Federal Healthcare Fraud in Kentucky
Federal healthcare fraud prosecutions under 18 U.S.C. § 1347 have become among the most frequently charged white-collar offenses in Kentucky. With Lexington’s and Louisville’s major hospital systems, extensive physician networks, and active Medicare Advantage markets, Kentucky’s federal healthcare fraud docket is substantial. Clark + Harris defends physicians, healthcare executives, business owners, and others facing federal healthcare fraud investigations and prosecutions.
The Healthcare Fraud Statute
Under 18 U.S.C. § 1347, healthcare fraud occurs when someone knowingly and willfully executes, or attempts to execute, a scheme to defraud any health care benefit program or to obtain money or property from a health care benefit program through false or fraudulent pretenses, representations, or promises. The statute carries a 10-year maximum, increasing to 20 years if serious bodily injury results and life imprisonment if death results.
Related Statutes
Healthcare fraud cases rarely stand alone. Related charges commonly include Anti-Kickback Statute violations (42 U.S.C. § 1320a-7b), Stark Law violations, Controlled Substances Act prosecutions targeting prescribers (21 U.S.C. § 841), money laundering (18 U.S.C. § 1956), wire fraud (18 U.S.C. § 1343), conspiracy (18 U.S.C. § 371), and aggravated identity theft (18 U.S.C. § 1028A).
Common Healthcare Fraud Investigations
Federal healthcare fraud investigations in Kentucky target billing for services not rendered, upcoding, unbundling, medically unnecessary services, kickback arrangements between providers and referral sources, improper billing for compounded medications, fraud in durable medical equipment (DME) supply, home health fraud, and substance abuse treatment fraud. DOJ’s Health Care Fraud Strike Force, HHS-OIG, and FBI lead these investigations alongside Kentucky’s state Medicaid Fraud Control Unit.
Prescribing Physician Cases
Kentucky has been the site of several major federal prosecutions of physicians accused of prescribing outside the usual course of professional practice — essentially using 21 U.S.C. § 841 as a fraud theory. The Supreme Court’s 2022 decision in Ruan v. United States clarified the mens rea standard, requiring the government to prove the defendant physician knowingly or intentionally acted in an unauthorized manner. This decision created significant new defense opportunities for physician defendants.
Defense Strategies
Healthcare fraud defense requires deep familiarity with coding (ICD-10, CPT, HCPCS), medical necessity standards, and program-specific rules. Defense strategies include good-faith defenses based on reliance on medical judgment or staff, challenges to loss calculations (often inflated in government theories), challenges to willfulness and scienter, and expert testimony rebutting government medical and billing experts.
Parallel Proceedings
Healthcare fraud defendants typically face parallel proceedings: criminal charges, civil False Claims Act exposure under 31 U.S.C. §§ 3729-3733, HHS-OIG exclusion proceedings, DEA administrative action against controlled substance registrations, state licensing board proceedings, and private insurer recoupment actions. Coordinated defense across these forums is essential.
Contact Clark + Harris for Healthcare Fraud Defense
Federal healthcare fraud cases can end careers built over decades. Clark + Harris provides the experienced, discreet defense you need.
Call 859-474-0001 today for a strictly confidential consultation.
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