Healthcare fraud under 18 U.S.C. § 1347 is a scheme to defraud a healthcare benefit program, or to obtain healthcare benefits by false or fraudulent pretenses, executed knowingly and willfully.¹ The benefit program can be public, like Medicare or Medicaid, or private, and the scheme is usually built from billing data: services billed but not rendered, services billed at a higher level than provided, or services that lack the clinical documentation to support them. Each execution of the scheme can be charged as a separate count, so a billing pattern across many claims can produce many counts.

The penalty is up to ten years per count, rising to twenty years where the conduct results in serious bodily injury and to life where it results in death.¹ The sentence the court actually imposes, however, is driven less by the count maximums than by the Guidelines loss calculation and the factors in 18 U.S.C. § 3553(a), which is why the loss number, not the number of counts, is usually the center of the case.²³

Healthcare fraud exposure is set by the per-count statutory maximum, then driven by the U.S. Sentencing Guidelines loss calculation and the enhancements the government argues. These are the variables that decide what a healthcare fraud charge means.

The elements the government must prove

The government must prove a scheme to defraud a healthcare benefit program, or to obtain benefits by false pretenses, executed knowingly and willfully.¹ Intent is usually the contested element, because the same billing decision can support either a fraud reading or a coding-dispute reading, and the line between aggressive billing and fraud is where many cases are fought.

The statutory maximum and the loss-driven Guidelines

Each count carries up to ten years, rising to twenty for serious bodily injury and life for death, but the advisory Guidelines range is anchored on a loss-amount table, with the offense level rising sharply as the loss figure increases, plus enhancements for the number of victims, sophisticated means, abuse of trust, and role.¹² The court must also weigh the Section 3553(a) factors.³

Intended loss versus actual paid loss

The loss figure the government argues in healthcare fraud is typically an intended-loss number drawn from the total amount billed, even though the amount the program actually paid may be a fraction of that, and it can be reduced by amounts properly supported by clinical documentation and by amounts the program denied on audit. Because the loss table moves the offense level by double digits across its ranges, contesting the intended-loss figure is the single most consequential piece of sentencing work.²

The counts healthcare fraud travels with

Healthcare fraud is frequently charged alongside a conspiracy to commit fraud under 18 U.S.C. § 1349, which is punishable the same as the underlying offense, alongside an aggravated identity theft count under 18 U.S.C. § 1028A where patient identifiers are misused, and alongside anti-kickback and false-statement counts.⁴⁵ How the government has packaged the scheme across these counts is a threshold question.

Healthcare fraud reaches physicians, nurse practitioners, and clinic owners, but it also reaches billing and coding staff, office managers, owners of home-health agencies, durable-medical-equipment suppliers, laboratories, and pharmacies, and the marketers who connect them. Because almost every clinical encounter generates a claim, the statute gives federal prosecutors broad reach over billing judgment that once would have been resolved through an audit, a recoupment, or a civil overpayment demand.

The collateral exposure is uniquely severe in this field. A conviction triggers mandatory exclusion from federal healthcare programs, which ends most provider careers,⁶ and it puts professional licenses and DEA registrations at risk. A parallel civil False Claims Act case and a qui tam relator often run alongside the criminal matter,⁷ and for a noncitizen a fraud offense above a statutory loss threshold can carry grave immigration consequences.⁸ Mandatory restitution to the affected programs is ordered on top of any prison term.⁹ That is the weight behind even a single count.

The criminal exposure is up to ten years per count, twenty for serious bodily injury and life for death, but the sentence the court imposes is driven by the Guidelines intended-loss calculation and the Section 3553(a) factors.¹²³ A paired conspiracy count under Section 1349 carries the same penalty as the underlying fraud, and a paired Section 1028A count adds a mandatory consecutive term where patient identifiers are misused.⁴⁵ Mandatory restitution to the affected programs is ordered in addition to any custodial sentence,⁹ and a multi-year term of supervised release follows.

The regulatory side is what sets this charge apart: mandatory program exclusion on conviction,⁶ license and DEA-registration actions, and a parallel civil False Claims Act case often run together,⁷ and statements made in one can affect the others. The realistic questions are whether the intended-loss figure can be reduced toward actual paid loss, whether intent can be contested as a coding dispute, and whether searches of clinic premises and electronic medical records hold up. Detention is decided early under the Bail Reform Act, though release on conditions is common in these cases.¹⁰ Outcomes turn on the specific record and are never promised.

A healthcare fraud case is usually built long before indictment, often starting with an audit by a program-integrity contractor or a qui tam complaint and a joint investigation by the FBI and HHS-OIG, and the first sign is commonly a records subpoena, a target letter, or a search warrant executed at a clinic rather than an arrest. What a person does at that first contact matters enormously. The most common mistake is agreeing to talk to agents without counsel, because a fraud case turns on intent and an informal explanation of a billing practice can be recast as an admission.

