Houston Healthcare Fraud Defense Attorney

Healthcare Fraud Defense Attorney in Houston, TX

A Houston healthcare fraud defense attorney represents doctors, pharmacy owners, DME suppliers, and healthcare executives facing federal Medicare and Medicaid fraud investigations. Cory Roth Law Office defends clients across the Southern District of Texas against charges under 18 U.S.C. § 1347, the Anti-Kickback Statute, Stark Law, and the False Claims Act.

What Is Healthcare Fraud Under Federal Law?

Federal healthcare fraud is the knowing and willful execution of a scheme to defraud any healthcare benefit program — including Medicare, Medicaid, TRICARE, the VA, and private insurers — or to obtain money or property from such a program through false or fraudulent pretenses. It is codified at 18 U.S.C. § 1347 and carries up to 10 years in federal prison, increased to 20 years if serious bodily injury results, and a potential life sentence if a patient dies.

Common conduct that draws prosecution includes billing for services never provided, billing for medically unnecessary services, upcoding to higher-reimbursement codes, unbundling procedures, falsifying patient records, paying or accepting kickbacks for referrals, and using stolen patient identities to bill federal programs.

Federal Statutes That Drive Houston Healthcare Fraud Prosecutions

Healthcare fraud cases rarely involve a single statute. Prosecutors typically stack charges to maximize exposure and leverage. The most common statutes in Southern District of Texas indictments include:

• Healthcare Fraud — 18 U.S.C. § 1347. The core federal healthcare fraud statute. Up to 10 years per count.
• Conspiracy to Commit Healthcare Fraud — 18 U.S.C. § 1349. Same penalty as the underlying offense; no overt act required.
• Anti-Kickback Statute (AKS) — 42 U.S.C. § 1320a-7b. Criminalizes knowingly paying or receiving anything of value to induce or reward referrals for federal program services. Up to 10 years and $100,000 per violation.
• Physician Self-Referral (Stark Law) — 42 U.S.C. § 1395nn. A civil statute (strict liability) prohibiting physicians from referring designated health services to entities they have a financial relationship with.
• False Claims Act (FCA) — 31 U.S.C. § 3729. Civil liability for treble damages plus per-claim penalties ($13,946 to $27,894 per false claim in 2024-2025, adjusted annually). The primary vehicle for whistleblower (qui tam) cases.
• False Statements Relating to Healthcare Matters — 18 U.S.C. § 1035. Five years per count for false statements in connection with payment for healthcare services.
• Money Laundering — 18 U.S.C. §§ 1956 & 1957. Frequently charged when fraud proceeds are moved through accounts or used to buy property; up to 20 years.
• Aggravated Identity Theft — 18 U.S.C. § 1028A. Adds a mandatory consecutive 2-year sentence when stolen patient or provider identifiers are used.

Houston Is a Federal Healthcare Fraud Enforcement Hub

Houston is one of the original ten cities targeted by the DOJ Medicare Fraud Strike Force, a joint operation of the Department of Justice, HHS Office of Inspector General, FBI, DEA, and the Texas Attorney General’s Medicaid Fraud Control Unit. The Strike Force uses CMS billing data analytics to identify outlier providers, then builds prosecutions out of the Southern District of Texas.

In recent national takedowns, dozens of Houston-area providers have been indicted in single coordinated actions, with billing losses in the hundreds of millions. If you practice in the Texas Medical Center, southwest Houston, the Heights, Sugar Land, The Woodlands, or any Harris County clinic, you are in the geographic footprint that federal investigators monitor most closely.

Agencies That Investigate Houston Healthcare Fraud

• S. Attorney’s Office, Southern District of Texas (Houston Division) — files indictments and tries cases.
• HHS Office of Inspector General (HHS-OIG). Lead investigative agency for Medicare and Medicaid fraud.
• Federal Bureau of Investigation (FBI). Conducts search warrants, witness interviews, and complex case workups.
• Drug Enforcement Administration (DEA). Joins fraud cases involving controlled substance prescribing.
• Texas Attorney General — Medicaid Fraud Control Unit (MFCU). State-level criminal investigations into Texas Medicaid fraud.
• CMS contractors (UPICs, RACs, MACs). Conduct audits, prepayment review, and data-mining that often precede a federal referral.

Early Signs You Are Under Federal Healthcare Fraud Investigation

Healthcare fraud investigations often run silently for months — sometimes years — before charges are filed. Recognizing the early warning signs gives you the window you need to mount a real defense.

