Federal Charges Against Medical Practice Owners
Welcome to Spodek Law Group. Our goal is to give you the reality of federal charges against medical practice owners - not the sanitized version your malpractice carrier presents, not the generic advice from healthcare compliance seminars, but the actual truth about what happens when federal prosecutors decide your practice is a criminal enterprise.
Here is something most medical practice owners dont realize until its too late. Over 80% of federal healthcare fraud cases start with your own employees filing qui tam whistleblower lawsuits. Not government audits. Not random enforcement actions. Your billing clerk. Your former partner. The nurse you let go last quarter. Each one has a financial incentive worth potentially hundreds of thousands of dollars - the False Claims Act rewards whistleblowers 15-30% of whatever the government recovers. That disgruntled employee? They can destroy your career and get paid millions for doing it. And by the time you learn youre under investigation, the government has already spent 18 to 36 months building a case while the lawsuit sits sealed and secret.
This is the Prometheus truth that nobody wants to tell you: your medical expertise is irrelevant to federal prosecutors. They have a 95% conviction rate at trial. They already interviewed your employees. They already have your billing records. They already know exactly what charges theyre bringing. The question isnt whether you practiced good medicine. The question is whether every business decision your practice made - decisions you probably delegated to people you trusted - can survive federal scrutiny.
The Business of Medicine Is the Crime
Medical practice owners facing federal charges are often confused by what theyre actually being accused of. You didnt hurt any patients. You didnt prescribe medications improperly. You didnt commit malpractice in any traditional sense. So why are federal agents at your door?
Heres the thing. The federal government has created an entire infrastructure for prosecuting the business side of medicine. The Anti-Kickback Statute. The Stark Law. The False Claims Act. These laws dont care about patient outcomes. They care about money flows, referral patterns, and billing codes.
Consider this scenario that plays out across the country. A practice owner invests in a diagnostic lab - something physicians have done for decades. Seems completley normal. But under the Stark Law, every single patient you refer to that lab becomes a seperate federal violation. Five hundred referrals over three years? Thats 500 counts. The statute provides penalties of up to $15,000 per violation. Do the math. Before criminal charges even begin, your looking at $7.5 million in civil penalties.
Or take billing codes. Your office manager - who youve trusted for 15 years - selects codes that maximize reimbursement. This is what billing departments do. But when federal investigators review those claims, they see a pattern. They call it upcoding. They call it fraud. And under federal law, the practice owner is responsible for every claim submitted, even if you never saw the billing sheets.
The 2025 National Health Care Fraud Takedown charged 324 defendants with schemes totaling $14.6 billion in alleged fraud. Of those defendants, 96 were licensed medical professionals - doctors, nurse practitioners, pharmacists. These werent criminals operating in the shadows. These were practitioners who woke up one morning to FBI agents at there door.
18 Months Before You Know
Let that sink in. The federal investigation into your practice likely started a year and a half before anyone told you about it.
This is how it actualy works. Somewhere in the federal system - probably at the DOJs new Health Care Fraud Data Fusion Center - an algorithm flagged your billing patterns. Maybe your practice billed more definitive urine drug tests then similar practices in your area. Maybe your referral patterns to a particular lab looked unusual. Maybe a disgruntled former employee filed a qui tam lawsuit and your the last person to find out.
Once your flagged, the investigation begins. Subpoenas go out to your billing company. Your employees are interviewed, often at there homes, often without lawyers present. Grand jury subpoenas compel document production from insurers, labs, and pharmacies you work with. All of this happens while your seeing patients, running your practice, living your life without any idea.
As Todd Spodek explains to clients facing federal investigation, the timeline is the hidden killer. By the time you receive a target letter or - worse - wake up to federal agents with a warrant, the government has already built there case. Theyve already decided your guilty. What happens next isnt really an investigation anymore. Its documentation.
The statistics are brutal. The Medicare Fraud Strike Force maintains a conviction rate of aproximately 95 percent. That number isnt because every defendant is guilty. Its because the government only brings cases they know they can win, after spending years making them unwinnable for the defense.
What makes this especialy dangerous is how the government uses the secrecy of the investigation. While your going about your daily practice - seeing patients, signing charts, making clinical decisions - prosecutors are building a narrative. They are selecting which employees to flip. They are identifying which billing codes to focus on. They are calculating which charges maximize sentencing exposure. And they are doing all of this without any input from you, without any opportunity for you to explain context, without any chance for you to provide the information that might change there conclusion. By the time you enter the picture, the story is already written.
The Delegation Trap: When Trusted Employees Become Government Witnesses
OK so heres were it gets really terrifying for medical practice owners. The very people you trusted to handle the business side of your practice - the people you delegated billing, compliance, and administrative tasks to - become the governments most powerful weapons against you.
