-OIG can issue subpoenas under 5 U.S.C. App. § 6(a)(4). Compliance and privilege review must happen quickly.
• Search warrants. When the case turns criminal, the practice or pharmacy gets a search warrant. Patient charts, billing software, and bank records leave on a truck. Pre-warrant lawyering preserves options the audit-stage client cannot reclaim.
• Indictment. Counts typically include 18 U.S.C. § 1347 (healthcare fraud), § 1349 (conspiracy), § 1343 (wire fraud), and frequently kickback charges under 42 U.S.C. § 1320a-7b(b).

Common Defenses

• Medical necessity. Whether a service was medically necessary turns on the standard of care, not the auditor's worksheet.
• Specific intent. 18 U.S.C. § 1347 requires intent to defraud. Reliance on coding consultants, compliance officers, and billing services is a defense.
• Sampling and extrapolation. Statistical sampling methodologies are routinely vulnerable to challenge under HHS-OIG and CMS guidance.
• Stark Law and AKS structuring. Many relationships fall within statutory safe harbors that the prosecution misreads.

Parallel Civil and Licensing Issues

Criminal healthcare prosecutions run alongside False Claims Act civil actions, OIG exclusion proceedings, and state licensing matters before OPMC, OPD, the Board of Pharmacy, or the Department of Health. We coordinate all four tracks so a move in one does not damage the others.

If you have received an audit demand, a subpoena, or an indictment in a healthcare-fraud case, call us at 212-233-1233 or email email@goodwindefense.com.