How Whistleblower Claims Can Lead to Criminal Charges in Healthcare Fraud Cases

It often starts with a billing review. A former employee, contractor, or even a competitor reports your practice or company to the government. Maybe they claim overbilling, improper coding, or kickbacks. What many providers don’t realize is this: whistleblower complaints under the False Claims Act (FCA) can quickly move beyond civil penalties and into criminal prosecution. And once that happens, you’re not dealing with just money, you’re dealing with your freedom.

If you’re in healthcare and receive any government funding such as Medicare, Medicaid, or TRICARE, you are exposed. And you don’t need to be running a massive operation to be at risk. Small practices and individual providers get targeted, too.

From Civil FCA to Criminal Charges

The False Claims Act allows private individuals (relators) to file lawsuits if they believe fraud has occurred. If the Department of Justice decides to intervene, the case becomes far more serious. And sometimes, the DOJ doesn’t stop at civil penalties. They open a parallel criminal investigation.

Once that happens, the tone changes. Instead of discussing fines or settlements, prosecutors start talking about indictments and prison time. The most common charges that arise from FCA cases include healthcare fraud, wire fraud, money laundering, and conspiracy.

The Red Flags That Trigger Criminal Investigations

Certain patterns tend to raise red flags. These include:

• Billing for services not rendered
• Upcoding procedures to higher reimbursement levels
• Paying or receiving kickbacks for referrals
• Submitting claims for medically unnecessary services
• Altering or falsifying documentation

You may think it’s a misunderstanding or that an employee acted without your knowledge. But prosecutors may not see it that way. And once a criminal investigation starts, it can be hard to stop without experienced legal help.

Whistleblowers Can Be Anyone

You don’t need to have enemies to be at risk. Whistleblowers can be former employees, billing staff, competitors, or even business partners. Some are motivated by conscience. Others are driven by the FCA’s financial incentive that whistleblowers can receive a percentage of whatever the government recovers.

In either case, once the complaint is filed, it sets off a chain reaction. The government can gain access to your records, your emails, and your bank accounts. Investigators may interpret inconsistencies as fraud even if you did nothing intentionally wrong.

Even Honest Providers Can Get Caught in the Crosshairs

Not every billing error is criminal. But in today’s enforcement environment, the line between mistake and fraud is thinner than ever. And once you’re under scrutiny, your personal and professional reputation is on the line.

If you’re a healthcare provider and you learn that an FCA claim has been filed, you need to take it seriously whether the government has intervened or not. That means getting a criminal defense attorney involved early, not just relying on your healthcare lawyer or compliance officer.

What You Should Do First

If you’re made aware of an FCA whistleblower suit or a federal audit tied to your billing practices:

• Do not contact the whistleblower
• Do not destroy or alter any documents
• Do not make statements to investigators without legal counsel
• Do retain an attorney who understands both the FCA and federal criminal prosecution

Early intervention matters. Many healthcare professionals make the mistake of thinking they can explain their way out of it. That rarely works. Prosecutors are trained to look for intent, and your words can be used against you later.

You’re Not Just Defending Your Practice, You’re Protecting Your Life

When you’re a provider, you’re not just running a business. You’re supporting your family, staff, reputation, and often your professional license. A criminal charge affects all of that. But the right legal strategy, grounded in reality and tailored to your situation, can make all the difference.

Barry Wax gives people in trouble the ability to make the right choices and regain control of their lives. If you’ve been accused of healthcare fraud or are facing whistleblower-related charges, call Barry. He’ll take the time to understand you, your practice, and everything at stake and give you a path forward.