Criminal Defense for Physicians Facing Billing Fraud Allegations in California

Strategic Legal Representation for Medical Professionals

When billing audits escalate into criminal investigations, physicians need defense counsel who understands criminal law and the complexities of healthcare reimbursement systems. At Law Office of Daniel Horowitz, we defend individual doctors and small practices throughout California against billing fraud allegations, Medicare/Medicaid investigations, and healthcare compliance violations. Our focused approach combines criminal defense experience with knowledge of medical coding standards, providing the strategic representation physicians need when their license and liberty are at stake.

Call (925) 291-5388 or contact us online to schedule a confidential consultation about your billing fraud defense case.

How Law Office of Daniel Horowitz Defends Physicians in California

Early Case Assessment

We begin with a thorough review of the allegations, audit findings, billing records, and any government communications. This assessment: 

• Identifies the specific theories of liability
• Evaluates the strength of potential defenses
• Determines whether the matter can be resolved administratively or requires criminal defense preparation

Strategic Response Development

Our approach considers multiple dimensions: 

• The criminal exposure
• Regulatory compliance issues
• Licensing implications
• Reputational concerns

We develop defense strategies that address immediate legal risks while protecting long-term professional interests.

Documentation Review & Expert Analysis

Billing fraud cases succeed or fail based on documentation. We work with coding consultants, medical experts, and healthcare compliance professionals to analyze medical records, evaluate whether documentation supports the services billed, and identify legitimate explanations for billing patterns flagged by investigators.

We Are Also Licensing Counsel

Criminal charges often trigger parallel investigations by the California Medical Board. We have expert licensing attorneys so that we manage both proceedings simultaneously, recognizing that statements or resolutions in one forum can impact the other.

Negotiation & Resolution

Many billing fraud investigations can be resolved without criminal charges through repayment agreements, civil settlements, or deferred prosecution arrangements. We negotiate with federal and state prosecutors, seeking outcomes that avoid criminal convictions while addressing any legitimate compliance concerns.

Trial Defense When Necessary

When cases cannot be resolved favorably through negotiation, we provide vigorous trial defense. Billing fraud prosecutions require the government to prove criminal intent: that the physician knowingly submitted false claims. We challenge these allegations by demonstrating:

• The complexity of billing regulations
• The reasonableness of the physician's conduct
• The absence of fraudulent intent

Why Physicians Need Specialized Criminal Defense

Healthcare billing fraud cases differ fundamentally from standard criminal matters. These investigations involve overlapping systems, all converging on a single physician:

• Criminal statutes
• Federal healthcare regulations
• Medicare compliance standards
• State medical board rules

The stakes extend beyond potential criminal penalties to include professional licensure, hospital privileges, and career viability.

Billing fraud allegations typically begin as administrative audits conducted by Medicare Administrative Contractors or state Medicaid programs. What starts as a request for documentation can quickly transform into a federal investigation involving the Department of Justice, the FBI, or the California Attorney General's office. During this transition, physicians often fail to recognize the shift from administrative review to potential criminal exposure, continuing to cooperate without the benefit of appropriate legal counsel.

This progression creates unique vulnerabilities. Statements made during audit responses, interviews with investigators, or attempts to resolve overpayment demands can become evidence in criminal proceedings. Defense strategy must begin early, ideally before the matter escalates beyond the audit stage, and must address both immediate criminal exposure and long-term professional consequences.

Billing Fraud Allegations We Defend Against in California

Upcoding & Procedure Misclassification

Allegations that physicians submitted CPT codes for higher-reimbursement services than actually provided. These cases often hinge on documentation standards and the clinical justification for the level of service billed.

Overbilling & Duplicate Claims

Charges involving billing for services not rendered, billing multiple times for the same service, or charging for services already included in bundled payment codes. Prosecutors frequently rely on electronic billing records and payment data to build these cases.

False Claims Act Violations

Federal prosecutions under the False Claims Act carry severe penalties, including treble damages and per-claim fines. These cases often involve whistleblower complaints from former employees or business associates who receive a percentage of any recovery.

Medicare & Medicaid Fraud Investigations

Federal and state investigations into billing practices related to government healthcare programs. These matters frequently involve CMS audits that identify overpayments, triggering referrals to law enforcement.

Kickback & Self-Referral Allegations

Cases involving alleged violations of the Anti-Kickback Statute or Stark Law, where physicians are accused of receiving or providing improper financial incentives for patient referrals or medical services.

Healthcare Compliance Violations

Criminal charges stemming from alleged failures to maintain proper documentation, follow Medicare billing guidelines, or adhere to compliance program requirements under corporate integrity agreements.

California Penal Code Section 550 Fraud Charges

This penal code section makes the filing of a false claim for insurance payments a criminal act.  Often, physicians have a disagreement with an insurance carrier or third-party payor and find that a legitimate disagreement has led to the filing of serious felony insurance fraud charges.

The Regulatory Landscape Physicians Navigate

California physicians operate within a maze of overlapping regulations: 

• Federal Medicare guidelines establish documentation requirements and medical necessity standards. 
• State Medicaid programs (Medi-Cal) impose additional billing rules. 
• The American Medical Association maintains CPT coding standards. 
• Meanwhile, the Medical Board of California enforces professional conduct rules that can be violated by the same conduct underlying criminal charges.

This regulatory complexity creates genuine ambiguity. Coding decisions that seem reasonable from a clinical perspective may be characterized as fraudulent by investigators lacking medical training. Documentation practices that meet hospital standards may fall short of Medicare's specific requirements. Billing staff errors can be attributed to physician intent. In this environment, the distinction between a coding mistake and criminal fraud often hinges on how the conduct is framed, rather than the physician's actual knowledge or intent.

Why Individual Physicians Need Focused Representation

Large healthcare organizations facing billing fraud investigations have compliance departments, in-house counsel, and substantial resources to mount comprehensive defenses. Individual physicians and small practices lack these advantages but face equally serious consequences. Many general criminal defense attorneys lack familiarity with healthcare billing systems, while healthcare attorneys may not have criminal trial experience.

Law Office of Daniel Horowitz focuses on individual physicians precisely because this population needs specialized representation that large firms often cannot provide efficiently. We accept a limited number of physician billing fraud matters each year, allowing us to dedicate substantial attention to each case. This focused approach means your defense receives the detailed analysis and strategic planning it requires rather than being treated as one of many similar matters in a large firm's healthcare fraud practice.

The Importance of Confidential Consultation

Physicians under investigation often hesitate to seek legal counsel, fearing that hiring an attorney signals guilt or will antagonize investigators. This misconception can be devastating. Government investigators are not neutral fact-finders; they are building criminal cases. Every communication with them creates potential evidence.

Consulting with criminal defense counsel is prudent and protected. Attorney-client privilege shields these conversations, allowing physicians to fully disclose facts and receive candid legal advice without creating discoverable communications.

If you are facing a billing audit, have received a government subpoena, or are under investigation for Medicare fraud, upcoding, or healthcare billing violations, contact us online for strategic criminal defense representation.