Health Care Fraud Defense in Los Angeles, California
Welcome to Spodek Law Group. Our goal is to give you the reality of healthcare fraud prosecution in Los Angeles - not the sanitized version you find on other websites, not the legal textbook fiction about "billing disputes," but the actual truth about what happens when the federal government decides you fit their fraud profile. If your reading this at midnight because something happened today, because agents showed up at your practice or a target letter arrived, you need to understand something critical: the investigation into your billing practices almost certainly started years before you knew about it.
The Central District of California is the nations most populous federal district. It also has the highest Medicare spending in the country. These two facts are not coincidental. The Department of Justice positioned a Health Care Fraud Strike Force in Los Angeles specifically because this is where the money flows. Since March 2007 - thats over seventeen years of prosecutorial infrastructure - this Strike Force has been building cases, analyzing data, and identifying "outliers" whose billing patterns deviate from expected norms. You might be an outlier. You might have been one for years. And you might just now be finding out.
The 93% federal conviction rate for healthcare fraud isnt because prosecutors are always right. Its because they only bring cases they've already won on paper. By the time you receive notice, they have analyzed your claims data, interviewed your staff, reviewed your patient files, and constructed a narrative that transforms billing irregularities into criminal intent. What you think is the beginning of your case is actualy the end of their investigation.
The Data Machine That Already Knows Your Name
Heres the thing nobody tells you about healthcare fraud prosecution: it doesnt start with a complaint. It starts with an algorithm.
Every claim you submit to Medicare or Medicaid flows into a massive database at CMS and HHS. Their data analytics systems run constanty, looking for statistical anomolies. Are you billing a particular code more frequently then your peers? Are you seeing more patients per day then what CMS considers "normal"? Are your reimbursement patterns trending upward in ways that deviate from the curve? If yes to any of these - you've been flagged. Not investigated. Not contacted. Just flagged. That flag sits in a database. It gets reviewed by analysts. And eventually, if it looks interesting enough, it gets referred to the Los Angeles Strike Force for investigation.
The Strike Force prosecutors dont announce themselves. They subpoena your records quietly. They interview former employees who left your practice three years ago. They pull five years of claims data and run their own analysis. They consult with medical billing experts who will testify about what "normal" billing looks like and how yours deviates from it. All of this happens in the background, sometimes for two to five years, while your still treating patients and submitting claims and having no idea your already a target.
Think about that. The investigation has been running for years. Your billing records have been analyzed by government contractors. Former staff members have sat down with FBI agents. And you had absolutly no knowledge this was happening.
Thats the first thing you need to understand about defending against healthcare fraud charges in Los Angeles: by the time you know about it, your already behind. Way behind.
Why Your Billing "Errors" Look Like Criminal Intent
Let me be direct about something most lawyers wont say out loud. The difference between a billing error and healthcare fraud isnt about whether you made a mistake. Its about whether the government can prove a PATTERN of mistakes that consistantly benefited you financialy.
One upcoded claim is an error. Fifty upcoded claims over eighteen months is evidence. The prosecution doesnt need to prove you knew the exact regulations you were violating. They need to prove you knew the claims were false when you submitted them. And heres were it gets complicated: medical professionals who meticulously document their work to justify medical necessity sometimes create the exact paper trail that proves a "pattern" of overbilling.
OK so you have a billing compliance program. You train your staff on coding. You conduct internal audits. You might think this protects you. But heres the kicker - prosecutors can flip that compliance program into evidence against you. Their argument becomes: "The defendant knew the rules. The defendant trained staff on the rules. The defendant violated the rules anyway. This wasnt ignorance - it was deliberate fraud."
Having a compliance program that you then deviated from is actualy worse, in the prosecutions narrative, then having no program at all. Sound familiar? Its the paradox of healthcare fraud defense - the things you did to protect yourself become weapons in their hands.
At Spodek Law Group, we've seen this pattern in case after case. Physicians who genuinly believed they were practicing good medicine, billing appropriatly, following the rules. But the governments experts reconstructed their billing patterns, identified deviations from "peer norms," and characterized every deviation as evidence of criminal intent. The doctor thought they were exercising medical judgment. The prosecution called it a scheme to defraud Medicare.
This is why early intervention matters more in healthcare fraud then almost any other federal crime. Once the narrative is set - once your billing patterns have been characterized as a "scheme" in an indictment - changing that narrative becomes exponentially harder.
The 27-Month Reality Check
Let me ground this in actual numbers so you understand what your facing.
According to the U.S. Sentencing Commission, the average federal sentence for healthcare fraud in fiscal year 2024 was 27 months. Thats down from 30 months in 2020, but dont let that trend comfort you. The number of healthcare fraud prosecutions has increased 19.7% since 2020. There were 395 federal healthcare fraud cases in 2024 alone. More cases, slightly shorter average sentences - but 27 months in federal prison is still 27 months away from your family, your practice, your life.
