Medicare and Medicaid Fraud in Florida: Federal Charges That Can Put Your Career at Risk
A Medicare or Medicaid fraud investigation can put far more than money on the line.
For a doctor, clinic owner, billing manager, pharmacy owner, or medical equipment supplier, a federal investigation can threaten a professional license, a business, future billing privileges, and years of work.
And in South Florida, these cases are not unusual.
If federal investigators are already asking questions, waiting to see what happens next can be a serious mistake. By the time charges are filed, prosecutors may have spent months — sometimes years — gathering records and building their case.
Why South Florida Faces Heavy Federal Healthcare Fraud Enforcement
South Florida has been a major federal enforcement jurisdiction for healthcare fraud for years. Miami was the first city in the country selected for the DOJ’s Health Care Fraud Strike Force model in 2007.
The numbers show how aggressive enforcement has become.
Nationally, False Claims Act recoveries hit a record $6.8 billion in fiscal year 2025. Healthcare accounted for roughly 84% of that total, while 1,297 whistleblower-initiated qui tam lawsuits were filed that same year.
Then came the June 2026 national healthcare fraud takedown, described as one of the largest in DOJ history. A Miami man was charged in connection with an alleged scheme involving $3.76 billion in fraudulent claims, and more than $27 million was seized from bank accounts belonging to South Florida clinics.
The government’s approach is also becoming more data-driven.
On April 30, 2026, DOJ formally launched FOCUS, or Fraud Oversight through Careful Use of Statistics. The program formalizes the government’s use of data analytics and what officials have called “data miner” whistleblowers.
That matters because an investigation does not always begin with someone walking into a federal office and making a complaint.
Sometimes, the numbers come first.
A billing pattern can raise a question. A statistical outlier can attract attention. A cluster of claims can look unusual compared with other providers in the same area.
Imagine a clinic that bills a certain procedure far more frequently than comparable providers. The owner may not realize that the billing pattern has attracted attention until a subpoena arrives.
By then, investigators may already be looking closely at the clinic’s records.
Doctors, clinic owners, billing companies, pharmacy owners, and medical equipment suppliers can all become targets of federal healthcare fraud investigations.
What Can Lead to a Medicare or Medicaid Fraud Charge?
There is no single type of conduct that makes up healthcare fraud.
Federal prosecutors can rely on several different statutes, including:
- The False Claims Act, 31 U.S.C. § 3729
- The Anti-Kickback Statute, 42 U.S.C. § 1320a-7b
- The Stark Law, 42 U.S.C. § 1395nn
- The federal healthcare fraud statute, 18 U.S.C. § 1347
Depending on the facts, conduct that may trigger an investigation or federal charges can include:
- Billing Medicare or Medicaid for services that were never provided.
- Upcoding — billing for a more expensive service than the one actually performed.
- Billing for services performed by unlicensed or uncredentialed personnel.
- Paying or receiving kickbacks for patient referrals.
- Unbundling services and billing separately for parts of a procedure that should not be billed that way.
- Operating a medical practice as a front for drug distribution.
- Using the identity of Medicare beneficiaries to submit fraudulent claims.
The details matter.
A billing mistake is not automatically the same thing as intentional fraud. But once federal investigators believe there is a knowing pattern of fraudulent conduct, the situation can become much more serious.
What Are the Federal Penalties for Healthcare Fraud?
Under 18 U.S.C. § 1347, federal healthcare fraud carries a potential sentence of up to 10 years in federal prison per count.
If the fraud results in serious bodily injury to a patient, the maximum increases to 20 years.
If a patient dies as a result, the statute allows any term of years up to life in prison.
There is another point that often gets overlooked.
Prosecutors do not have to prove that you knew the specific healthcare fraud statute or specifically intended to violate that law. The issue is whether you knowingly carried out the fraudulent conduct.
That distinction can become extremely important in a federal case.
The consequences can continue after prison
A criminal conviction may also affect whether a healthcare professional can continue participating in federal healthcare programs.
Convictions can trigger exclusion from federal healthcare programs under 42 U.S.C. § 1320a-7.
For a program-related fraud conviction, that exclusion is mandatory, meaning HHS has no discretion to decline it, with a minimum term of five years.
Five years is only the starting point.
The exclusion can extend beyond five years depending on aggravating factors such as the scope, duration, or financial impact of the conduct, as well as prior convictions. In serious or repeat cases, the consequences can become effectively permanent.
For a healthcare provider, that can be devastating.
Think about what happens to a medical practice when its primary provider cannot bill federal programs for five years. Referral relationships change. Employees leave. Patients move elsewhere. The business infrastructure built over years may not survive.
The damage can extend well beyond the courtroom.
Federal Prosecutors Can Target More Than the Doctor
A healthcare fraud investigation is not necessarily limited to the physician who signed the charts.
Federal prosecutors may also investigate:
- Billing managers
- Office administrators
- Marketing personnel who recruited patients
- Drivers who transported patients in exchange for kickbacks
- Clinic owners
- Pharmacy owners
- Medical equipment suppliers
- Other people who knowingly participated in the alleged scheme
That is why an employee or business partner should not assume that being “just the billing person” or “just the driver” automatically protects them.
If prosecutors believe someone knowingly participated in the scheme, that person’s role can become part of the federal case.
