Health Care Fraud Defense in Nashville, Tennessee
Welcome to Spodek Law Group. Our goal is to give you the reality of healthcare fraud defense in Nashville - not the sanitized version other law firms present, not the reassuring fiction that everything will be fine, but the actual truth about what happens when federal prosecutors decide you're a target in the nation's healthcare capital.
Most healthcare providers in Nashville believe federal prosecutors only pursue obvious criminals. The pill mill operators. The phantom billing schemes. The kickback artists running fake clinics out of strip malls. They believe that good intentions and legitimate medical practices provide some kind of protection against federal investigation.
They're wrong. And by the time they realize how wrong they are, the government has already spent two years building a case against them - often using their own employees as paid informants and their own meticulous documentation as evidence of criminal intent.
Why Nashville Sits at the Center of Federal Healthcare Enforcement
Heres the thing most Nashville providers dont understand. When United States Attorney Henry Leventis announced healthcare fraud charges in 2024, he made a statement that should terrify every provider in Middle Tennessee. He called Nashville "the nation's health care capital."
That wasnt a compliment. That was a target designation.
Think about what that means for your practice. Nashville hosts the headquarters of HCA Healthcare, the largest hospital operator in America. Community Health Systems. Envision Healthcare. LifePoint Health. The concentration of healthcare companies here isnt just an economic advantage - its a prosecutorial opportunity. More healthcare revenue means more potential fraud. More potential fraud means more federal attention.
The Middle District of Tennessee collected more then $137 million in Fiscal Year 2024. The vast majority came from False Claims Act cases - civil healthcare fraud. Thats not abstract enforcement happening somewhere else to other providers who were obviously doing something wrong. Thats happening here, in Nashville, to providers who thought they were operating legitimatly for decades.
In June 2025, the Department of Justice announced the largest healthcare fraud takedown in American history. The numbers are staggering. 324 defendants charged across 50 federal districts. $14.6 billion in alleged fraud. That number doubled the previous record of $6 billion. Nashville had multiple defendants in that takedown, including three charged with a $28.7 million scheme involving the Federal Employees' Compensation Fund and a Hendersonville doctor indicted alongside her office manager husband.
This isnt slowing down. Its accelerating. And if your in healthcare in Nashville, your already on there radar whether you know it or not.
The Data Analytics Trap Nobody Warns You About
The DOJ Health Care Fraud Unit doesnt investigate the way you think it does. They dont sit around waiting for tips from disgruntled employees. They dont respond to random complaints and then decide whether to look into them. They hunt proactively, using technology that would have seemed like science fiction twenty years ago.
The governments own materials describe how they use "advanced data analytics and algorithmic methods" to identify fraud schemes and target what they call "the most egregious fraudsters." But heres were that language becomes terrifying. Who decides what "egregious" means? The algorithm does. The pattern analysis does.
What does that mean in practice? It means your billing patterns are being analyzed right now, today, as you read this article. Every claim you submit to Medicare or Medicaid gets compared against statistical baselines for your specialty, your region, your patient population. Every outlier gets flagged for further review.
Heres were it gets truly dangerous. The government doesnt need to prove you intended to commit fraud in the way you understand intent. They dont need an email where you wrote "lets defraud Medicare today." They need to prove a pattern. And patterns that "consistently result in higher reimbursement" - thats a direct quote from federal prosecutors describing how they identify targets - arent seen as billing errors. There seen as evidence of criminal intent that you can claim you never had.
Think about the perverse logic of that. The same documentation you create to demonstrate medical necessity becomes the prosecution's roadmap to conviction. Your compliance efforts, ironicaly, create the very paper trail they use to prove you knew what you were doing. The more thorough your records, the more ammunition they have.
Michael Kestner learned this the hard way. The 72-year-old Nashville businessman owned pain clinics across Tennessee, North Carolina, and Virginia under the Pain MD brand. He wasnt a physician running a pill mill and prescribing opioids without examinations. He was an entrepreneur who created a legitimate business model that prosecutors recharacterized as a "systematic pattern" of unnecessary procedures designed to maximize billing.
