Fort Worth Federal Health Care Fraud Lawyers
A target letter is not a conviction. The work that changes the outcome starts now. Your fight is ours.
Varghese Summersett defends doctors, nurse practitioners, clinic owners, billing managers, and marketers against federal health care fraud charges out of Fort Worth, Dallas, Southlake, and Houston. Our team includes former prosecutors who have sat on the other side of these investigations and know exactly how the government builds, charges, and tries a health care fraud case.
Our headquarters at 300 Throckmorton Street sits minutes from the Eldon B. Mahon U.S. Courthouse, where Northern District of Texas cases are heard. If you have been indicted, served with a target letter, or visited by federal agents, the earliest decisions shape the entire outcome.
Charged After the 2026 DOJ Takedown?
On June 23, 2026, the U.S. Department of Justice announced its 2026 National Health Care Fraud Takedown, the largest coordinated enforcement action it says it has ever run. The charges reached directly into North Texas. A charge is an allegation, not a conviction. Every defendant is presumed innocent. But the government spends months, sometimes years, building these cases before you ever hear about them, and you need to move just as deliberately on defense.
The North Texas Footprint
This is not a distant, out-of-state problem. Among the local defendants, Neel Vivek Paithankar, 25, of Irving, owner of VMP Health Care LLC, was charged with health care fraud for allegedly submitting Medicare claims for unnecessary and unwanted durable medical equipment. A Fort Worth physician with ties to Decatur was named in connection with an $89 million health care fraud and wire fraud case. If you practice or run a health-related business in North Texas, the takeaway is blunt: federal data analytics are being run against providers right here, and being a smaller, local operation offers no shelter. It can make you an easier target.
How These Cases Now Get Built
Federal officials were explicit that they have shifted from a pay-and-chase model to data analytics that flag billing before money ever goes out. Practices are investigated because their billing data looks different from their peers'. An outlier on a single CPT code, an unusual volume of a high-reimbursement service, or a pattern an algorithm scored as anomalous can open a file. Individual physicians are now easier targets than large hospital systems precisely because analytics make them simple to isolate. That matters for your defense, because a case that starts with a statistical anomaly is a case that can be answered with context the algorithm never had.
The Statutes Behind a Health Care Fraud Indictment.
Health care fraud prosecutions are rarely built on a single statute. The government stacks charges, and understanding each one tells you where the real exposure, and the real defenses, live.
Health Care Fraud, 18 U.S.C. 1347
The core charge. It criminalizes knowingly and willfully executing, or attempting to execute, a scheme to defraud any health care benefit program, or to obtain money from one by false pretenses. The penalty is up to 10 years per count, rising to 20 years if the violation results in serious bodily injury, and up to life if it results in death. The words knowingly and willfully are the entire battleground. The government has to prove you knew the conduct was wrong, not merely that a claim was incorrect.
Conspiracy, 18 U.S.C. 1349
Conspiracy is the prosecutor's favorite tool because it does not require the scheme to succeed, and it lets the government rope in everyone connected to the practice: the physician, the billing company, the marketer, the office manager. The penalty mirrors the underlying offense. The key vulnerability is that a conspiracy requires a genuine agreement to commit fraud. People working in the same office, even sloppily, are not automatically co-conspirators.
Wire Fraud, 18 U.S.C. 1343
Because virtually every modern claim is submitted electronically, wire fraud (up to 20 years per count) gets layered on top of health care fraud. Each electronic transmission can be charged as a separate count.
The Anti-Kickback Statute, 42 U.S.C. 1320a-7b(b)
This criminalizes knowingly paying or receiving anything of value to induce referrals of items or services reimbursed by federal programs, with penalties up to 10 years per violation. Many of the 2026 allograft cases were, at their core, kickback cases.
The Stark Law, 42 U.S.C. 1395nn
A civil prohibition on physician self-referral. It frequently runs alongside criminal exposure and drives parallel False Claims Act liability.
The False Claims Act, 31 U.S.C. 3729
The civil engine of health care enforcement. It carries treble (triple) damages plus per-claim penalties, and it is the basis for whistleblower (qui tam) suits. Many criminal cases begin life as a False Claims Act complaint filed under seal by a former employee.
The practical reality is that a single indictment can carry health care fraud, conspiracy, wire fraud, and kickback counts simultaneously, with a parallel civil False Claims Act case and a separate administrative proceeding against your license and billing privileges. You are fighting on three fronts at once, criminal, civil, and administrative, and a misstep on one can sink the others.