What Happens Before Federal Healthcare Fraud Charges Are Filed?
The investigation stage can be one of the most important parts of the entire case.
In many healthcare fraud cases, the process begins with a qui tam lawsuit filed by a whistleblower. That person may be a disgruntled employee, a competitor, or even a patient.
The government can then investigate while the lawsuit remains under seal.
You may know nothing about it.
That can go on for months or years.
A subpoena can be a warning sign
There are several signs that federal investigators may already be looking into a healthcare practice.
For example:
- Your billing company or clearinghouse receives a subpoena for records.
- Federal agents identifying themselves as OIG or FBI investigators appear at the clinic.
- Medicare or Medicaid suddenly suspends, reviews, or scrutinizes your billing.
- Former employees tell you they have been contacted by federal investigators.
- Investigators begin asking questions about billing practices, referrals, patients, or financial relationships.
Do not assume that the absence of an indictment means nothing serious is happening.
Federal investigations can remain quiet for a long time.
A major qui tam issue is being litigated in the Eleventh Circuit
There is also a developing legal issue involving the mechanism used for whistleblower lawsuits.
In United States ex rel. Zafirov v. Florida Medical Associates, LLC, a federal district court in the Middle District of Florida found that the False Claims Act’s qui tam provisions — the provisions that allow private whistleblowers to sue on the government’s behalf — are unconstitutional.
That decision is currently on appeal to the Eleventh Circuit, which covers the Southern District of Florida.
This issue has not been finally decided.
It is not something a defendant should treat as an automatic defense. But it is a significant issue to watch in cases originating through the qui tam process, particularly in this federal circuit.
How Is a Healthcare Fraud Case Defended?
Healthcare fraud defense is not simply about arguing that a doctor or business owner made a mistake.
The defense may require an understanding of both federal criminal law and the complicated rules governing Medicare and Medicaid billing.
An attorney handling the case may need to examine billing codes, coverage requirements, medical records, referral arrangements, compliance procedures, financial transactions, and communications between the people involved.
The goal is to understand what actually happened — not simply what the government’s spreadsheet appears to show.
Challenging criminal intent
One possible defense strategy is showing that the provider acted in good faith and did not have the criminal intent required for the charge.
That may involve examining compliance efforts, billing procedures, advice from professionals, internal policies, or the circumstances surrounding the disputed claims.
Challenging whether the conduct actually violated the rules
Healthcare regulations are complicated.
A billing practice that looks suspicious when viewed in isolation may have a different explanation once the underlying records and applicable rules are examined.
The defense can challenge whether the conduct actually violated the applicable law or regulations under the circumstances.
Negotiating before an indictment
A healthcare fraud case does not always have to begin with an indictment.
Depending on the facts, defense counsel may be able to communicate with prosecutors and work toward a resolution before charges are formally filed.
That is one reason timing matters.
Once an indictment is filed, the case has entered a very different stage.
Challenging the government’s financial calculations
Money is often a major part of federal healthcare fraud cases.
The government’s calculation of alleged losses may therefore become an important issue.
Defense counsel can examine how those numbers were calculated and whether the government’s damages figure accurately reflects the underlying conduct.
The spreadsheet is not the case. It is evidence about the case.
Seeking a civil resolution when appropriate
Not every allegation of wrongdoing has to end in a criminal conviction.
In some cases, particularly where some misconduct occurred but the facts do not justify criminal prosecution, the defense may negotiate toward a civil resolution under the False Claims Act rather than a criminal case.
Whether that option exists depends heavily on the circumstances.
What Should You Do If Federal Investigators Contact You?
If you are a healthcare provider or business owner in South Florida and something feels wrong, do not wait for an indictment before getting legal advice.
A subpoena. A federal agent at the door. A sudden Medicare or Medicaid review.
Those events deserve immediate attention.
Do not try to explain everything yourself just because you believe the billing issue was a misunderstanding. And do not assume that cooperating informally with investigators cannot affect you later.
Get counsel involved early.
The earlier a federal criminal defense attorney can review the situation, the more opportunity there may be to understand what investigators are looking at, protect your interests, and explore available options before the case moves further.
Facing a Medicare or Medicaid Fraud Investigation in South Florida?
If you are a healthcare provider in South Florida and believe you may be under federal investigation — or if you have received a subpoena or contact from federal agents — call Albert Quirantes, Esq. at (305) 644-1800.
The earlier we’re involved, the more options we may have.
Available 24/7.
Sources
- 18 U.S.C. § 1347, Cornell Law School Legal Information Institute — federal healthcare fraud statute and penalty structure
- 42 U.S.C. § 1320a-7 exclusion provisions, LegalClarity — mandatory exclusion mechanics, minimum term, and extension factors
- Medical Economics, False Claims Act recoveries hit a record $6.8 billion in 2025 — FY2025 healthcare’s share of FCA recoveries and qui tam filing volume
- Dentons On Call, DOJ Data Analytics Putting Health Care Under the Microscope — the FOCUS initiative, launched April 30, 2026
- DLA Piper, False Claims Act Year in Review: 2025 trends and what’s ahead in 2026 — the Zafirov v. Florida Medical Associates constitutional challenge pending before the Eleventh Circuit