Your office manager who handled Medicare billing for 15 years? When federal investigators interview her, they offer immunity. Full immunity. In exchange for her cooperation, she testifies that you directed the billing practices. She produces emails were you approved reimbursement strategies. She describes conversations about maximizing collections.
Your billing company that you paid $50,000 a year for compliance? They were never your ally. The moment the government contacts them, there lawyers advise full cooperation. They turn over every record. They explain exactly how billing codes were selected. And they make clear that the practice owner - not the billing company - signed the Medicare enrollment agreement that made you personally liable for every claim.
This is the irony that destroys medical practices. You hired people to protect you from exactly this situation. You paid for compliance services. You trusted profesionals to handle the business side so you could focus on patients. And every one of them becomes a witness against you when the government comes calling.
Critical Warning: Under federal law, your Medicare Provider Enrollment Agreement makes you personaly responsible for all claims submitted to Medicare by your practice, regardless of whether you personaly reviewed them or even knew about them.
Think about that. Your responsible for claims you never saw, generated by staff using codes you didnt select, in a system you delegated because you were too busy practicing medicine. And when those claims become federal charges, the person who selected the codes has immunity, while you face prison.
Stark Law: The Strict Liability Nightmare
Heres the part nobody talks about when discussing federal healthcare fraud. The Stark Law - officialy the Physician Self-Referral Law - is a strict liability statute. What does that mean? It means intent doesnt matter.
Under the Anti-Kickback Statute, prosecutors must prove you "knowingly and wilfully" engaged in prohibited conduct. There at least arguement about intent. But Stark Law violations dont require proof of intent at all. If you violated the law, your liable. Period. Even if you didnt know. Even if you tried to comply. Even if you hired lawyers and consultants who told you the arrangement was fine.
Picture this scenario that plays out more then you would think. A physician practice employs another doctor. They pay fair market value for their services. They have a written contract. They consulted lawyers. But somewhere in the arrangement - maybe the compensation formula, maybe the bonus structure, maybe the way overhead is allocated - theres a technical Stark Law violation. Every claim submitted while that doctor was employed becomes a false claim. Hundreds of claims. Maybe thousands. Each one a seperate violation.
The government dosent need to prove you intended to defraud anyone. The government dosent care about proving any patient was harmed. The government only needs to prove the arrangement existed and claims were submitted. Your intent is completly irrelevant.
At Spodek Law Group, we've seen physicians who genuinly believed they were in compliance - who spent significant money on compliance programs - destroyed by technical Stark Law violations they never knew existed. The law was not designed to be fair. It was designed to give prosecutors leverage.
95% Conviction Rate: Why Going to Trial Is Often Suicide
Let me be direct about something that defense attorneys in this field know but rarely say out loud. Going to trial in a federal healthcare fraud case is almost always a catastrophic mistake.
The Medicare Fraud Strike Force maintains a 95% conviction rate. Ninty five percent. When you go to trial, your not facing 50-50 odds or even 70-30 odds. Your gambling your life against a 95% chance of conviction.
But wait - it gets worse. When defendants plead guilty, the average sentence is around 27 months. Thats the number. Twenty seven months. But when defendants go to trial and lose - which happens 95% of the time - the sentences explode.
Look at the cases from 2025. Peter Roussonicolos, a Florida DME owner, got 12 years federal prison for his role in a $61 million Medicare fraud scheme. Twelve years. Not for hurting patients. For billing fraud. A South Florida healthcare facility owner recieved 20 years - in what DOJ called the largest healthcare fraud scheme ever charged. Twenty years in federal prison for running a healthcare business. A pain clinic CEO faced charges for making patients "human pin cushions" with unecesary procedures. He was looking at 20 years if convicted. He negotiated a plea and recieved 18 months. Thats the delta the system produces: cooperate or get destroyed.
The system isnt designed for trials. Its designed for pleas. Federal prosecutors know exactly what sentencing guidelines apply to each charge. They know that defendants who plead guilty get credit for acceptance of responsibility. They know that defendants who go to trial and lose face the full weight of the guidelines. The message is clear: plead guilty and get 27 months, or fight and risk a decade.
Heres were people get confused. They think this means they should plead guilty to anything. Thats not what we're saying. What we're saying is that the decision to go to trial must be made with clear eyes about what your actually facing. And for most medical practice owners, the math makes trial irrational even if their genuinly innocent.
According to U.S. Sentencing Commission data, 88.6% of healthcare fraud defendants had little or no prior criminal history. These arent career criminals. These are physicians, practice administrators, and healthcare executives who never imagined they would face federal prosecution. The average age of a healthcare fraud defendant is 49 years old - people at the peak of there careers, with families depending on them, with decades of patient care behind them. And they are facing a system specificaly designed to make them plead guilty.
