Connecticut Federal Medicare and Medicaid Fraud Defense Attorney

What makes federal Medicare and Medicaid fraud cases particularly dangerous is the layered exposure they create. Criminal prosecution, civil liability under the False Claims Act, mandatory exclusion from all federal healthcare programs, and professional license revocation can all flow from the same set of facts. Early intervention — before any statement is made to investigators and ideally before charges are filed — is the decision that matters most. At Marin & Murphy Law Firm, we represent Connecticut healthcare providers at every stage of federal Medicare and Medicaid fraud proceedings — backed by deep experience as Connecticut federal criminal defense attorneys.

How Federal Medicare and Medicaid Investigations Begin

Healthcare providers rarely learn they are under federal investigation through an arrest. These cases develop over months or years before any charges are filed. The government builds its case quietly, often through billing records obtained via administrative subpoena, whistleblower complaints filed under the False Claims Act, or referrals from CMS program integrity contractors conducting pattern audits.

The first contact most providers receive takes one of several forms: a civil investigative demand (CID) requesting records and communications, a federal grand jury subpoena for billing data or employee testimony, a prepayment review or suspension of Medicare reimbursements, or a request for a “voluntary” interview from agents who identify themselves as working for HHS-OIG, the FBI Healthcare Fraud Unit, or the IRS Criminal Investigation division.

None of these contacts are routine. A CID is the opening move of a federal investigation. A request for a voluntary interview is an attempt to lock in statements before an attorney is involved. Providers who respond without counsel — by producing documents informally, by speaking with agents at the office, or by allowing employees to be interviewed without guidance — routinely provide the government with evidence it would otherwise have had to obtain through formal process.

If agents contact you or anyone at your practice, the response is the same regardless of whether you believe the situation is serious: decline to speak, preserve all potentially relevant records, and contact defense counsel immediately. That sequence — in that order — protects your options. Our guide to Connecticut healthcare provider federal investigations walks through the response sequence in more detail.

What the Government Must Prove

Federal healthcare fraud prosecutions primarily proceed under 18 U.S.C. § 1347, which criminalizes knowingly and willfully executing a scheme to defraud any healthcare benefit program through false or fraudulent representations. The statute reaches Medicare, Medicaid, TRICARE, and private insurers. Convictions carry up to ten years per count, rising to twenty years if serious bodily injury is connected to the fraud, and life imprisonment if a death results.

The government typically does not charge isolated billing errors. Prosecutors build cases around patterns — systematic upcoding across hundreds of claims, billing for services not rendered, billing for services by providers who did not actually perform them, using unlicensed staff while billing under a licensed provider’s NPI, or structuring documentation after the fact to support claims that were never legitimate. The pattern is usually established through billing data that the government obtains long before any arrest.

Anti-Kickback Statute violations (42 U.S.C. § 1320a-7b) are frequently charged alongside § 1347. The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce referrals of items or services covered by federal healthcare programs. Referral arrangements, fee splits, and marketing relationships that were never documented through proper safe harbor compliance can create AKS exposure even where the underlying services were legitimate.

Federal wire fraud (18 U.S.C. § 1343) is layered on in virtually every case involving any electronic submission to a government payer — which means every modern Medicare and Medicaid claim. Each electronic claim submission is a potential wire fraud count, multiplying exposure significantly. For broader context on how federal fraud charges are structured, see our overview of Connecticut federal healthcare fraud defense.

The Civil Track: False Claims Act Liability

Federal healthcare fraud cases almost always carry a parallel civil track. The False Claims Act (31 U.S.C. § 3729) allows the government to pursue civil damages of three times the amount allegedly defrauded, plus per-claim penalties that currently range from approximately $13,900 to $27,900 per false claim submitted. Clients facing overlapping fraud counts often consult our guide to Connecticut federal fraud defense for context on how multiple charges are evaluated together.

Many False Claims Act cases begin with a qui tam whistleblower complaint — filed under seal by a current or former employee, a competing provider, or anyone with knowledge of the alleged scheme. The whistleblower’s attorney files the complaint in federal court without the provider’s knowledge, the government investigates, and the first indication the provider receives may be a CID or the unsealing of the complaint. The civil and criminal tracks can proceed simultaneously, meaning a provider who cooperates with the civil investigation may be providing evidence used in the criminal prosecution.