And thats the average. The statutory maximum under 18 U.S.C. Section 1347 is 10 years. If the fraud resulted in serious bodily injury to any patient, the maximum jumps to 20 years. If a patient died - and prosecutors can sometimes draw a line between fraudulent care decisions and patient outcomes - the maximum is life imprisonment.
Do not assume you will receive the average sentence. Sentencing depends on the loss amount, your role in the scheme, whether you obstructed justice, and dozens of other factors. A case involving $500,000 in fraudulent claims carries very different guideline calculations then a case involving $5 million or $50 million.
The 2025 National Health Care Fraud Takedown resulted in 324 defendants charged nationwide. Among them - 96 were doctors, nurses, pharmacists, and other licensed medical professionals. Think about that number. Nearly a hundred medical professionals facing federal charges in a single coordinated enforcement action. The DOJ isnt targeting just billing clerks and administrators. There targeting the people who sign the orders, the certifications, the prescriptions.
What Todd Spodek always tells clients is this: the numbers are sobering, but there not destiny. Federal sentencing involves guidelines, not mandates. The right defense strategy, implemented early enough, can influence every factor that determines where you fall within those ranges - or whether you face charges at all.
What Happened to Dr. Wijegoonaratna Could Happen to You
In the Central District of California - right here in Los Angeles - two doctors were convicted of federal healthcare fraud for falsely certifying Medicare patients as "terminally ill" when they werent actually dying.
Dr. Sri Wijegoonaratna, known as "Dr. J," was 61 years old, practicing in Anaheim. Dr. Boyao Huang was 43, based in Pasadena. They were connected to California Hospice Care, which submitted approximately $8.8 million in fraudulent claims to Medicare and Medi-Cal. The government programs paid out nearly $7.4 million.
Read that again. Dr. J was convicted on seven counts of healthcare fraud. Dr. Huang on four counts. Each count carried a potential 10-year sentence.
Heres were people get confused: these werent doctors running some obvious scam operation. They were signing hospice certifications. They were making medical judgments about patient conditions. But the prosecution's experts analyzed the PATTERN of certifications, compared patient files to the certifications, and concluded that the doctors were systematically certifying patients as terminal when medical evidence didnt support that conclusion.
The doctors probably thought they were exercising clinical judgment. The prosecution called it fraud.
This is the reality of healthcare fraud prosecution in Los Angeles. Medical judgment gets second-guessed by billing analysts. Certification patterns get reconstructed by experts who never treated a single patient. And physicians who spent decades building careers find themselves facing federal indictments because their documentation patterns looked "abnormal" to an algorithm.
Could this happen to you? If your reading this article, you've probably already asked yourself that question. If you've received a target letter, if agents have contacted you, if a former employee mentioned being interviewed by the FBI - then yes. It could be happening right now.
And consider another case from the Central District - the Pacific Hospital kickback scheme. Michael Drobot owned the hospital and paid surgeons over $3.3 million in bribes to perform spinal surgeries at his facility. Nearly a billion dollars in fraudulent billings. Ten of seventeen defendants convicted. The surgeons thought they were receiving legitimate referral fees for legitimate work. The prosecution proved kickbacks.
Drobot got five years. Think about that math for a second - nearly a billion in fraud, five years in prison. That sounds light until you realize what else he lost. His hospital. His medical career. His reputation. His assets seized. Everything he built over decades, gone. The prison sentence is almost secondary to the total destruction of everything he had worked for.
Thats the pattern we see over and over in Los Angeles healthcare fraud prosecutions. The prison time matters, obviously. But the collateral damage - the license, the practice, the life you built - thats often worse.
The License Destruction Cascade
Lets talk about what happens beyond the criminal case. Because prison time, as devastating as it is, might not be the worst outcome your facing.
When a federal indictment drops for healthcare fraud, a cascade begins that most providers dont anticipate. Your state medical board opens a parallel investigation. They have their own standards, their own timeline, and their own ability to suspend or revoke your license - independant of the criminal case outcome. Even if your eventualy acquitted at trial, the board action continues.
Simultaneously, the HHS Office of Inspector General can initiate exclusion proceedings. They can exclude you from Medicare and Medicaid participation based on the indictment alone - not a conviction, just the charges. Once excluded, you cant bill federal healthcare programs. For most medical practices, thats financial death.
Private insurers and hospital systems dont wait for trials either. The moment they learn of federal charges, they start terminating contracts and revoking privileges. Your revenue streams evaporate while your still technically innocent.
So the cascade looks like this: Federal indictment → State board investigation → OIG exclusion proceedings → Insurance terminations → Hospital privilege revocations → Staff departures (because they need jobs) → Patient transfers → Practice closure → Personal asset forfeiture proceedings → Trial → Potential conviction → Prison → Post-release professional exclusion.
By the time you get to trial, even if you win, there might not be a practice to return to. The license restoration process takes years. Your reputation has been destroyed. Your finances are decimated from legal fees and lost income. Your collegues have distanced themselves.
This is why Todd Spodek and the team at Spodek Law Group emphasize early intervention so strongly. Once the cascade starts, stopping it becomes exponentialy harder. But before charges are filed, before the indictment is public, there are oppurtunities to influence the trajectory that simply dont exist later.
