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Wisconsin Medicare Fraud - Medicaid Fraud in Racine

Call Cafferty & Scheidegger, S.C. if you are accused of Wisconsin Medicare fraud. Top-rated Racine, Kenosha federal criminal defense attorney.

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Racine, Kenosha, and Walworth Federal Criminal Lawyer

If you have been accused of Medicare or Medicaid fraud, you are in serious legal trouble. The federal authorities are heavily involved in identifying those who are defrauding these agencies and holding them accountable in federal criminal court. Medicare fraud can include billing for services that were not medically necessary, charging excessively for services or supplies or misusing codes, upcoding or unbundling codes, or billing for supplies that were not provided to the patient.

The federal False Claims Act (FCA) is the law that is applied if any person knowingly submits a false or fraudulent claim. The penalties that are imposed can include fines from $5,500 to $11,000 per claim, and up to three times the damages to the federal government that resulted from that claim. These penalties, as they are based on a per-claim basis, can add up to hundreds of thousands of dollars or more and lead to years in federal prison. Are you charged with Medicare or Medicaid fraud? It is imperative that you have legal representation from a highly skilled federal criminal defense lawyer.

The Governing Federal Statutes

Healthcare-fraud prosecutions most often rest on two federal statutes:

  • 18 U.S.C. § 1347: Federal health-care fraud. Knowingly and willfully executing, or attempting to execute, a scheme to defraud any health-care benefit program. Up to 10 years in prison, or up to 20 if the conduct causes serious bodily injury.
  • 42 U.S.C. § 1320a-7b: The federal Anti-Kickback Statute. Offering, paying, soliciting, or receiving any remuneration to induce referrals for services paid by a federal health-care program. Up to 10 years in prison and substantial fines.

The False Claims Act at 31 U.S.C. §§ 3729-3733 runs alongside the criminal statutes. Qui tam (whistleblower) suits brought under the FCA frequently precede a criminal indictment, which means an early, quiet defense strategy can sometimes resolve matters before they become public. Knowing and willful are not the same as careless or mistaken. Billing-code interpretation, industry practice, and the documentation behind each disputed claim are all fertile ground for defense work.

Federal Laws and Medicare or Medicaid Fraud

There are various federal statutes that can lead to criminal charges being filed in federal court for Medicare or Medicaid fraud, including the FCA as well as the Anti-Kickback Statute (AKS). It is a crime to offer, pay, solicit or receive willfully any remuneration (directly or indirectly) that rewards referrals of items or services that are paid by one of the federal healthcare programs. The penalties can include fines of up to three times the amount of the kickback, and criminal penalties can mean fines and imprisonment in a federal correctional facility.

Medicaid fraud charges can be related to accusations of patient abuse and neglect in health care facilities. Medicaid Fraud Control Units (called MFCU) are located in both Wisconsin and Illinois, and are involved in identifying those that they believe are fraudulently collecting funds for services or equipment. The Office of the Inspector General, U.S. Department of Health and Human Services is the oversight agency for these cases, and charges are usually filed after an extensive investigation from the state MCFU. These cases involve a substantial amount of documentation and other evidence, all of which could have been misinterpreted by the authorities. It could not be more important that you get a qualified attorney with extensive knowledge and experience in federal criminal defense. The outcome of your case will in large part be the result of the actions taken by your lawyer.

Our Qualifications for Defending Against Medicare or Medicaid Fraud Charges

At Cafferty & Scheidegger, S.C., you will find highly respected and accomplished federal criminal defense lawyers. We have achieved many honors and accolades, including being listed in Wisconsin Super Lawyers® from 2008 - 2020, members of our team having a 10.0 Superb rating on Avvo, and Mr. Patrick K. Cafferty rated AV Preeminent® in criminal defense by Martindale-Hubbell®, as well as being listed in Best Lawyers. You can be confident that your case will be handled by a true legal professional. Call now.

