A billing error. A referral arrangement you’ve had in place for years. A former employee with a grudge. Any one of these can be the starting point for a federal healthcare fraud investigation, and by the time you know it’s happening, the government may have been building its case for months.

At Capitelli & Wicker, our healthcare fraud defense attorneys in New Orleans have seen exactly how fast these situations escalate. Our team includes former state and federal prosecutors who know how the government constructs these cases and what it takes to dismantle them.

What is Health Care Fraud?

Health care fraud, under 18 U.S.C. § 1347, is when a person intentionally deceives the health care system to receive unlawful benefits or payments. 

• Healthcare fraud attempts count the same as completed fraud. If you tried to commit fraud but didn’t succeed, the penalties are identical.
• You don’t have to know it was illegal. If the government can show you deliberately ignored obvious warning signs, that’s enough to meet the intent requirement.
• Penalties scale with the outcome. A standard conviction means up to 10 years in federal prison. If someone is seriously hurt, that rises to 20 years. If someone dies, it can mean life in prison.

Investigations are typically run by the FBI, the Department of Justice, the U.S. Postal Service, and the HHS Office of Inspector General, often by more than one at the same time.

Common Health Care Fraud Charges in Louisiana

Medicare, Medicaid, and Billing Fraud

These charges involve false billing to Medicare or Medicaid by means of:

• Upcoding: billing for a more expensive service than the one actually performed
• Unbundling: splitting services that should be billed together to inflate the total
• Phantom billing: submitting claims for services, procedures, or patients that don’t exist
• Medically unnecessary services: running up claims for treatments the patient didn’t actually need

Given the size of Louisiana’s Medicare and Medicaid population, these cases are a consistent enforcement priority. Each false claim submitted to Medicare or Medicaid can carry its own civil penalty. Across a large volume of billing, these add up fast.

Prescription Fraud

With opioid prescribing under intense national scrutiny, prescription-related charges remain a major exposure area for providers across Louisiana. This includes prescribing without a legitimate medical reason, participating in or operating a pill mill, forging prescriptions, and the illegal distribution of controlled substances.

Anti-Kickback Violations

Under the Anti-Kickback Statute, it is a federal felony to pay, offer, ask for, or accept anything of value in exchange for patient referrals that involve a federally funded health program. “Anything of value” could mean anything from cash to free rent, meals, consulting fees, and other perks.

Even if referral inducement were just one part of your payment arrangement, you may still be violating the law. For that, you could be looking at up to 10 years in prison and fines up to $100,000.

Stark Law Violations

The Stark Law prohibits doctors from referring Medicare or Medicaid patients to facilities or services in which they or an immediate family member has a financial stake, unless a specific legal exception applies. Unlike the Anti-Kickback Statute, Stark is a civil law, which means the prosecution doesn’t have to prove criminal intent to establish a violation. 

Whistleblower Actions

Many health care fraud investigations don’t start with a government audit. They start with a whistleblower, like a current or former employee, a competitor, or even a patient, who files a complaint under the False Claims Act. 

These investigations can run quietly for months before you’re even aware. If you have any reason to believe a complaint has been filed against you, get legal counsel immediately to start proactively building your defense.

Capitelli & Wicker: Health Care Fraud Defense in New Orleans

Being under investigation is not the same as being convicted. How a case is handled from the very beginning, before charges are filed against you, during the investigation, and through any grand jury process, can make an enormous difference in the outcome.

At Capitelli & Wicker, our attorneys have stood on both sides of these cases. Ralph Capitelli served as First Assistant District Attorney for Orleans Parish. Our white-collar defense team brings that same inside knowledge to every defense we build throughout New Orleans, the surrounding parishes, and nationwide for federal cases. The earlier you have counsel involved, the better your position.

If you suspect you’re under investigation or concerned about the potential exposure, schedule a consultation online or call 504-582-2425.

Frequently Asked Questions About Healthcare Fraud Charges in Louisiana

1. What is healthcare fraud?

Health care fraud is a deliberate scheme to get money from a health care program, like Medicare or Medicaid, using false information, fake claims, or deceptive billing. Under 18 U.S.C. § 1347, even if you attempt to defraud one of these programs and don’t succeed, you still face the penalties as if you did.

2. Is health care fraud a state or federal crime in Louisiana?

It can be both. Most major cases are prosecuted under federal law, but Louisiana has its own Medicaid fraud statutes, which you may face charges under at the same time. If you are under investigation, speak with a health care fraud defense attorney as soon as possible.

3. What are the penalties for federal health care fraud?

A conviction carries up to 10 years in federal prison. If the fraud results in serious bodily injury to a patient, that maximum rises to 20 years. If someone dies, you could face life in prison. Civil fines, exclusion from federal health programs, and losing your professional licenses can also follow a conviction.

4. What is the Anti-Kickback Statute?

It’s a federal law that makes it a felony to pay or receive anything of value in exchange for steering patients toward a provider or program funded by Medicare or Medicaid. Each violation can mean up to 10 years in prison and fines of up to $100,000. Got questions about a financial arrangement in your practice? Talk to a white-collar defense attorney before it becomes a problem.

5. What is the Stark Law, and how is it different from the Anti-Kickback Statute?

The Stark Law is a civil law, not a criminal one, that prohibits doctors from referring Medicare or Medicaid patients to facilities where they or a family member has a financial interest, unless a specific exception applies. Unlike the Anti-Kickback Statute, no criminal intent needs to be proven. But the financial penalties are steep, and Stark violations often trigger further liability under the False Claims Act.

6. Can a whistleblower trigger a health care fraud investigation against me?

Yes, and it’s one of the most common ways we see these investigations start. A current or former employee, a competitor, or a patient can file a complaint under the False Claims Act, and the investigation can run for months before you know it exists. If you have any reason to believe your practice is under scrutiny, contact a fraud defense attorney for early intervention.