We've had clients come to us after the cascade has already begun. The indictment dropped. The medical board sent a letter. The OIG initiated exclusion. And we did what we could - which in some cases was alot, negotiating better outcomes then they would have gotten otherwise. But we've also had clients come to us early, when they first heard about an investigation, before any charges were filed. The difference in outcomes is stark. Early clients have options. Late clients have damage control.
If theres one thing you take away from this article, let it be this: the window for meaningful intervention is smaller then you think, and its closing faster then you realize.
Why Southern California Is Ground Zero
Theres a reason the Department of Justice established the LA Strike Force in 2007. And theres a reason its still here, bigger and more aggressive then ever.
Southern California has a concentration of factors that make it a target-rich environment for healthcare fraud prosecution. The highest Medicare spending in the nation. A massive population of elderly beneficiaries. An enormous healthcare industry with thousands of providers. And - importantly - a history of specific fraud patterns that the Strike Force has learned to identify and prosecute.
The LA Strike Force leads the DOJ's "Sober Homes Initiative," which targets substance abuse treatment facilities for healthcare fraud and kickback violations. If you operate or work with addiction treatment facilities in Southern California, your in the crosshairs of a dedicated prosecutorial unit thats been building cases in this space for years.
COVID-19 made it worse. The CARES Act Provider Relief Fund, the PPP loans, the HRSA Uninsured Program - all of that money flowed through Southern California healthcare providers. And all of it is still being investigated. The statute of limitations on federal fraud doesnt start running until the government discovers the fraud. For COVID-related programs, that means cases from 2020 can potentialy be prosecuted well into the 2030s.
Heres a number that should concern you: since its inception in 2007, the Health Care Fraud Strike Force has charged more then 5,400 defendants for collectively billing Medicare, Medicaid, and private insurers over $27 billion. The 2025 takedown alone involved $14.6 billion in alleged fraud. The government seized over $245 million in assets - cash, luxury vehicles, cryptocurrency - from that single enforcement action.
There is a financial incentive built into aggressive healthcare fraud prosecution. Asset forfeiture recovers money. Restitution orders recover money. Civil settlements under the False Claims Act recover money - often triple damages plus per-claim penalties. The system isnt just about justice. Its about revenue recovery.
If your a healthcare provider in Los Angeles, you are operating in the most intensely scrutinized healthcare market in the country. The Strike Force has seventeen years of experience identifying patterns, building cases, and securing convictions in this district. They know what billing anomolies look like. They know which facility types generate fraud referrals. They know how to reconstruct a "scheme" from claims data that you thought was ordinary medical practice.
Notice the pattern here. The same concentration of healthcare spending that creates opportunity for providers also creates opportunity for prosecutors. LA is both the best place to run a medical practice and the worst place to be investigated for healthcare fraud. The infrastructure for prosecution is built out. The expertise is deep. The resources are allocated. And the political will to pursue these cases isnt going anywhere - healthcare fraud prosecution makes great headlines and generates asset seizures that fund more prosecutions.
What Early Intervention Actually Looks Like
Everything I've described - the data-driven prosecution machine, the pattern analysis, the cascade of professional consequences, the Southern California targeting - is meant to show you the reality of what your facing. Its not meant to create despair. Its meant to create urgency.
Because heres the truth: the earlier you engage experienced federal healthcare fraud defense counsel, the more options you have.
If you recieved a target letter but havent been indicted, there is still time to present your side to the prosecution. To provide context they might not have. To demonstrate compliance efforts they didnt know about. To challenge their expert's characterization of your billing patterns before it becomes part of an indictment.
If agents have contacted you but you havent been interviewed, there is time to prepare - to understand what there likely looking for, to organize your documentation, to protect yourself from saying things that become evidence against you.
If you've learned that former employees were interviewed, there is still time to understand what narrative is being constructed and to develop a counter-narrative before charges are filed.
But if you wait until the indictment drops, until your name is in a press release, until the medical board and OIG and insurers have all been notified - then you are reacting rather then influencing. And in federal healthcare fraud cases, reaction is a losing posture.
The goal of early intervention isnt to make problems disappear. Its to shape outcomes. To potentially keep cases civil rather then criminal. To negotiate resolutions that preserve licensure. To identify weaknesses in the governments case before they become leverage in plea negotiations.
Spodek Law Group handles federal healthcare fraud defense in the Central District of California and across the country. We understand how Strike Force cases are built, because we've defended against them. We know what the data analytics actually show and how to challenge the characterizations. We've worked with medical billing experts to deconstruct government theories. And we've seen what happens when providers wait too long versus engaging early.
The clock is running. It started when the algorithm first flagged your billing patterns, and you didnt even know it. What happens next depends on what you do right now.
Call us at 212-300-5196. The conversation is confidential. The initial consultation focuses on understanding exactly where you are in the process and what realistic options remain. We dont promise outcomes we cant deliver. We do promise to tell you the truth about what your facing - which is what this entire article has been about.
The system has been watching. Its time you had someone watching back.