The Exclusion Weapon: Worse Than Prison
Most medical practice owners fixate on prison time. How many years could I face? What would happen to my family? But theres another consequence that, for many physicians, is actually worse: exclusion from federal healthcare programs.
When your convicted of healthcare fraud - or even when you settle civil fraud allegations - the government can exclude you from Medicare, Medicaid, and other federal healthcare programs. This isnt temporary. This isnt a slap on the wrist. This is permanent career destruction.
Important: Medicare exclusion means you can never bill Medicare again. For many medical practices, especially those serving elderly populations, Medicare is 40-60% of revenue. Exclusion is a death sentence for the practice.
But its worse then that. Exclusion wont just affect your ability to bill Medicare. It means no hospital with Medicare patients can credential you. No healthcare system can employ you. Your effectively unemployable in American medicine.
Consider the leverage this gives prosecutors. They can offer a deal: plead guilty to a minor charge, accept minimal prison time, but avoid exclusion. Or fight the charges, risk conviction, and face both prison AND permanent exclusion. For a physician in their 50s or 60s, the calculation is devistating. Even if their innocent, can they risk losing the ability to practice medicine for the rest of there life?
This is why so many healthcare fraud cases end in plea deals even when defendants beleive their innocent. The exclusion weapon is more powerful then prison.
Reality Check: The Health and Human Services Office of Inspector General maintains an exclusion database. Once your name appears on that list, every healthcare organization in the country can see it. Hospitals check before credentialing. Insurance companies check before contracting. Employment verification services check before hiring. Your name on that list follows you forever.
What Happens in the First 48 Hours
If your reading this because federal agents just showed up at your practice - or because you just got a target letter - the next 48 hours are critical. What you do now determines what options you have later.
Heres what typically happens. Federal agents arrive at your practice, usually in the morning. They have a search warrant. They will seize computers, files, patient records, and any documents related to billing and referrals. They may interview your staff on the spot. They may attempt to interview you.
This is critical: you have the right to remain silent, and you should use it. Anything you say to federal agents can and will be used against you. The agents are not there to hear your side of the story. They are there to build evidence. Even innocent explanations can be twisted into consciousness of guilt or false statements charges.
Simultaneosly, the government may be executing financial seizures. Your bank accounts. Your practice accounts. Even personal assets. Under federal asset forfeiture laws, the government can freeze assets they believe are connected to the alleged fraud, often before your convicted of anything.
Within days, your medical license may be in jeopardy. State medical boards often initiate investigations when they learn of federal charges. Your hospital priviliges may be suspended. Your malpractice insurer may initiate policy review. The destruction cascades faster then most people can process.
Todd Spodek has seen this pattern in hundreds of cases. The clients who fare best are those who have experienced federal healthcare fraud counsel involved within hours of first contact. Not days. Hours. The window for protecting assets, managing license issues, and shaping the narrative closes extremly fast.
The Narrow Window That Actually Exists
Despite everything we've described, there is a window - a narrow one - where effective defense can make a meaningful difference. But that window exists primarily before indictment, not after.
Pre-indictment intervention is the phase where an experienced federal healthcare fraud attorney can actualy change outcomes. During this phase, its sometimes possible to present evidence to prosecutors that changes there calculation. Its sometimes possible to negotiate civil resolution instead of criminal charges. Its sometimes possible to get your side of the story in front of decision makers before charges are filed.
Once your indicted, options narrow dramaticaly. The government has committed publicly to prosecution. The case has momentum. Your leverage drops to nearly zero.
At Spodek Law Group, our approach focuses intensley on this pre-indictment window. If your under investigation but not yet charged, there may still be options. If your just gotten a target letter, the clock is ticking but hasnt run out. If your aware of a qui tam lawsuit or government subpoenas to your billing company, intervention now is infinitley more valuable then intervention after indictment.
The federal healthcare fraud system is designed to produce guilty pleas from medical practice owners who delegated business functions to people they trusted. Its designed to leverage your medical license and exclusion threat against you. Its designed to make trial a irrational gamble.
But within that system, there are pressure points. There are moments where the right defense strategy, executed at the right time, can change outcomes. Finding those moments requires understanding exactly how federal prosecutors build these cases and where there assumptions can be challanged.
If federal agents have contacted you, your practice, or your employees about healthcare billing - call us at 212-300-5196. The investigation may have started 18 months ago. But your defense starts now. And how you use the time you have left may determine whether your spending the next decade treating patients or sitting in federal prison.
The government had years to build their case. You have days to respond. Use them.