The trial evidence showed that Kestner pressured nurse practitioners and physician assistants to provide multiple back injections to patients seeking opioid treatment. Was that good medicine or bad medicine? Reasonable practitioners might disagree. But the jury convicted him of conspiracy plus 12 counts of healthcare fraud. He faces 10 years in federal prison per count. His sentancing is scheduled for February 2025.
The pattern was the crime. Not a smoking gun email. Not a confession. A pattern that prosecutors argued demonstrated intent.
Your Employees Could Be Building a Case Against You Right Now
This is the threat nobody talks about, and its potentially more dangerous then any federal investigation.
Under both federal and Tennessee qui tam laws, your employees can file sealed complaints against you and collect between 25 and 50 percent of whatever the government recovers. Let that sink in. On an $18 million case - which is absolutly achievable in Nashville healthcare fraud enforcement given the Vanguard settlement - that means your employee walks away with somewhere between $4.5 and $9 million.
For turning you in. For documenting your billing practices. For becoming the governments star witness against you.
Tennessee has both a False Claims Act covering fraud against the state generally and a separate Medicaid False Claims Act applying specifically to TennCare fraud. The whistleblower rewards under state law range from 15 to 50 percent depending on whether the government intervenes in the case. These arent theoretical numbers. There real payments that create real incentives for your staff to become informants.
The Diversicare Health Services case shows exactly how this plays out in practice. The company, which operated nursing homes and rehabilitation facilities, submitted claims for "consistently high therapy levels" that prosecutors argued werent medically necesary for the patients receiving them. They also allegedly had physician signatures that were forged, photocopied, or pre-signed on therapy orders. The settlement totaled $9.5 million.
The whistleblowers who brought the case? Former employees of Diversicare. People who worked alongside management, observed the billing practices, and decided - whether for idealistic reasons or financial ones - to report what they saw.
That disgruntled billing manager you terminated last month because she wasnt a team player? She has standing to file a qui tam case. That nurse who disagreed with your treatment protocols and quit in frustration? He could be meeting with a whistleblower attorney right now. That coder who made mistakes and got written up? She might be documenting everything to protect herself by destroying you.
Tennessee law protects these employees from retaliation. You cant fire them, demote them, threaten them, or discriminate against them for lawful whistleblowing. And the law pays them handsomly for coming forward - more then most of them will earn in a decade of honest work.
Heres the part thats truly terrifying. Qui tam cases are filed under seal with the court. The government investigates for months or years while you continue operating normaly, completely unaware that the case exists. Your going about your business, seeing patients, submitting claims, running your practice. Meanwhile, federal investigators are analyzing every billing record you've submitted.
And then one day, FBI agents show up at your clinic. Or you recieve a grand jury subpoena. Or your learn that the case has been unsealed and your facing civil and criminal liability simultaniously.
By then, the investigation is essentialy complete. By then, the government has already decided your guilty.
What the First 48 Hours After a Subpoena Actually Look Like
When you recieve that grand jury subpoena or watch FBI agents walk through your front door asking to speak with you, you need to understand something critical that most providers miss. This isnt the beginning of the investigation. Its closer to the end.
Federal prosecutors dont show there hand until they've already built a substantial case. The subpoena isnt about gathering evidence they dont have - they already have your billing records, your patient files, your employment records, your bank statements. The subpoena is about locking in your response, creating a record of your statements that can be used against you at trial, and pressuring you toward cooperation before you've had time to think clearly or consult with counsel.
OK so what happens in those critical first hours after contact?
The government runs civil and criminal investigations simultaniously on most healthcare fraud cases. This is crucial to understand because it creates a trap. Your civil deposition testimony in the False Claims Act case can become evidence in the criminal prosecution. Statements you make trying to resolve the civil liability and minimize financial penalties can be used to prosecute you criminaly and send you to prison.