• A grand jury subpoena for patient records, billing data, or financial documents.
• A Civil Investigative Demand (CID) under the False Claims Act, signed by the U.S. Attorney or DOJ.
• Surprise visits from HHS-OIG or FBI agents at your office, home, or that of your employees.
• Patient or employee interviews conducted by federal agents — often the first signal a case exists.
• Prepayment review or payment suspension by a Medicare Administrative Contractor (MAC) or Unified Program Integrity Contractor (UPIC).
• A target letter from the U.S. Attorney’s Office identifying you as the subject of a federal investigation.
• A search warrant executed on your practice seizing computers, charts, and billing records.
• An unsealed qui tam complaint filed by a current or former employee, contractor, or competitor.

What To Do If Federal Agents Arrive at Your Practice

This is the most important section on this page. What you say and do in the first hours of contact with federal agents directly shapes the rest of the case.

• Do not consent to questioning without counsel. Politely tell the agent you will cooperate through your attorney. Get the agent’s name, agency, and contact information.
• Do not answer questions in your office, your car, or your driveway. Agents are trained to use informal settings to obtain statements that lock you in.
• Do not allow searches without a warrant. If they have a warrant, do not interfere — but ask for a copy and note what is taken.
• Do not destroy, alter, or remove documents or electronic files. Doing so is obstruction of justice under 18 U.S.C. § 1519 and a separate felony.
• Do not call patients, referral sources, or co-workers to discuss the investigation.
• Do call a Houston healthcare fraud defense attorney immediately — before you speak to anyone else, including your accountant, billing company, or business partner.

Common Houston Healthcare Fraud Allegations We Defend

Cory Roth Law Office defends the full range of federal and state healthcare fraud matters in the Houston area, including:

Billing & Coding Fraud

• Billing for services not rendered (“phantom billing”).
• Upcoding to higher-reimbursement CPT codes.
• Unbundling procedures that should be billed together.
• Billing for medically unnecessary services or tests.
• Falsified patient records or signatures.

Kickback & Referral Schemes

• Anti-Kickback Statute violations involving cash, gifts, marketing fees, or sham consulting arrangements.
• Stark Law violations from improper physician self-referrals.
• Patient recruiter and marketer schemes paying per-head fees.

Provider-Specific Schemes

• DME fraud (power wheelchairs, orthotic braces, CGMs).
• Home health fraud (fabricated patient eligibility, ghost patients).
• Hospice fraud (ineligible patient enrollment, falsified terminal certifications).
• Pharmacy fraud (compounding fraud, opioid diversion, kickback prescriptions).
• Telemedicine fraud (fraudulent telehealth visits used to authorize unnecessary DME, labs, or genetic tests).
• Genetic and cardiovascular testing fraud — a current DOJ Strike Force priority.
• Pain management and pill mill prosecutions blending healthcare fraud with controlled substance distribution.

Related Financial Crimes

Healthcare fraud cases routinely include related charges. We also defend federal embezzlement and white-collar property crimes, identity theft, credit card fraud, and embezzlement charges that often run parallel to a healthcare fraud indictment.

Three Tracks of Healthcare Fraud Exposure: Criminal, Civil, Administrative

Most providers focus on the criminal track and miss the two parallel tracks that can end a career on their own. A complete defense addresses all three from day one.

1. Criminal Prosecution

Filed by the U.S. Attorney for the Southern District of Texas. Carries prison, supervised release, forfeiture, and restitution. Requires proof beyond a reasonable doubt.

2. Civil False Claims Act Litigation

Filed by DOJ Civil Division or a private qui tam relator (whistleblower). Carries treble damages plus per-claim penalties. Lower burden of proof (preponderance of evidence). Settles often, but settlements may trigger automatic exclusion.

3. Administrative Action by HHS-OIG and CMS

This is the “career death penalty.” Even without a criminal conviction, HHS-OIG can pursue exclusion from federal healthcare programs and Civil Monetary Penalties. An excluded provider cannot bill Medicare, Medicaid, TRICARE, or the VA — and cannot work for any provider that does. State medical, nursing, and pharmacy boards routinely impose parallel license actions.

Critical: Pleading guilty to a single healthcare fraud count typically triggers mandatory minimum 5-year program exclusion under 42 U.S.C. § 1320a-7(a). For a provider, that exclusion is often more devastating than the prison term.

