Healthcare fraud investigations typically start months or years before the person or company being investigated finds out. It can start with something simple like a billing discrepancy or a patient complaint, and then snowball into federal charges fast. And it doesn’t matter if you committed a crime intentionally or made a mistake – federal prosecutors won’t drop your case just because you say you didn’t mean any harm.
If you’re facing a healthcare fraud investigation, it’s crucial to understand how these cases are prosecuted so you can protect yourself as much as possible.
It can start with something small
Healthcare fraud cases usually begin with a small issue that might be a sign of fraud, even if it was a genuine mistake.
“Most healthcare fraud indictments start with something simple like upcoding or a billing error,” says an attorney from SBBL Law. “In my years defending medical professionals, I’ve seen providers indicted over incorrect CPT codes. The government treats repeated mistakes as intent.”
Some of the most common triggers are:
- Irregular billing patterns. Federal prosecutors will use algorithms to compare a healthcare provider’s claims to national averages. Even if your billing is standard, if you consistently bill at higher rates or a higher frequency, that can be flagged as deliberate inflation.
- Patient or employee complaints. Just one patient claiming they never received a treatment they were billed for can trigger a review. The government will assume there’s a pattern behind that one complaint. And if a resentful former employee reports that your clinic pushes unnecessary treatments, that report could be taken seriously.
- Coding mistakes that repeat over time. Repetition is often interpreted as intent. If the same CPT or HCPCS errors appear across months of claims, it will be assumed that the incorrect coding was intentional.
Healthcare fraud is something the government takes very seriously. In fact, the Justice Department announced that 2025 saw the largest healthcare fraud takedown in history. Not every case results in a conviction, but the government treats every issue as a potential lead, even if it’s just a harmless mistake.
Investigations start long before you’re told
By the time you know you’re under investigation, the federal government has all the information it needs to make a case against you. Medicare and private insurance algorithms flag anomalies long before any person gets involved. And if an insurer forwards their findings to HHS-OIG, you may not know about it until you get subpoenaed.
Investigators also reach out to people close to you before informing you of the investigation. For example, patients might be asked if they received all the services they were billed for, and former employees might be asked about clinic processes, documentation procedures, and whether there was any internal pressure to hit quotas or productivity targets.
When you’re finally contacted, investigators have already formed their narrative.
You might be investigated by multiple agencies
Healthcare fraud is unique because one anomaly can draw attention from multiple agencies. For instance, the Department of Justice (DOJ) has a Health Care Fraud Unit that prosecutes large-scale fraud, kickback schemes, opioid distribution, and complex billing fraud. The Federal Bureau of Investigation (FBI) works with insurers and fraud control units to gather evidence. And the HHS Office of Inspector General (OIG) conducts audits, imposes civil penalties, and can exclude providers from federal programs. Even if you aren’t charged criminally, OIG actions can tank your career.
What to do if you learn you’re under investigation
First of all, don’t panic if you receive a subpoena, and don’t try to talk or explain your way out of it. Federal investigators are trained to frame casual conversations as admissions.
Since it doesn’t take much evidence to establish the probable cause needed for an indictment, it’s crucial to remain silent and call a lawyer right away. But don’t just call any lawyer. You need an attorney with experience handling federal healthcare fraud cases. The sooner you get a lawyer, the faster you’ll be protected from self-incrimination.
Don’t delete any emails or attempt to correct documentation, even if the correction is legitimate. Altering documentation after knowing you’re under investigation will be treated as obstruction. Preserve everything, no matter how messy it is.
How you respond when you find out you’re being investigated will have a big impact on the outcome of your case.
Protect yourself against the government’s story
If you’re facing a healthcare fraud investigation, contact an experienced federal defense attorney right away. The government will build a case against you that won’t take your intent into consideration, and one small error can land you in hot water. Don’t let them control the narrative. The sooner you obtain legal counsel, the faster you can protect your future.