The Fifth Amendment protects you from self-incrimination, but invoking it in the civil case creates its own problems. The civil case proceeds regardless, and your silence can be used against you to draw adverse inferences. Your trapped between talking and incriminating yourself or staying silent and losing the civil case by default.
And heres the kicker that makes everything worse. The first person to cooperate gets the best deal. Federal prosecutors explicitly use this prisoner's dilemma to turn co-defendants against each other. If your billing manager, your physician assistant, your office administrator, your medical director - if any of them gets a cooperation agreement before you do, your options narrow dramaticaly.
They become the governments witness. You become the target.
As Todd Spodek explains to clients facing these situations, the window for effective intervention is shockingly small. What you do in those first 48 hours shapes everything that follows for years. The wrong statement, the wrong document produced, the wrong cooperation offer rejected or accepted - any of these can determine whether you spend the next decade in federal prison or walk away with your license and freedom intact.
The Cooperation Trap That Destroys Healthcare Providers
Most providers instinct, when federal agents come knocking, is to cooperate fully. To explain everything. To demonstrate there good faith and honest intentions. To prove they didnt mean to do anything wrong and would never intentionaly defraud the government programs that fund there practice.
This instinct is catestrophic. It is the single most dangerous thing you can do.
Heres the reality that defense attorneys know and providers learn too late. By the time the FBI shows up at your door, they've already decided your guilty. The agents havent come to investigate whether fraud occurred - they've come to document there case against you. The interview isnt about determining what happened. Its about getting you to incriminate yourself on tape, to make statements that contradict documents they already have, to lock you into a version of events they can destroy at trial.
Every statement you make voluntarilly becomes evidence. Every explanation you offer gets picked apart by prosecutors who've spent months analyzing your billing data. Every attempt to clarify or explain or provide context becomes another rope they use to hang you.
The compliance program you implemented to protect yourself? It cuts both ways, and often it cuts against you.
On one hand, evidence of a robust compliance program can demonstrate lack of criminal intent. If you had training programs, billing audits, coding reviews, hotlines for reporting problems - all of that shows you tried to follow the rules. Todd Spodek has seen cases where comprehensive compliance documentation saved clients from prosecution by making it impossible for the government to prove willful conduct.
But it also proves you knew the rules. Prosecutors argue that if you had a compliance program, received compliance training, and still submitted claims they consider improper, you did so knowingly. You cant claim ignorance when your own compliance materials prove you educated yourself on the regulations. Your defense becomes there evidence of guilty knowledge.
The Vanguard Healthcare case demonstrates the stakes involved. The Brentwood-based nursing home operator settled for $18 million in 2019 - the largest worthless services resolution in Tennessee history at that time. The allegations included grossly substandard nursing care and preadmission forms with signatures that were allegedly forged to obtain Medicaid reimbursement from TennCare. Once those patterns were documented, once the systematic nature of the conduct became clear, the outcome was basicly inevitable.
What you say in those first conversations with investigators matters more then almost anything else in determining your fate.
When "Billing Errors" Become Federal Crimes
The line between a billing error and healthcare fraud seems clear in theory. Mistakes are accidents. Fraud is intentional. Errors get corrected with refunds. Fraud gets prosecuted with prison sentences.
In practice, that line is almost invisible. And prosecutors have become extraordinaraly skilled at erasing it completly.
Healthcare fraud under 18 U.S.C. 1347 requires the government to prove you "knowingly and willfully" executed a scheme to defraud a healthcare benefit program. That sounds like it requires proving intent - proving you actually meant to steal from Medicare or Medicaid or private insurers. But heres how prosecutors actualy establish that intent without any direct evidence of criminal purpose:
They look for patterns in your billing. If your billing errors consistantly favor higher reimbursement - if they always go in your favor rather then randomly distributing in both directions - prosecutors argue that proves intent. The "errors" are to systematic to be accidents. Random chance would produce some underbilling mixed with the overbilling, but when every mistake makes you more money, thats not randomness. Thats fraud.
