A federal False Claims Act matter can begin with a sealed whistleblower case, Department of Justice contact, Civil Investigative Demand, subpoena, audit, interview request, preservation notice, or inquiry from HHS-OIG, CMS, a contractor, or another agency. Healthcare providers, owners, executives, marketers, contractors, billers, and licensed professionals may face allegations involving claims, coding, medical necessity, referrals, records, overpayments, or services allegedly not provided.
The federal False Claims Act is principally a civil statute. It is not itself a generic criminal healthcare-fraud charge. But the same facts may be referred for criminal review under statutes such as 18 U.S.C. sections 1347 or 1035, the Anti-Kickback Statute, conspiracy, or obstruction laws. Our California healthcare fraud guide explains that broader criminal and regulatory setting.
Call 888-702-8882 for a free, confidential consultation about parallel criminal exposure in a federal healthcare investigation.
Our healthcare investigation and subpoena guide discusses early-response issues. Federal criminal exposure should be evaluated through a dedicated federal defense strategy.
31 U.S.C. section 3729 creates civil liability for several distinct acts. These include knowingly presenting or causing a false or fraudulent claim; knowingly making or using a false record or statement material to a false claim; conspiring to violate listed FCA provisions; and knowingly concealing or improperly avoiding or decreasing an obligation to pay or transmit money or property to the government.
The statute does not make every denied claim, regulatory violation, documentation defect, overpayment, medical disagreement, or coding error an FCA violation. The specific claim or obligation, alleged falsity, material statement, actor, causation, government money, timing, and knowledge evidence must be identified. Civil liability can involve treble damages and inflation-adjusted penalties, but this page does not state a mutable per-claim amount.
Section 3729 defines “knowingly” to include actual knowledge, deliberate ignorance of truth or falsity, or reckless disregard of truth or falsity. It states that no proof of specific intent to defraud is required. That does not eliminate the knowledge element. Negligence, an innocent mistake, and a good-faith disagreement should not automatically be relabeled as actual knowledge, deliberate ignorance, or reckless disregard.
In United States ex rel. Schutte v. SuperValu Inc., the U.S. Supreme Court held that FCA scienter concerns a defendant’s knowledge and subjective beliefs. A facially ambiguous rule does not automatically defeat scienter when evidence may show what the defendant actually thought. The decision did not make every ambiguous billing dispute actionable; evidence of the accused person’s contemporaneous understanding remains central.
A defense should not collapse falsity, materiality, knowledge, and causation. A claim may be factually accurate even when a record is imperfect. A requirement can be important to compliance yet not material to the government’s payment decision in the way alleged. A person may have made no representation, lacked claim control, or not caused the submission. The government or relator must prove the applicable elements, not merely identify an unfavorable audit or rule.
Billing and coding mechanics are addressed in our medical billing fraud guide. Medicare and Medi-Cal program issues are separated in our program-fraud guide.
31 U.S.C. section 3730 permits a private person, called a relator, to bring a civil action for the United States. The complaint is initially filed under seal and served on the government, not the defendant. The government investigates and may intervene and proceed, decline intervention, seek dismissal, settle subject to statutory procedures, or pursue other authorized action. A declination is not a finding that the allegations are true or false, and intervention is not a judgment of liability.
Whistleblower allegations can contain inside information, misunderstandings, disputed clinical opinions, incomplete records, or mixed motives. The response should test the relator’s access, role, dates, personal knowledge, documents, claim linkage, interpretations, and inconsistencies without retaliation, evidence tampering, witness coaching, or unauthorized contact.
31 U.S.C. section 3733 authorizes DOJ, before commencing an FCA civil proceeding, to demand documents, written interrogatory answers, or oral testimony when the Attorney General or a designee has reason to believe a person may possess information relevant to a false-claims investigation. A CID is civil process, but its production and testimony may affect parallel proceedings.
A CID response may require defensible collection, custodians, search terms, privilege review, confidentiality analysis, sequencing, declarations, testimony preparation, and negotiations about burden. Deadlines and challenge procedures are technical. Do not assume a CID can be ignored or that producing everything without strategy is harmless.
Record allegations require the granular analysis described in our false medical records and certifications guide. DME and testing allegations are addressed in our DME, laboratory, and diagnostic-testing guide.
