New Jersey Federal Health Care Fraud Lawyer

New Jersey is one of the most aggressively policed states in the country for federal health care fraud. With dense networks of physicians, pharmacies, laboratories, home health agencies, durable medical equipment suppliers and billing companies, the state has long been a priority for the U.S. Attorney’s Office for the District of New Jersey and its Health Care Fraud Unit. If you are a doctor, nurse, pharmacist, practice owner, biller, marketer or patient recruiter and you have learned that you are under investigation, you need a New Jersey federal health care fraud lawyer who understands both the medicine and the federal criminal system.

At Keith Oliver Criminal Law, we represent health care professionals and business owners across New Jersey who are facing investigation or prosecution in federal court. This page explains what federal health care fraud is, which statutes prosecutors use, what penalties are on the table, how these cases are investigated and how they can be defended.

What Is Federal Health Care Fraud?

The core statute is 18 U.S.C. § 1347. It makes it a crime to knowingly and willfully execute, or attempt to execute, a scheme to defraud any “health care benefit program,” or to obtain money or property from such a program through false or fraudulent pretenses, in connection with the delivery of or payment for health care benefits, items or services. The term health care benefit program is defined broadly in 18 U.S.C. § 24. It covers Medicare and Medicaid, but it also covers TRICARE, the New Jersey State Health Benefits Program, workers’ compensation carriers and private insurers such as Horizon, Aetna, UnitedHealthcare and Cigna. In other words, a case can be federal even if no government program paid a single claim.

To convict, the government must prove beyond a reasonable doubt that the defendant:

1. Knowingly and willfully executed or attempted to execute a scheme to defraud a health care benefit program, or to obtain its money or property by materially false representations;
2. Acted with intent to defraud; and
3. Did so in connection with the delivery of or payment for health care benefits, items or services.

Importantly, the statute was amended by the Affordable Care Act to state that a person does not need actual knowledge of § 1347 or specific intent to violate it. But the government still must prove the person acted knowingly and willfully with intent to defraud. That distinction between fraud and honest billing error, aggressive but lawful coding, or a good-faith interpretation of a payer’s rules is where many cases are won.

Common Types of Health Care Fraud Charged in New Jersey

Federal prosecutors in Newark, Trenton and Camden have charged a wide variety of schemes. Some of the most frequent include:

• Billing for services not rendered. Claims submitted for office visits, therapy sessions, tests or equipment that patients never received.
• Upcoding. Billing a higher-paying CPT code than the service supports, such as billing a level-5 evaluation and management visit for a brief follow-up.
• Medically unnecessary services. Ordering tests, procedures, braces, genetic screens or compounded medications that were not needed.
• Kickbacks and patient brokering. Paying or receiving money, gifts or “marketing fees” for patient referrals, prescriptions or lab orders. These cases are often charged under the federal Anti-Kickback Statute alongside § 1347.
• Compounded medication and pharmacy schemes. New Jersey saw a major wave of prosecutions involving compounded creams billed to the State Health Benefits Program and other insurers, and pharmacy cases remain common.
• Telemedicine and durable medical equipment (DME) fraud. Orders signed by providers who never examined the patient, often generated by call centers.
• Laboratory and genetic testing fraud. Cancer genetic screens, toxicology and respiratory panels billed without medical necessity.
• Opioid diversion and “pill mill” conduct. Prescribing controlled substances outside the usual course of professional practice, often charged under the Controlled Substances Act together with health care fraud counts.

Federal Health Care Fraud Penalties

Each count of health care fraud carries up to 10 years in federal prison. If the violation results in serious bodily injury, the maximum rises to 20 years, and if it results in death, the maximum is life imprisonment. Prosecutors almost never charge a single count. They typically charge one count per claim or per patient, along with conspiracy under 18 U.S.C. § 1349, which carries the same penalties as the underlying offense.