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Frequently Asked Questions

How long do you go to federal prison for Medicare fraud?
Federal healthcare fraud under 18 U.S.C. § 1347 carries up to 10 years per count. The maximum jumps to 20 years if the conduct results in serious bodily injury, and to life if it results in death. The Anti-Kickback Statute under 42 U.S.C. § 1320a-7b also carries up to 10 years. Actual sentences are driven by U.S. Sentencing Guidelines based on loss amount to the federal program, with sophisticated-means and abuse-of-trust enhancements common.
What does the government have to prove for healthcare fraud?
Under 18 U.S.C. § 1347 the government must prove the defendant knowingly and willfully executed (or attempted to execute) a scheme to defraud a healthcare benefit program. 'Knowing and willful' is the key element: billing-code interpretation disputes, industry practice, and good-faith reliance on coding consultants or compliance staff are all routine defenses to the intent element.
What is the difference between Medicare fraud and the Anti-Kickback Statute?
Medicare fraud under 18 U.S.C. § 1347 covers schemes to defraud the program through false billing, upcoding, billing for services not rendered, or medically unnecessary services. The Anti-Kickback Statute under 42 U.S.C. § 1320a-7b covers payment, solicitation, or receipt of remuneration to induce referrals for federally reimbursed services. The two statutes often charge in tandem in indictments arising from referral arrangements.
Is restitution required in Medicare fraud cases?
Yes, in nearly every case. The Mandatory Victims Restitution Act (18 U.S.C. § 3663A) requires full restitution to Medicare and Medicaid for the loss they incurred. Restitution is enforceable as a federal civil judgment for 20 years and is separate from any fine. The False Claims Act (31 U.S.C. §§ 3729-3733) also runs in parallel and exposes defendants to treble damages plus per-claim penalties on the civil side.
What is a qui tam case and how does it lead to criminal charges?
Qui tam (whistleblower) suits under the False Claims Act allow private parties to sue on behalf of the government and share in any recovery. The Department of Justice reviews each qui tam complaint and decides whether to intervene; many criminal healthcare-fraud indictments begin with a sealed qui tam filing reviewed by federal prosecutors. Early defense intervention during the sealed-review period can sometimes resolve matters before they become criminal.
Can a Medicare fraud case be defended through industry standard practice?
Often yes, on the intent element. The government must prove knowing and willful conduct, not negligence or honest billing-code disagreement. Documentation of compliance training, retention of outside coding consultants, contemporaneous chart notes supporting medical necessity, and good-faith reliance on advice of counsel or compliance staff are all productive defense themes.
How long does a Medicare fraud conviction stay on your record?
Permanently. Federal felony convictions are not expungeable; pardon by the President is the only route to removal. Beyond the criminal record, conviction triggers mandatory exclusion from Medicare and Medicaid participation under 42 U.S.C. § 1320a-7 for at least 5 years (longer for repeat offenses), which functionally ends most healthcare careers. Professional licensing boards typically follow with their own discipline.
Should I talk to federal agents in a Medicare fraud investigation?
Not without federal defense counsel present. Statements to federal agents can themselves be charged under 18 U.S.C. § 1001 (false statements, up to 5 years per count). Healthcare fraud investigations frequently begin with what feels like a routine HHS-OIG or FBI interview at the office; the right answer is to politely decline and call counsel. Practice staff should be advised of the same rule in advance.
Can Medicare fraud charges be reduced through cooperation?
Often yes. Federal sentencing under USSG § 5K1.1 allows the government to file a substantial-assistance motion in exchange for cooperation against other targets (referring physicians, suppliers, billing companies). Cooperation is risk-laden; proffer agreements must be negotiated carefully through experienced federal counsel, and the actual sentence benefit must be weighed against the disclosure exposure.
What defenses work against Medicare fraud charges?
Effective defenses include lack of intent to defraud (good-faith billing disputes, reliance on coding consultants, industry practice), insufficient evidence of knowing participation (especially for non-prescriber staff), suppression of evidence obtained through overbroad search warrants or improper administrative subpoenas, statute-of-limitations defenses on older claims, and challenges to the government's loss calculation that can substantially reduce the USSG offense level.
How much does a Wisconsin Medicare fraud lawyer cost?
Generally flat-fee for charging and pre-trial work, hourly in complex multi-defendant or multi-count cases. The range tracks document volume (often millions of claims records), forensic billing analysis, anticipated grand jury and motion practice, parallel False Claims Act civil exposure, and trial preparation. Free initial consultation produces a scoped quote against the actual investigation or indictment.

Why Choose Cafferty

Free Consultation

From our offices in Racine and Kenosha Wisconsin, the criminal defense lawyers at Cafferty & Scheidegger defend the rights of people charged with state and federal criminal offenses throughout Southeastern Wisconsin (Racine, Kenosha, Walworth). If you or a loved one is charged with a crime, contact us today to arrange a free initial consultation with an experienced Racine criminal defense attorney right away. For urgent matters, you are welcome to call or text us 24 hours a day at (262) 632-5000.

We Defend You

The attorneys at Cafferty & Scheidegger have excellent knowledge of the state and federal court system throughout Southeastern Wisconsin. They are aggressive trial lawyers that are recognized for integrity and hard work. Our law firm’s strength lies in our exceptional pre-trial investigation and case preparation. We come to the prosecutor’s office prepared with the facts and ready to help you get the best possible outcome for your charges. Our priority is always to keep you out of jail and avoid a conviction on your record, whenever possible.

Proven Experience

The dedication of the team at Cafferty & Scheidegger to client service and their record of success has earned them listings as Wisconsin Super Lawyer® from 2008 - 2026. In addition, their reputation for high standards has earned them an AV Distinguished rating by Martindale-Hubbell. Cafferty & Scheidegger is backed by more than 32 years of trial skills and courtroom experience.

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