How Many Medical Providers Could Be Prosecuted Until 2020??

While the supplied research does not establish a total number of healthcare prosecutions in the United States through 2020, it identifies thousands of individual healthcare-related enforcement proceedings. As a result of being limited through 2020, an analysis of this information does not reflect the volume of enforcement activity that has occurred since, including throughout 2025 and 2026. The references to the volume of healthcare providers’ legal proceedings that appear in law-firm marketing materials do not constitute independently sourced national healthcare-prosecution statistics. Instead, law-firm marketing materials present results and experience, and provide examples that are representative in nature. These examples are illustrative of the volume of healthcare enforcement, but they do not represent a total number of medical providers’ prosecutions. The issue of calculating a single total number is further complicated by the fact that federal, state, civil, criminal, and licensing proceedings are all forms of healthcare enforcement. While providers may refer to all of these as “prosecution,” they are actually different categories of legal proceedings. Examples of healthcare-related enforcement include:

• Federal criminal prosecutions (including those targeting healthcare providers, pharmacies, labs, DME companies, and healthcare executives)
• Federal civil proceedings (including civil False Claims Act cases and other Medicare and Medicaid-related matters)
• State criminal and civil proceedings
• Licensing proceedings and administrative sanctions (including those initiated by state medical boards, other professional licensing boards, and other state-level administrative agencies)
• Exclusions from federal healthcare benefit programs The provided research does not report the number of providers involved in each of these categories, and does not report annual totals for each year covered by the analysis.

Does a civil settlement or licensing action count as a provider prosecution?

The concept of provider “enforcement” is broad. It includes civil False Claims Act settlements, criminal healthcare-fraud convictions and pleas, licensing action settlements, and others. Within this broad category of provider enforcement, there are several key aspects that explain why it is difficult to derive national statistics regarding the number of medical providers prosecuted.

Civil False Claims Act Proceedings

The False Claims Act (FCA) is one of the primary laws the federal government uses to pursue civil enforcement actions against healthcare providers. The FCA allows for treble damages (three times the damages incurred by the government), and per-claim civil penalties. While these are civil rather than criminal penalties, the costs of settling can be substantial enough to effectively shut down many healthcare practices.

Qui Tam Actions (FCA Whistleblower Actions)

Another hallmark of federal healthcare fraud enforcement is the prevalence of qui tam (whistleblower) lawsuits. Under the FCA, private citizens, or whistleblowers, can file lawsuits on behalf of the government. When a whistleblower files a qui tam complaint, the complaint must be filed in camera and remain under seal for at least 60 days while the government may investigate the claims; the seal may be extended for good cause.

Parallel Civil and Criminal Proceedings

Civil and criminal healthcare-fraud proceedings frequently proceed in parallel. Because the civil and criminal aspects of healthcare fraud have significant overlap, the government often pursues both types of enforcement action simultaneously.

Civil Settlement Not Equivalent to Criminal Immunity

A resolution of a civil False Claims Act case does not preclude a provider’s criminal liability. While reaching a civil settlement may offer an initial opportunity to work with the government to resolve any underlying criminal matters, it does not automatically mean a provider will avoid criminal charges or penalties.

State Licensing and Other Administrative Actions

Administrative actions brought by state licensing boards, like medical boards or pharmacy boards, also fall into the broad category of provider “enforcement actions.” These actions can occur independently, or they can follow the resolution of federal or state civil or criminal litigation.

How can billing data turn into a criminal healthcare case?

Billing audits are just one way that federal healthcare fraud investigations get off the ground. If an auditor determines that an audit reveals evidence of healthcare fraud, they can refer the matter to federal law enforcement for further investigation. Either the audit itself serves as the basis of the investigation, or the audit serves as a catalyst for investigators to pursue their own investigation. Another frequent catalyst is claims data. Federal agencies such as the OIG and CMS analyze claims data on an ongoing basis, and they use these analyses to identify healthcare providers that are statistical billing outliers. A billing outlier is a healthcare provider whose billing records appear to deviate significantly from those of providers in the same region and field of practice. At Spodek Law Group, we defend clients against these allegations. One important fact to remember is that a provider’s status as a statistical billing outlier does not prove that the provider is involved in healthcare fraud. An apparent deviation from billing patterns may be for a legitimate purpose, but a provider’s status as an outlier is usually sufficient for federal investigators to look into the provider further. As federal investigators look into suspected healthcare fraud, they can use civil investigative demands (CIDs) and grand-jury subpoenas to compel the production of records and documents. These powerful tools allow investigators to access the private records of providers, businesses, and other targets of healthcare fraud investigations, often without the targets’ knowledge or consent. In many healthcare fraud investigations, federal investigators will not notify a provider that they are under investigation until the end of the process. By the time the target of an investigation learns about the inquiry, federal agents may have already executed search warrants, arrested the target’s employees, and conducted undercover operations. While these steps may be taken, the investigation may still be open for further developments, and the execution of a search warrant is not, in and of itself, proof of wrongdoing or criminal liability.

What can a federal healthcare-fraud conviction cost a provider?

The primary law at issue in federal healthcare fraud prosecutions is 18 U.S.C. § 1347, which provides that:

A person who knowingly and willfully executes, or attempts to execute, a scheme or artifice (1) to defraud any health care benefit program; or (2) to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program, in connection with the delivery of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 10 years, or both. Under 18 U.S.C. § 1347, a conviction “shall be fined... or imprisoned not more than 10 years, or both.” But, in addition to those ordinary penalties, the law also states that if the fraud offense “If the violation results in serious bodily injury (as defined in section 1365 of this title), such person shall be fined under this title or imprisoned not more than 20 years, or both;” the federal government can prosecute the offender to a maximum prison term of 20 years. To determine a defendant’s potential sentence, the sentencing court will refer to the United States Sentencing Guidelines (“USSG”). Under USSG § 2B1.1, a healthcare-fraud offense referenced to that guideline is sentenced using a tiered system of factors applied by the sentencing court to calculate the guideline range. Specifically, this section includes “... a fraud that involves the submission of claims or seeking of payment for goods or services under a health care benefit program.” The primary driver of the offense level (and thus the sentence) under USSG § 2B1.1 is the “loss amount.” While there are a number of possible sentencing enhancements, the loss amount plays a central role in the calculation under § 2B1.1.

Under USSG § 2B1.1, loss is generally the greater of actual loss or intended loss. Although it sounds like a matter of simple arithmetic, calculating the loss amount for healthcare fraud is often complex, and calculations of this nature require a detailed understanding of the Medicare billing rules and Medicaid regulations at issue.

Speak With a Federal Defense Lawyer

If you are dealing with any part of what this article describes, the next step is a conversation with a lawyer who handles these cases. Spodek Law Group is a second generation criminal defense firm practicing since 1976, representing clients nationwide from offices in New York, Brooklyn, Queens and Los Angeles. Call 888 348 8028 to speak with our team.