What the Government Must Prove.
Federal courts in Fort Worth sit in the Fifth Circuit, and the Fifth Circuit has spelled out exactly what the government must prove. To convict you of health care fraud under 18 U.S.C. 1347, the government must establish each of the following beyond a reasonable doubt:
- A scheme, executed or attempted. That you knowingly and willfully executed, or attempted to execute, a scheme to defraud a health care benefit program, or to obtain money or property from one by false or fraudulent pretenses, in connection with the delivery of or payment for health care benefits, items, or services.
- Specific intent to defraud. That you acted with the specific intent to defraud, not by accident or mistake.
- Materiality. That you made a material false or fraudulent representation. A statement is material if it was capable of influencing the program's decision to pay.
- Interstate commerce. That the health care benefit program affected interstate commerce, an element the government meets easily in Medicare and Medicaid cases.
For a conspiracy charge under 18 U.S.C. 1349, the government must instead prove that two or more people agreed to commit health care fraud, that you knew the unlawful purpose of that agreement, and that you joined it willfully. Note what conspiracy does not require: the scheme need not have succeeded, and the government does not have to prove you personally submitted a single false claim. That breadth is why prosecutors lean on conspiracy in multi-defendant practices, and why pulling your client out of the alleged agreement is so often the decisive move.
"Knowingly" and "Willfully": Where These Cases Are Won and Lost
The two words that decide most health care fraud cases are knowingly and willfully. "Knowingly" means you acted voluntarily and intentionally, not because of a mistake. "Willfully" means you acted purposefully, with a bad purpose to disobey or disregard the law. In the large majority of these cases, the real disagreement between the government and the defense is whether the defendant acted willfully.
The Fifth Circuit has held that the government does not have to prove you knew about the health care fraud statute specifically, only that you acted with knowledge and a specific intent to defraud generally. That sounds like a low bar, but it is not the same as proving a billing error. In United States v. Nora (2021), the Fifth Circuit reversed the conviction of a 22-year-old office manager at a home health agency because, although he coordinated intake, scheduled visits, and tracked recertifications, the government never proved he understood the agency's practices to be fraudulent. The court was clear that mere exposure to unlawful activity, or evidence that "everybody knew," is not enough to establish willfulness. For employees, billers, marketers, and others on the periphery of an alleged scheme, that holding is frequently the heart of the defense.
How Federal Sentencing Works.
The statute sets the ceiling, but the U.S. Sentencing Guidelines usually drive the real number, and one figure drives the Guidelines more than any other: the loss amount.
Statutory maximums. Health care fraud under 18 U.S.C. 1347 carries up to 10 years in prison per count, rising to up to 20 years if the violation results in serious bodily injury and up to life if it results in death. Fines can reach $250,000 for an individual or $500,000 for an organization, or twice the gross gain or loss, whichever is greatest. Each wire fraud count carries up to 20 years.
Loss is the engine. Under the Guidelines, the amount of loss is a specific offense characteristic that raises your base offense level, often dramatically. Loss is the greater of the actual or the intended loss from all reasonably foreseeable acts in furtherance of the scheme. The government normally bears the burden of proving that amount. But the Fifth Circuit applies a rule every provider should understand: when the government shows the fraud was so pervasive that separating legitimate billings from fraudulent ones is not reasonably practicable, the burden shifts to the defendant to prove which amounts were legitimate. If the defense cannot make that showing, the court can treat the entire amount billed as the loss. In United States v. Mazkouri and United States v. Mesquias, that rule turned the whole of the Medicare billings, tens and even hundreds of millions of dollars, into the loss figure.
Common enhancements. On top of the loss-driven base level, federal prosecutors routinely seek a two-level increase for 10 or more victims, a two-level increase for the unauthorized use of another person's means of identification, a two-level increase for one or more vulnerable victims, a two-level increase for abuse of a position of trust (which often applies to physicians and other licensed professionals), and a four or five-level increase if you were an organizer or leader of criminal activity involving five or more people.
The court then weighs the factors in 18 U.S.C. 3553(a), including the nature of the offense, your history and characteristics, the need to avoid unwarranted sentence disparities, and the need to provide restitution. The Presentence Investigation Report prepared by U.S. Probation drives all of this, which is why a careful, documented challenge to the PSR and a strong sentencing memorandum are not optional. Failing to object to errors in the PSR can waive them on appeal.