The most common companion charges include:

Charge	Statute	Maximum Penalty
Health care fraud	18 U.S.C. § 1347	10 years per count (20 with serious bodily injury; life if death results)
Conspiracy to commit health care fraud	18 U.S.C. § 1349	Same as the object offense
Anti-Kickback Statute	42 U.S.C. § 1320a-7b(b)	10 years and $100,000 per violation
False statements relating to health care matters	18 U.S.C. § 1035	5 years
Theft or embezzlement in connection with health care	18 U.S.C. § 669	10 years (1 year if $100 or less)
Aggravated identity theft	18 U.S.C. § 1028A	Mandatory 2 years, consecutive
Money laundering	18 U.S.C. §§ 1956, 1957	20 years / 10 years

Aggravated identity theft deserves special attention. When a provider uses a real patient’s name or Medicare number on a false claim, prosecutors frequently add a § 1028A count, which carries a mandatory two-year sentence that must run consecutively to any other sentence. The U.S. Supreme Court narrowed this statute in Dubin v. United States (2023), holding that the use of another person’s identity must be at the crux of what makes the conduct criminal. That decision gives defense counsel a powerful argument in many billing cases. Learn more about related charges on our federal identity theft page.

How Sentences Are Actually Calculated

Statutory maximums tell only part of the story. In practice, federal judges begin with the U.S. Sentencing Guidelines. For health care fraud, the guideline is § 2B1.1, and the most important factor is the “loss” amount. The guidelines add offense levels as loss climbs, and in federal health care offenses involving a government health care program, the aggregate dollar amount of fraudulent bills submitted is treated as prima facie evidence of the intended loss. That rule can drive the numbers far above what was actually paid.

There is also a special enhancement for health care fraud against government programs: two, three or four additional levels when the loss to the government program exceeds $1 million, $7 million or $20 million. Other enhancements frequently argued in New Jersey cases include abuse of a position of trust (common for licensed professionals), sophisticated means, number of victims and role in the offense. On the other side, reductions are available for acceptance of responsibility, a minor role and, since 2023, for certain defendants with zero criminal history points.

Because the loss figure drives so much of the sentence, an experienced defense lawyer will often retain a certified coder, a billing expert or a forensic accountant to rebut the government’s numbers. Showing that many claims were legitimate, that services were actually provided or that the “intended loss” was overstated can reduce a guideline range by years.

Who Investigates Health Care Fraud in New Jersey?

Health care fraud investigations are usually long and document-heavy. The agencies most often involved are:

• HHS Office of Inspector General (HHS-OIG), which investigates fraud against Medicare and Medicaid;
• The FBI, which handles many large-scale and private-insurer schemes;
• The Drug Enforcement Administration (DEA), when controlled substance prescribing is involved;
• The Defense Criminal Investigative Service (DCIS) and the Office of Personnel Management OIG for TRICARE and federal employee plan claims;
• The New Jersey Office of the State Comptroller’s Medicaid Fraud Division and the Office of the Insurance Fraud Prosecutor, which frequently share information with federal agents.

Investigations often begin with a data analytics flag, a whistleblower lawsuit under the False Claims Act (filed under seal by an employee or competitor), a patient complaint or a cooperating witness. By the time agents knock on the door or serve a search warrant, they have usually been reviewing claims data for months. National enforcement remains intense: the Department of Justice’s 2025 National Health Care Fraud Takedown charged 324 defendants nationwide in schemes alleged to involve more than $14.6 billion in intended losses, and New Jersey defendants have been included in these coordinated actions year after year.

Criminal Charges vs. Civil and Administrative Exposure

A health care fraud allegation can trigger three separate tracks at once: a criminal case, a civil False Claims Act case that can impose treble damages and per-claim penalties, and administrative action such as exclusion from Medicare and Medicaid by HHS-OIG, payment suspensions, or discipline by the New Jersey State Board of Medical Examiners or Board of Pharmacy. A conviction for health care fraud against a federal program results in mandatory exclusion from federal health care programs for at least five years. For a physician or pharmacist, that can end a career even if the prison term is modest.