Connecticut federal prosecutors recovered over $40 million across all fraud categories in 2025, with healthcare fraud accounting for a significant portion. Recent District of Connecticut cases have included a Branford laboratory that settled a $1.2 million False Claims Act case for billing Medicare and Medicaid for medically unnecessary urine drug tests, a multi-defendant Medicaid case involving $1.8 million in fraudulent ABA therapy billings, and a former state official whose guilty plea in November 2025 included charges tied to a cancelled state audit of a Medicaid provider.

Consequences Beyond the Courtroom

For healthcare providers, the consequences of a federal conviction extend well past the criminal sentence. Mandatory exclusion from Medicare, Medicaid, TRICARE, and all other federal healthcare programs follows conviction under the healthcare fraud statute or the Anti-Kickback Statute. For physicians, nurse practitioners, and other licensed providers, exclusion means the inability to bill federal programs — effectively ending any practice that depends on Medicare or Medicaid reimbursement. Related financial fraud charges — including Connecticut federal bank fraud defense — frequently accompany healthcare fraud prosecutions in complex cases.

Exclusion can also be imposed administratively before any conviction, as part of a permissive exclusion determination by HHS-OIG. Providers who accept an administrative settlement without counsel may inadvertently trigger exclusion they could have negotiated around.

Professional licensing consequences run parallel. The Connecticut Department of Public Health monitors federal convictions and charges involving healthcare providers and initiates its own disciplinary proceedings. In serious cases, the licensing board can seek emergency suspension of a provider’s license before any federal trial.

Asset forfeiture proceedings can reach practice revenues, personal accounts, and real property alleged to be derived from fraud proceeds. In large cases, the government may seek a pre-indictment restraining order freezing assets before charges are filed — before the provider has any meaningful opportunity to defend.

Defense Strategy in Healthcare Fraud Cases

Effective defense in federal Medicare and Medicaid fraud cases requires understanding both federal criminal procedure and the regulatory architecture that governs healthcare billing. The government frequently builds cases using compliance standards that were not clearly defined at the time of the alleged conduct, billing code guidance that changed over the period in question, and documentation requirements that vary by payer and specialty.

Early case assessment examines the billing data the government is likely working from and identifies whether the alleged patterns are consistent with intentional fraud or with the billing errors, coder errors, and compliance failures that exist in virtually every practice. Intent is the element the government must prove — and the difference between a billing error and criminal fraud is the difference between a civil settlement and a prison sentence.

For providers already convicted, challenging a federal conviction or sentence under § 2255 may still be possible.

Defense strategy typically addresses several parallel tracks. On the factual side: identifying the scope of the alleged conduct, evaluating whether expert testimony on billing standards and medical necessity can rebut the government’s characterization of the claims, and examining whether any cooperating witnesses or qui tam relators have their own credibility or motive issues. On the procedural side: evaluating whether records were obtained lawfully, whether the CID or subpoena scope exceeded authority, and whether any statements made to investigators before counsel was retained can be challenged.

Pre-indictment negotiation is a serious option in healthcare fraud cases, particularly where the conduct can be characterized as a compliance failure rather than intentional fraud. The U.S. Attorney’s Office for the District of Connecticut has structured civil settlement resolutions with healthcare providers — including the Genco Lab and Connecticut dental practice settlements in 2025 — that resolved False Claims Act exposure without criminal prosecution. These outcomes are not available to every case, but early engagement, before indictment and before the government has committed to a criminal theory, creates options that close once charges are filed.

Attorney Stefanie A. Murphy brings a trial-tested foundation to the defense of serious federal cases. The Providence Journal has reported her as lead counsel in cases ranging from a murder acquittal — representing a defendant in a case involving co-defendants serving life sentences — to complex post-conviction DNA litigation pursuing exoneration for a client incarcerated for nearly four decades. Her work on behalf of clients in high-stakes proceedings requiring sustained engagement with federal criminal evidence standards informs how Marin & Murphy approaches cases where the government’s proof depends on billing records, expert testimony, and regulatory interpretation. Matthew T. Marin’s background in constitutional litigation and his recognition by Rhode Island Lawyers Weekly for advancing suppression arguments and evidentiary challenges strengthens the firm’s federal defense capability across both jurisdictions. Prior results do not guarantee a similar outcome. The cases referenced above are described to illustrate the nature of Attorney Murphy’s trial and post-conviction practice. Every case is evaluated on its individual facts, applicable law, jurisdiction, and procedural posture. Post-conviction matters described as ongoing remain in active litigation, and no outcome has been adjudicated.