Do the Counts Stack? Yes.
This is one of the most important and most misunderstood features of federal health care fraud exposure. The short answer is yes, the counts stack.
Health care fraud is charged per execution of the scheme, so the government can break a single course of conduct into many counts. Each claim, each billing event, each electronic transmission can become its own count, and each 18 U.S.C. 1347 count carries its own 10-year maximum. Layer in wire fraud, and each electronic transmission can add a count carrying up to 20 years.
When the Guidelines range comes out higher than the maximum on any single count, federal sentencing law directs the judge to run the counts consecutively, that is, to stack them, to the extent needed to reach the total punishment the Guidelines call for. That is how a statute with a 10-year-per-count cap produces sentences far longer than 10 years. In Mazkouri, the doctor's offense level came out at 43, which ordinarily recommends life. Because each count maxed out at 10 years, the court stacked the counts to build an advisory range of roughly 60 years, then varied downward to 12.5 years in prison, plus $22 million in restitution and $500,000 in forfeiture. In Mesquias, a finding of roughly $100 million in loss produced a 24-level enhancement and an advisory range of life.
Two practical lessons follow. First, the number of counts and the loss amount are not side issues. They are the case, because together they set your real exposure. Second, restitution and forfeiture run on top of the prison exposure, so the financial consequences survive even a favorable sentence. Attacking the count structure, the loss calculation, and each enhancement, one at a time, is where an experienced federal defense team changes the outcome.
Leave Nothing To Chance.
How These Cases Are Built.
Understanding the government's playbook is the first step to dismantling it.
It starts quietly. The first sign is rarely an arrest. It is a CMS audit, a payment suspension, a civil investigative demand, a subpoena to your billing company, a qui tam complaint you never see because it is under seal, or a visit from HHS-OIG and FBI agents to a former employee's home. By the time you know you are a target, the government has often already gathered claims data, interviewed staff, and mapped your finances.
The data drives it. Analytics now trigger investigations. Agents pull every claim you submitted, compare your billing to regional and specialty peers, and flag outliers, then work backward to build a narrative around the numbers.
They follow the money and the records. Bank records, asset purchases, medical files, and the gap between what was documented and what was billed become the spine of the case. In the 2026 cardiovascular case, the government alleged results were signed off on in as little as 11 seconds, the kind of detail prosecutors use to argue that no real medical judgment occurred.
They pressure the periphery to reach the center. Prosecutors charge or threaten lower-level employees, billers, office managers, and marketers, to flip them against the physician or owner. This is why a unified, coordinated defense across everyone in the practice matters enormously.
Parallel proceedings squeeze you. While the criminal case proceeds, CMS may suspend payments and cut off cash flow, the DEA may move on your registration, and the civil False Claims Act case advances. The government uses the leverage of all three to push toward a plea.
How These Cases Are Defended.
These are not hopeless cases. They are winnable cases, and the defenses are specific.
Attack intent. Nearly every charge requires that you acted knowingly and willfully. Health care billing is staggeringly complex: thousands of codes, shifting CMS guidance, and contradictory payer rules. A billing error, a good-faith interpretation of an ambiguous rule, or reliance on a billing company or coder is not fraud. The line between an aggressive-but-defensible billing practice and a criminal scheme is exactly where these cases are won or lost.
Challenge the data. The government's statistical case is a starting point, not proof. Outlier billing often has an innocent explanation: a sicker patient population, a sub-specialty practice, or a geographic concentration of certain conditions. We retain our own coding experts, statisticians, and medical experts to show where the algorithm compared apples to oranges.
Establish medical necessity. When the allegation is that services were unnecessary, the defense is the patient record and independent medical judgment. Treating physicians are entitled to clinical discretion, and what a prosecutor's expert calls unnecessary, a defense expert may call appropriate and within the standard of care.
Reliance on professionals. Good-faith reliance on the advice of counsel, accountants, compliance consultants, or professional billing services can negate the willfulness the government must prove.
Break the conspiracy. Proving that people in an office agreed to defraud, as opposed to simply working together, is hard. Separating your client from the alleged agreement is often the single most powerful move in a multi-defendant case.
Suppress and exclude. Overbroad subpoenas, defective search warrants, and improperly obtained statements can all be challenged, with key evidence kept out.