They use your own documentation against you. Every medical record you create, every billing code you select, every explanation you provide for procedures, every note justifying medical necessity - all of it becomes evidence. The very thoroughness that makes you a good provider, that protects you in malpractice cases, that demonstrates your commitment to patient care - all of that makes you an easier target for prosecutors. The more complete your records, the more ammunition they have.
They leverage your professional knowledge and experience. If you've been in healthcare for decades, attended billing seminars and compliance conferences, implemented compliance programs, hired billing consultants - prosecutors argue you knew the rules you were breaking. Ignorance isnt a defense when you've demonstrably educated yourself. Experience becomes proof of criminal knowledge.
The federal conviction rate exceeds 93 percent in healthcare fraud cases. That number isnt because federal prosecutors are brilliant litigators who win every case they try. Its because they only bring cases there essentialy certain to win. They investigate for years, build overwhelming evidence, flip cooperators to testify against remaining defendants, and only then file charges. By the time your charged with healthcare fraud, you've been pre-selected for conviction based on the strength of evidence against you.
Average guideline sentance under the federal sentencing guidelines: 51 months. Average actual sentance imposed by judges: 27 months. That gap - those two years of freedom - represents what cooperation buys you. It also represents what refusing to cooperate costs you.
How Spodek Law Group Fights Healthcare Fraud Charges
Most defense attorneys take healthcare fraud cases and immediately start negotiating plea deals. They look at the federal conviction rate, they look at the sentencing guidelines, they look at the evidence the government has compiled, and they tell there clients to cooperate as quickly as possible to minimize the damage.
We take a different approach at Spodek Law Group.
We understand that healthcare fraud cases live or die on the question of intent. Billing errors happen in every medical practice in America. Documentation gets messy under the pressure of patient care. Patterns emerge over time that look suspicious in retrospect but made perfect sense in the context of legitimate clinical decisions.
Our defense strategies focus on several key approaches that can mean the difference between conviction and acquittal:
Challenging the pattern narrative. Just because billing trends favor higher reimbursement doesnt automaticaly mean fraud occurred. We work with medical billing experts, certified professional coders, healthcare consultants, and statistical analysts to demonstrate why your billing patterns reflect legitimate medical judgement rather then criminal intent. What looks like fraud to a prosecutor reviewing spreadsheets often looks like good medicine to an expert reviewing patient charts.
Protecting you during the investigation phase. Those first 48 hours after federal contact matter enormously to the outcome of your case. We intervene before you make statements that become evidence, before the civil and criminal proceedings run ahead of you in ways you cant control, before your co-defendants cut there deals and position you as the primary target.
Leveraging your compliance efforts properly. A documented compliance program can demonstrate you tried to follow the rules and never intended to violate them. We help position your compliance history as evidence of good faith rather then allowing prosecutors to recharacterize it as proof of guilty knowledge. The framing matters as much as the facts.
Exploiting prosecutorial overreach. Federal prosecutors in Nashville face pressure to maintain there enforcement statistics and justify there resources. Sometimes they charge cases that dont hold up under careful scrutiny. Sometimes the pattern they identified has innocent explanations they didnt consider. Sometimes cooperating witnesses have credibility problems that undermine there testimony. We identify these weaknesses and exploit them aggressively.
If you've recieved a subpoena from a grand jury investigating healthcare fraud, if federal agents have contacted you or your employees, if you've learned that a qui tam whistleblower case has been filed against you - the clock is already running. The government had years to build there case while you operated in ignorance. You have days or weeks to respond effectively.
The next 48 hours determine the next 20 years of your life.
Call Spodek Law Group at 212-300-5196. We defend healthcare providers across Nashville and throughout Tennessee against federal fraud charges. The consultation is confidential and protected by attorney-client privilege. The representation is aggressive and uncompromising. And the stakes are too high to wait another day hoping the problem goes away on its own.
The government is ready. Are you?
