Los Angeles Medicare and Medi-Cal Fraud Lawyer

Medicare and Medi-Cal Fraud Defense in Los Angeles

When the payer is Medicare or Medi-Cal, a billing dispute stops being a business disagreement and becomes a government enforcement matter. Medi-Cal fraud is prosecuted by the California Department of Justice’s Division of Medi-Cal Fraud and Elder Abuse (DMFEA); Medicare fraud draws federal prosecutors, HHS-OIG agents, and — in the Los Angeles area — the U.S. Attorney’s Office for the Central District of California. My Rights Law Criminal Defense and DUI Lawyers defends Los Angeles providers, owners, and clinics facing Medicare and Medi-Cal fraud investigations. This page explains the two programs, the statutes prosecutors use, and how defense works when both systems move at once.

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Medi-Cal and Medicare Are Different Programs

Medi-Cal is California’s Medicaid program, funded jointly by the state and federal government and administered by the California Department of Health Care Services (DHCS). Medicare is purely federal, covering seniors and disabled beneficiaries. The distinction matters: Medi-Cal cases are usually state court matters filed at the Los Angeles County Superior Court’s Clara Shortridge Foltz Criminal Justice Center at 210 West Temple Street, prosecuted under California Penal Code section 550 and related statutes. Medicare cases are federal, charged under 18 U.S.C. section 1347 (health care fraud), 18 U.S.C. section 1035 (false statements in health care matters), and — where referrals are involved — 42 U.S.C. section 1320a-7b, the federal Anti-Kickback Statute. One billing pattern can implicate both programs and both court systems simultaneously.

How These Investigations Begin Locally

• a DHCS audit or Medi-Cal provider number suspension affecting Los Angeles area patients;
• data mining that flags outlier utilization compared to regional peers;
• a beneficiary complaint or elder-abuse referral routed to DMFEA;
• payment suspensions imposed while the investigation continues;
• a search warrant executed at the clinic without any prior warning;
• a target letter or grand jury subpoena for records and testimony.

Federal agents do not schedule courtesy calls. By the time Medicare fraud suspects hear from the government, an agent has usually already interviewed employees, patients, and referral sources.

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Program Exclusion: The Penalty That Outlasts the Case

For many providers the worst consequence is not custody — it is exclusion. A Medicare or Medi-Cal fraud conviction can trigger mandatory exclusion from federal health programs, ending participation for years or permanently. Add board licensing action, loss of hospital privileges, and commercial network termination, and a misdemeanor plea can end a clinical career. Defense strategy has to price every option against the whole stack of consequences, not just the sentence.

Defenses in Medicare and Medi-Cal Cases

• billing accuracy disputes are documentation and interpretation problems, not crimes;
• medical necessity is a clinical judgment the record actually supports;
• intent is absent — staff, vendors, or prior owners caused the false claims;
• the government’s statistical sampling overstates the loss;
• statements to agents were voluntary but uninformed, or obtained improperly;
• repayment and corrective action plans were available and appropriate remedies.

No outcome can be promised. But investigations that are engaged early, documented, and answered with complete records resolve without charges far more often than ones ignored until arraignment. Call 888-702-8882 for a free confidential consultation.

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Related Los Angeles Defense Resources

• California Medicare and Medi-Cal Fraud Lawyer — the statewide program fraud page.
• Los Angeles Healthcare Fraud Defense Lawyer — the local overview page.
• Los Angeles Fraud Attorney — all fraud defense practice areas.

Frequently Asked Questions

Can I keep billing while under Medi-Cal investigation?

It depends. DHCS can suspend Medi-Cal payments during an investigation, and continued billing for disputed services can compound exposure. Counsel can often negotiate scope limits or restoration terms so a practice survives the investigation.

Does paying back the money end the case?

Not automatically. Repayment resolves the civil overpayment, but prosecutors can still file charges if they believe the claims were knowingly false. Repayment done with legal guidance is also mitigation evidence; repayment done in panic can be misread as an admission.

What is the Anti-Kickback Statute?

42 U.S.C. section 1320a-7b is the federal law that criminalizes paying or receiving remuneration to induce referrals of federal program business. Many Medicare cases that start as billing audits become kickback cases once referral payments surface.

Official Legal and Agency References

• California DMFEA — the state unit prosecuting Medi-Cal fraud.
• DHCS Investigations Division — Medi-Cal audits and referrals.
• HHS-OIG enforcement — federal investigations and exclusions.
• 42 U.S.C. section 1320a-7b — federal Anti-Kickback Statute.

Important Legal Disclaimer

This page is legal information, not legal advice, and reading it does not create an attorney-client relationship. Laws and enforcement priorities change, and outcomes depend on the facts of each case.

Los Angeles office: My Rights Law Criminal Defense and DUI Lawyers - Los Angeles, 527 W 7th St #936, Los Angeles, CA 90014. Call 888-702-8882 for a free confidential consultation.