Get ahead of the parallel cases. Coordinating the criminal defense with the civil False Claims Act exposure, the CMS administrative fight, and any DEA proceeding, rather than treating them as separate problems, protects you from inadvertently conceding in one forum what hurts you in another.
Why the First 72 Hours Matter Most.
The decisions made immediately after you learn you are under investigation often matter more than anything that happens at trial.
- Do not talk to agents without counsel. Agents are trained interviewers. "Just clearing things up" is how the government builds its case. You have the right to counsel. Use it.
- Do not touch the records. Altering, deleting, or cleaning up files turns a defensible billing case into an obstruction case, which is far easier to prove and often carries its own heavy penalties.
- Preserve everything and say nothing publicly. Litigation holds, not deletions.
- Get counsel involved before the indictment. The most valuable defense work frequently happens pre-charge: persuading prosecutors not to indict, narrowing the charges, or positioning for a favorable resolution before the government has publicly committed to a theory.
Federal Court in Fort Worth.
If you are charged in the Fort Worth area, your federal case will most likely be handled in the Fort Worth Division of the Northern District of Texas and prosecuted by the U.S. Attorney's Office for the Northern District of Texas. Federal proceedings in Fort Worth are heard at the Eldon B. Mahon U.S. Courthouse, 501 West 10th Street. The Northern District has long been a priority district for health care enforcement, with a dedicated Health Care Fraud Strike Force presence working alongside HHS-OIG, the FBI, and the DEA.
Defending a federal case in this district is different from defending a state case across town at the Tim Curry Criminal Justice Center. Federal practice runs on the Federal Rules of Criminal Procedure, the federal grand jury, the U.S. Sentencing Guidelines, and a charging culture in which the government rarely indicts unless it believes it can convict. Knowing how the local Assistant U.S. Attorneys build and try these cases, and how the judges in the Fort Worth Division handle them, is part of what makes early intervention so valuable. We defend federal matters across the Northern, Eastern, and Southern Districts of Texas from our offices in Fort Worth, Dallas, Southlake, and Houston.
The State Side of the Case.
Health care fraud can be charged under federal law, Texas state law, or both at once, and the two systems run on separate tracks. On the state side, the Texas Medicaid Fraud Control Unit, a division of the Office of the Texas Attorney General established in 1979, conducts criminal investigations into allegations of fraud by Medicaid providers. It investigates providers, not Medicaid recipients. Recipient fraud is handled by the Texas Health and Human Services Commission Office of Inspector General.
State violations are charged under the most applicable statute, including theft, tampering with a governmental record, or Medicaid fraud. The Texas Medicaid Fraud Prevention Act, contained in Chapter 36 of the Texas Human Resources Code and enacted in 1995, imposes liability on those who knowingly submit false or fraudulent claims to the state Medicaid program. It also contains a whistleblower reward provision and protects whistleblowers from employer retaliation. Because the same billing conduct can draw both a federal indictment and a state case, coordinating the defense across both systems is essential.
Medicaid and Medicare: Why the Distinction Matters
Medicaid is a financial assistance program for low-income patients of any age. It is a federal-and-state cost-sharing program administered by the states under federal guidelines, which is why both the Texas Medicaid Fraud Control Unit and federal authorities can have jurisdiction. Medicare is a federal insurance program primarily for patients age 65 and older, administered by the federal Centers for Medicare and Medicaid Services, so Medicare fraud is overwhelmingly a federal matter.
Our Experience Defending These Cases.
Doctors and practice owners come to us because we have actually done this work, and because these cases reward a level of experience and bandwidth that most firms cannot bring.
We represented a local physician charged with Medicare fraud. He hired our firm specifically because of our experience with these matters and because mounting his defense meant going through roughly nine years of medical records, claim by claim. That is the kind of painstaking, document-intensive work these cases demand, and we had the team and the experience to do it the right way.
In two other matters, physicians came to us after being accused of health care fraud. Through our efforts, we negotiated resolutions in which each paid back approximately one million dollars over the course of a year, avoided federal prison, and avoided criminal prosecution altogether.
No two of these cases look alike. Outcomes turn on who is on the other side, how much energy that office puts into prosecuting, the political environment at the time, and the judge you are in front of. That variability is exactly why experience matters, and it is why providers come to us: for the judgment to read a case correctly and the knowledge to push it toward the best outcome available on the facts.
Past results do not guarantee future outcomes. Every case depends on its specific facts and circumstances.
Your Federal Defense Team.
