Health Care Fraud Defense in Miami

If you own or work at a clinic, pharmacy, lab, home health agency, medical equipment company, or billing company, or if you were paid to refer patients, you may be in the middle of an investigation long before anyone tells you.

Dennis Gonzalez Jr. is a former Miami-Dade prosecutor who has been defending people since 2012, in state court and in federal court in the Southern District of Florida. Our office answers 24 hours a day.

This page is part of our Economic Crimes Defense practice. For Medicare and Medicaid cases specifically, see Medicare Fraud and Medicaid Fraud.

Federal Health Care Fraud

The main federal statute. Federal law makes it a crime to knowingly and willfully carry out, or try to carry out, a scheme to defraud any health care benefit program, or to get its money or property by false or fraudulent pretenses, in connection with the delivery of or payment for health care benefits, items, or services.

• Penalty: up to 10 years in prison and a fine.
• Up to 20 years if the violation results in serious bodily injury.
• Any term of years or life if the violation results in death.

It is not only Medicare. Federal law defines a "health care benefit program" as any public or private plan or contract, affecting commerce, under which any medical benefit, item, or service is provided to any individual. That means private health insurance can be the basis of a federal case too.

False statements. A separate federal law makes it a crime to knowingly and willfully falsify or conceal a material fact, or make a materially false statement or use a false document, in any matter involving a health care benefit program. That carries up to 5 years.

Conspiracy and attempt. Anyone who attempts or conspires to commit federal health care fraud faces the same penalties as the fraud itself. That is how people can be charged even if they never submitted a single claim.

Knowledge. The federal health care fraud statute says a person does not need actual knowledge of that statute, or specific intent to violate it. The government still has to prove the person acted knowingly and willfully in carrying out a scheme. What you knew, and when, is usually where the fight is.

Kickbacks and Paid Referrals

Federal anti-kickback law. It is a federal felony to knowingly and willfully offer, pay, solicit, or receive any payment, including a kickback, bribe, or rebate, in cash or in kind, to induce or reward referring patients, or ordering or recommending items or services, that a federal health care program may pay for in whole or in part. The penalty is up to 10 years in prison and a fine of up to $100,000.

The law lists exceptions, such as properly disclosed discounts and pay to a real employee under a bona fide employment relationship. Whether an arrangement fits an exception is a technical question, and it is often the heart of the defense.

Florida patient brokering. Florida law separately makes it a crime for anyone, including a health care provider or facility, to offer or pay, or to solicit or receive, a commission, bonus, rebate, kickback, bribe, or split fee to induce or in return for patient referrals, or in return for accepting treatment. This law is not limited to government programs.

• Third-degree felony and a $50,000 fine.
• Second-degree felony and a $100,000 fine if the conduct involves 10 or more patients but fewer than 20.
• First-degree felony and a $500,000 fine if it involves 20 or more patients.

Florida's patient brokering law has its own exceptions, including payment practices that the federal anti-kickback law does not prohibit.

Florida Insurance Fraud Charges in Health Care Cases

Florida's insurance fraud law covers false, incomplete, or misleading statements made with intent to injure, defraud, or deceive an insurer, including claims under a health maintenance organization (HMO) contract. Bills, diagnoses, prescriptions, medical records, X-rays, and test results each count as a "statement" under that law.

The degree depends on the value involved: a third-degree felony under $20,000, a second-degree felony from $20,000 to under $100,000, and a first-degree felony at $100,000 or more. In Florida, those carry up to 5, 15, and 30 years in prison respectively. Licensed physicians and other practitioners who knowingly and willfully help an insured commit insurance fraud can be charged too, and their licensing board must hold a hearing on sanctions after an adjudication of guilt.

See Insurance Fraud for PIP and auto cases.

How Health Care Fraud Cases Get Built

These are data cases. Investigators look at billing patterns, claims that don't match patient files, patients who say they never got the service, referral sources, and where the money went after the payment came in. They may interview employees and patients before they ever contact the owner.

Common pressure points we look for:

• Who actually controlled the billing? Owners, managers, billers, and doctors often had very different roles and very different knowledge.
• Was the service real and documented? Missing paperwork is not the same as fraud.
• Was the payment arrangement legal? Marketing pay, salaries, and contractor fees are not automatically kickbacks.
• What is the real loss? The government's number often counts legitimate services as fraud.

Target Letters, Agent Visits, and Search Warrants

If agents come to your home or business:

1. Be polite. Do not physically resist or block them.
2. Ask for a copy of the warrant if they have one, and read what it covers.
3. Do not answer questions. Say you want to speak with your lawyer first.
4. Do not delete, move, or change records, texts, emails, or files. That can become a separate crime.
5. Do not call coworkers, patients, or recruiters to "get stories straight."
6. Call us right away. (305) 209-0384.

If you receive a target letter or subpoena: do not call the agent or prosecutor yourself to explain. A target letter is a serious signal, and it is often your best chance to shape what happens next. Let a lawyer respond.

Early counsel matters. Before charges, a lawyer can find out whether you are viewed as a witness, a subject, or a target, protect your records, deal with the agents for you, and plan ahead for bond. In fraud cases, the government may question where bond money comes from. See Bond & Nebbia Hearings. If charges are coming, we can often arrange a self-surrender instead of an arrest at your clinic or home.

Why Choose Dennis Gonzalez Law, P.A.

• Former Miami-Dade prosecutor.
• Defending people since 2012.
• Super Lawyers recognition and an Avvo Rating of 10.0.
• Bilingual office — se habla español.
• We answer 24 hours a day. Call (305) 209-0384.

You can read about some of our past cases on our Results page.

Frequently Asked Questions

Can I be charged with federal health care fraud if the claims went to a private insurer, not Medicare?

Yes, it is possible. The federal definition of a health care benefit program includes private plans and contracts that affect commerce.

I was only the biller (or the doctor, or the recruiter). Can I be charged?

Yes. People can be charged for attempting or conspiring to commit health care fraud, and the penalties are the same as for the offense itself. Your actual role and knowledge are central to your defense.

Is paying a marketer or recruiter illegal?

Not always. Federal and Florida law prohibit paying for patient referrals, but both laws list exceptions. Whether a specific arrangement is legal depends on the facts and the paperwork.

If I pay the money back, will the case go away?

Not automatically. Repayment can matter in negotiations, but it should be handled through your lawyer, as part of a strategy.

Agents want to "just talk." Should I meet with them?

Not without a lawyer. What you say can be compared, line by line, to the billing data they already have.

How fast can you help?

Our office answers 24 hours a day. Call (305) 209-0384.