42 U.S.C. section 1320a-7b(g) states that a claim including items or services resulting from an Anti-Kickback Statute violation constitutes a false or fraudulent claim for FCA purposes. The criminal Anti-Kickback Statute and civil FCA still have distinct elements, defenses, causation questions, procedures, and remedies. The alleged remuneration, referral or order, federal-program item or service, claim, safe-harbor or exception evidence, and each person’s role must be analyzed.
Our kickback and patient-referral guide addresses remuneration and referral issues in detail.
The FCA is principally civil. Potential criminal theories may separately include 18 U.S.C. section 1347 for a healthcare-fraud scheme, 18 U.S.C. section 1035 for specified materially false statements or writings in healthcare matters, the Anti-Kickback Statute, conspiracy, false statements, or obstruction provisions when their facts and elements fit.
Civil discovery, a relator interview, document production, internal investigation, payer appeal, refund, self-disclosure, licensing response, or settlement communication may produce evidence used elsewhere. Criminal-defense counsel’s role is to protect individual and company rights, assess exposure, preserve defenses, and coordinate compelled and voluntary responses. It is not a claim that MRL serves as general civil FCA litigation counsel in every matter.
Doctors and other licensees may also face board, credentialing, exclusion, or employment consequences. Those risks may require coordinated professional criminal and licensing defense.
California has a separate False Claims Act in Government Code sections 12650 through 12656 for qualifying state or political-subdivision claims. It has its own definitions, procedures, liability, and remedies. A federal FCA theory should not be treated as automatically proving a California claim, and a Medi-Cal matter may require careful allocation of federal, state, and local funds and conduct.
The DOJ Civil Division describes the FCA as a civil statute covering knowing false claims, material false records, reverse false claims, and conspiracies. DOJ’s January 2026 report for fiscal year 2025 says healthcare remained a leading source of FCA settlements and judgments and expressly notes that, except where stated, government claims described in its release were allegations without a determination of liability.
A May 2026 DOJ announcement states that certain new benefits-fraud qui tam matters may be referred for criminal and administrative evaluation. That enforcement policy is not a new element of section 3729 and does not prove liability in a particular case. No pending federal or California proposal is presented here as enacted law or predicted to pass.
No defense applies automatically. Do not make a refund, certification, disclosure, waiver, witness contact, interview, or settlement decision based only on a general webpage. No civil, criminal, administrative, licensing, or payer result can be promised.
No. The federal FCA is principally civil. The same facts may support a separate criminal investigation, but a criminal statute’s own elements and proof are required.
No. Section 3729 requires a qualifying false claim, record, conspiracy, or obligation theory and the statutory knowledge level. Negligence or an innocent mistake is not automatically actual knowledge, deliberate ignorance, or reckless disregard.
It is a civil case filed under seal by a private relator in the name of the United States. DOJ investigates and decides whether to intervene. Filing, intervention, or declination is not a final determination of liability.
A CID is compulsory civil process authorized by section 3733. Its scope, deadline, production, testimony, privilege, and challenge procedures should be reviewed promptly.
Potentially. Section 1320a-7b(g) connects claims resulting from an AKS violation to the FCA, but the remuneration, intent, causation, claim, exception, safe-harbor, and individual-role facts remain important.
Preserve native claims, charts, orders, contracts, messages, EHR and billing audit trails, policies, training, advice, refund and appeal records, system data, devices, and every version of requested material.
Yes. DOJ, HHS-OIG, program agencies, contractors, and licensing bodies may pursue different tracks. One response can affect several proceedings, so strategy should be coordinated.
This page provides general information, not legal advice. Reading it, calling the firm, or submitting information does not by itself create an attorney-client relationship. Laws and procedures can change, and every matter depends on its facts, evidence, forum, payer, jurisdiction, and timing. Past results do not guarantee a future outcome.
Call 888-702-8882 to discuss criminal-defense risks arising from a healthcare FCA investigation, CID, subpoena, or qui tam matter.
This page was written by the My Rights Law Editorial Team and reviewed for legal accuracy by Bobby Shamuilian.
Attorney Shamuilian is the founder and managing partner of My Rights Law and is widely recognized as a legal authority, frequently appearing as a legal analyst and TV pundit on national news outlets.
He has earned a perfect “10.0 – Top Attorney” rating on AVVO and a “10.0” rating on Justia, and has been named among the “Top 40 Under 40” and the “Top 100 Trial Lawyers” by The National Trial Lawyers.
With his proven expertise and dedication, Mr. Shamuilian is committed to protecting your rights and achieving the best possible outcome for your case.
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