Coordinating these tracks is essential. Statements made in a civil deposition or a licensing interview can be used in the criminal case. Conversely, an early, carefully negotiated civil resolution can sometimes persuade prosecutors that criminal charges are unnecessary.

Defenses to Health Care Fraud Charges

Every case is fact-specific, but strong defenses frequently include:

• Lack of intent to defraud. Billing mistakes, staff errors, reliance on a billing company and confusing payer rules are not crimes. The government must prove willfulness.
• Good-faith reliance on advice. Reliance on counsel, a compliance consultant or a coding professional can negate criminal intent when the advice was sought in good faith and followed.
• Medical necessity was legitimate. Physicians are entitled to clinical judgment. Expert testimony can show that ordered services were reasonable for the patients involved.
• Safe harbors to the Anti-Kickback Statute. Bona fide employment relationships, properly structured personal services contracts and other regulatory safe harbors make many payment arrangements lawful.
• Challenging the loss calculation. Even where some wrongdoing occurred, contesting the dollar figure can dramatically change the sentencing outcome.
• Suppression and privilege issues. Search warrants for medical offices raise patient privacy and attorney-client privilege concerns, and filter-team procedures can be challenged.

What to Do If You Are Contacted by Investigators

If agents from HHS-OIG or the FBI appear at your office or home, you have the right to decline an interview and to speak with a lawyer first. Be polite, take their business cards and do not lie, because a false statement to a federal agent is a separate felony under 18 U.S.C. § 1001. Do not destroy, alter or “clean up” patient files or billing records, which can lead to obstruction charges. If you receive a subpoena, target letter or civil investigative demand, contact a federal defense attorney before responding. Early representation allows your lawyer to communicate with the Assistant U.S. Attorney, learn whether you are a witness, subject or target, and sometimes resolve matters before indictment.

Health care fraud cases often overlap with other federal charges, including mail fraud, wire fraud, federal conspiracy and money laundering. Our white-collar crime team handles these cases together.

Related Federal Defense Guides

• Federal identity theft and aggravated identity theft
• Federal wire fraud
• Federal investigations, target letters and grand jury subpoenas
• How the federal sentencing guidelines work

Frequently Asked Questions

Can I be charged with federal health care fraud if only private insurance was billed?

Yes. The federal health care fraud statute applies to any “health care benefit program” affecting commerce, which includes private insurers such as Horizon, Aetna and UnitedHealthcare, not just Medicare and Medicaid.

What is the statute of limitations for health care fraud?

The general federal statute of limitations is five years from the offense under 18 U.S.C. § 3282. In a continuing scheme or a conspiracy, the clock usually runs from the last act in furtherance, so older conduct can still be charged.

Will I lose my medical license if I am convicted?

Very likely, unless the matter is resolved carefully. A conviction can lead to discipline by the New Jersey State Board of Medical Examiners and mandatory exclusion from Medicare and Medicaid for at least five years.

Should I talk to an HHS-OIG agent who shows up at my practice?

You should speak with a defense attorney first. You may politely decline an interview. Anything you say can be used against you, and an inaccurate statement can itself be charged as a federal crime.

Where are New Jersey health care fraud cases prosecuted?

In the U.S. District Court for the District of New Jersey, which sits in Newark, Trenton and Camden. Cases are prosecuted by the U.S. Attorney’s Office for the District of New Jersey, sometimes together with the DOJ Fraud Section’s Health Care Fraud Unit.

Talk to a New Jersey Federal Defense Lawyer Today

Federal cases are won or lost early, often before an indictment is ever filed. If an agent has contacted you, a search warrant has been executed, or you have received a target letter or grand jury subpoena, call Keith Oliver Criminal Law at (732) 858-6959 or contact us online for a confidential consultation. We defend clients throughout New Jersey in the U.S. District Court in Newark, Trenton and Camden, with offices in Monmouth, Mercer and Somerset Counties and Jersey City. Learn more about our federal criminal defense practice and attorney Keith G. Oliver.