Penalties for Medicare and Medicaid Fraud

Penalties depend on the statute, the loss amount, and aggravating factors such as patient harm or use of stolen identities.

• Healthcare fraud (§ 1347): Up to 10 years per count. Up to 20 years if serious bodily injury results. Life if a patient dies.
• Anti-Kickback Statute: Up to 10 years and $100,000 per violation, plus exclusion.
• False Claims Act civil liability: Treble damages plus per-claim penalties (currently $13,946 to $27,894 per false claim, adjusted annually for inflation).
• Aggravated identity theft: Mandatory consecutive 2-year sentence on top of underlying charges.
• Restitution: Mandatory under the Mandatory Victims Restitution Act; often the largest single financial exposure.
• Asset forfeiture: Criminal and civil forfeiture of bank accounts, real estate, vehicles, and other proceeds traceable to fraud.
• Federal Sentencing Guidelines: Loss amount drives the guideline range. Loss of $1.5 million produces a base offense level near 20; loss over $25 million pushes the range above 10 years.

Sentencing also depends on the Federal Sentencing Guidelines, which apply loss-amount tables, sophistication enhancements, and role adjustments. The same conduct can produce dramatically different sentences depending on how loss is calculated. Loss calculation is a defense battleground.

Defenses to Healthcare Fraud Charges

Healthcare fraud cases turn on intent, billing complexity, and the technical specifics of what was coded, when, by whom, and for what reason. The defenses we develop most often include:

• Lack of intent. Section 1347 requires that the defendant acted “knowingly and willfully.” Honest billing mistakes, reliance on coders or third-party billing companies, and reasonable interpretations of complex CMS guidance are not crimes.
• Medical necessity supported by the record. Independent expert review of charts often shows that services prosecutors call “unnecessary” were within the standard of care.
• Good-faith reliance on counsel or compliance. Reliance on documented advice from a healthcare attorney, billing consultant, or in-house compliance program can negate willfulness.
• AKS Safe Harbor protection. The Anti-Kickback Statute has more than two dozen regulatory safe harbors. Many arrangements that appear suspect actually fit within one.
• Stark Law exception compliance. Stark is strict liability — but only if no exception applies. Many practices fit within bona fide employment, in-office ancillary services, personal services, or fair-market-value rental exceptions.
• Loss calculation challenges. Government loss figures are routinely inflated. Driving the loss number down often drives the sentence down dramatically.
• Statute of limitations. Most federal healthcare fraud charges have a five-year limitations period (six years for certain offenses). Older conduct may be time-barred.
• Fourth and Fifth Amendment challenges. Defective search warrants and improperly obtained statements are suppression opportunities.

Why Choose Cory Roth Law Office for Houston Healthcare Fraud Defense

Cory Roth Law Office handles serious federal and state investigations with the speed, discretion, and depth these cases require. Healthcare fraud defense demands more than general criminal defense — it requires command of CMS billing rules, agency procedure, and the unique parallel-track structure of federal healthcare prosecutions.

• Federal court experience. We handle matters in the Southern District of Texas, where Houston healthcare fraud cases are prosecuted.
• Early intervention focus. The most valuable work in any healthcare fraud case happens before indictment. We work to keep cases out of the indictment stage when possible.
• Three-track coordination. Criminal exposure, civil FCA liability, and HHS-OIG exclusion are managed together — not as separate problems.
• Coordinated white-collar defense. Healthcare fraud rarely arrives alone. We coordinate with our
• Comprehensive felony defense. From first-degree felonies to state jail felonies, we handle the full range of Houston felony defense — including the parallel state-law charges that can accompany federal healthcare fraud cases.
• Every consultation is confidential, and we understand the professional, family, and reputational stakes that make these cases different from routine criminal matters.
• Direct attorney access. You speak with the attorney handling your case from the first call forward.

Schedule a Confidential Healthcare Fraud Consultation

If you have been contacted by federal agents, received a subpoena or CID, had your billing privileges suspended, or learned you are the subject of an HHS-OIG or DOJ investigation, do not wait. Every day you remain unrepresented is a day the government builds its case without your defense in motion.

Call Cory Roth Law Office at (832) 650-0770 for a confidential consultation with a Houston healthcare fraud defense attorney. We respond quickly, work discreetly, and build defenses early. We represent providers and executives across Houston, Harris County, the Texas Medical Center, Sugar Land, The Woodlands, and the broader Southern District of Texas.