Former prosecutors who understand both the medicine and the money: the coding, the CMS rules, the billing systems, and the financial records these cases turn on. This is who handles your case.
What People Say About Us.
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At Home In Fort Worth.
Our headquarters at One City Place, 300 Throckmorton Street, Suite 700 is located in downtown Fort Worth, minutes from the Eldon B. Mahon U.S. Courthouse where Northern District cases are heard. We offer free, confidential consultations in person or by phone at (817) 203-2220, and we defend federal health care fraud matters from our offices in Fort Worth, Dallas, Southlake, and Houston.
Take the elevators to the 7th floor. Learn more about our Fort Worth office, explore our Fort Worth federal criminal defense practice, or meet our team.
Frequently Asked Questions.
What should I do if federal agents contact me about my billing?
Do not answer questions without a lawyer. Agents are trained interviewers, and an informal conversation to clear things up is how the government develops evidence. Politely decline to be interviewed, do not consent to a search, do not alter or delete any records, and call a federal criminal defense attorney immediately. The first 72 hours often shape the entire case.
What does the government have to prove to convict me of health care fraud?
Under Fifth Circuit law, which governs Fort Worth, the government must prove beyond a reasonable doubt that you knowingly and willfully executed or attempted a scheme to defraud a health care benefit program, that you acted with specific intent to defraud, that you made a material false representation, and that the program affected interstate commerce. The fight in most cases is over willfulness. A billing error or a good-faith reading of an ambiguous rule is not the bad purpose the statute requires.
What are the penalties for federal health care fraud?
Under 18 U.S.C. 1347, health care fraud carries up to 10 years in prison per count, up to 20 years if the violation causes serious bodily injury, and up to life if it causes death. Wire fraud and conspiracy counts add further exposure, and a parallel civil False Claims Act case can carry treble damages plus per-claim penalties. The real number is usually set by the U.S. Sentencing Guidelines, where the loss amount drives the offense level, and enhancements for vulnerable victims, 10 or more victims, abuse of a position of trust, and a leadership role can push it sharply higher.
Does each count of health care fraud stack into a longer sentence?
Yes. The government can charge each claim or electronic transmission as a separate count, and each health care fraud count carries its own 10-year maximum, while wire fraud counts carry up to 20 years each. When the Guidelines range exceeds the maximum on a single count, federal law directs the judge to run the counts consecutively, or stack them, to reach the total punishment. That is how cases governed by a 10-year-per-count statute can produce advisory ranges of decades or even life, which is why reducing the count structure and attacking the loss calculation are central to the defense.
Can a billing mistake become a federal crime?
Health care fraud requires that you acted knowingly and willfully. A genuine billing error, a good-faith reading of an ambiguous rule, or reasonable reliance on a billing company or coder is not fraud. The fight in most of these cases is precisely over intent, which is why early, expert-driven defense work matters so much.
What is the difference between a federal and a state health care fraud case in Texas?
Federal cases are brought under statutes like 18 U.S.C. 1347 and prosecuted by the U.S. Attorney's Office, in the Fort Worth area through the Northern District of Texas. State cases are brought under Texas law, such as the Texas Medicaid Fraud Prevention Act, and investigated by the Texas Attorney General's Medicaid Fraud Control Unit. The same billing conduct can lead to both at once, which is why the defense has to be coordinated across systems.
How does the government decide who to investigate?
Increasingly through data analytics. Federal agencies compare your billing to your peers and flag outliers, then build a case around the numbers. Because a case that starts with a statistical anomaly is missing the clinical and operational context behind your billing, that context is frequently the heart of the defense.
Why does it matter that I hire counsel before I am indicted?
The most valuable work in these cases often happens before charges are filed. Experienced counsel can engage prosecutors during the investigation, present exculpatory context, push to narrow or avoid charges, and coordinate the criminal, civil, and administrative exposure before the government publicly commits to a theory. Once an indictment is returned, your options narrow.
Do you handle federal health care fraud cases outside Fort Worth?
Yes. We defend federal matters across the Northern, Eastern, and Southern Districts of Texas from our offices in Fort Worth, Dallas, Southlake, and Houston. Federal practice is its own system, and we bring the same comprehensive, expert-driven approach wherever the case is filed.
Put Us In.
This page is for general informational purposes and is not legal advice. Past results do not guarantee future outcomes. Every case is decided on its own facts and procedural posture. Reach Varghese Summersett 24 hours a day at (817) 203-2220 for a free consultation.