A few steps help in nearly every case. Do not discuss the matter with agents, staff, or colleagues; say only that counsel will respond. Preserve every patient chart, billing record, audit response, and email, and do not delete or alter anything, because destruction can itself become a charge. Keep any subpoena, target letter, or charging paperwork. If the case is still at the audit or pre-indictment stage, that window is often the most valuable time to be represented.

This is general information about how these cases work in Texas. It is not legal advice about any specific case, and reading it does not create an attorney-client relationship.

A healthcare fraud case often has a long audit-and-investigation phase before any public step, then moves on heavy paper. Knowing the order of events makes the decision points easier to see. The matter is heard in the U.S. District Court for the Western District of Texas, San Antonio Division, and prosecuted by the U.S. Attorney's Office for that district.¹¹¹²

Initial appearance

After indictment and arrest or a summons, the person is brought before a U.S. Magistrate Judge for an initial appearance under Federal Rule of Criminal Procedure 5, where the charge and rights are stated and counsel is addressed.¹³

Detention or release

Release or detention pending trial is decided under the Bail Reform Act, 18 U.S.C. § 3142; in healthcare fraud cases release on conditions is common.¹⁰

Grand jury indictment

A federal felony proceeds by indictment returned by a grand jury, frequently after a long joint investigation by the FBI, HHS-OIG, and program-integrity contractors, and a superseding indictment can add counts or defendants later.

Discovery and motions

The government produces its evidence under Federal Rule of Criminal Procedure 16, which in a healthcare fraud case can run to millions of billing lines, patient charts, audit reports, and recorded interviews, supplemented by the prosecution's constitutional duty to disclose exculpatory evidence under Brady and credibility evidence under Giglio.¹⁴¹⁵¹⁶ Motion practice on a bill of particulars, on suppression of clinic-premises and medical-record warrants, and on intended-loss evidence happens here.

Plea or trial, then sentencing

A case resolves by a guilty plea taken under Federal Rule of Criminal Procedure 11 or by trial.¹⁷ At sentencing the court calculates the advisory Guidelines range, with the intended-loss figure central, and weighs the factors in 18 U.S.C. § 3553(a).²³

A federal fraud case runs on the Speedy Trial Act clock once charged and on a series of court-set deadlines, and the early ones decide what evidence survives and what options remain.

A healthcare fraud case is worked as a careful read of the billing data alongside the clinical records that support, or fail to support, each billed encounter. The audit report and the data analytics the government relies on are read first, because they typically frame the indictment, and the production under Federal Rule of Criminal Procedure 16 is read methodically against the elements.¹⁴ Brady and Giglio scrutiny applies to every cooperator, every former employee, and every patient witness whose statement appears in the file.¹⁵¹⁶

The intended-loss analysis is the dominant sentencing variable, because the government typically argues the total billings as intended loss while the actual paid loss may be a fraction of that, and the loss table moves the offense level by double digits across its ranges.² The billed amount, the paid amount, the amounts denied on audit, and the amounts properly supported by clinical documentation are each evaluated and pushed back on with specifics. Motion practice often includes a bill of particulars to force the government to identify the specific billing entries it considers fraudulent, motions to suppress overbroad warrant searches of clinic premises and electronic medical records, and motions in limine on data-analytics summary witnesses. The Presentence Investigation Report is reviewed line by line and met with written objections to intended-loss inflation, victim-count enhancements, and role adjustments the proof does not support, with parallel collateral-consequence work on licenses, DEA registrations, and program exclusion coordinated with administrative counsel where appropriate.⁶

The hour estimate

Forrest Good PLLC estimates this matter at 100 to 300 hours of attorney time, billed at $250 per hour. The lower end reflects a solo-provider, single-modality case that resolves by an early plea; the upper end reflects a multi-defendant clinic indictment with millions of billed lines, contested intended-loss litigation, a parallel False Claims Act case,⁷ and a trial posture. The pricing methodology explains how the charging instrument, the evidence load, and the procedural stakes drive the estimate.

How the fee is set

This matter is priced by scoped consultation rather than a fixed flat fee, because federal exposure depends on the Guidelines intended-loss calculation, the volume of discovery, and whether the case resolves by plea or goes to trial, and those variables are only knowable after the indictment or the target letter and the available records are reviewed.² After that review, the engagement letter sets the scope and the fee for the matter in writing, still billed at the $250-per-hour rate for work beyond the scoped fee. The fee approach shown here is honored while this page is published, consistent with Texas Disciplinary Rule of Professional Conduct 7.02(d).¹⁸

Any work outside the scoped fee is billed at $250 per hour and is disclosed in the written engagement letter before it begins. The engagement letter is the binding contract for the matter.

The first step is a conversation. The initial 30-minute consultation with Forrest Good PLLC is free and is scheduled through the office's Google Booking page. It is the time to walk through the audit or investigation posture, the scope of the alleged scheme, and the intended-loss figure the government is likely to argue, and to understand where the case sits before any setting. Bringing any audit notice, target letter, subpoena, indictment, or records already received makes the half hour far more useful.

No attorney-client relationship is formed until a written engagement letter is signed; the consultation itself carries no obligation.

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