If you live in West Michigan or Grand Rapids, you know how much health care costs are based on your trip to a hospital or doctor’s office. Clearly, getting quality health care service, or any other type of professional service is a costly endeavor. One reason the cost of health care has gone up is because of health care fraud. You can rest assured, that any state, local or federal investigation into fraud will result in serious criminal charges being issued if the evidence suggests criminal activity by a person.
Health Care Fraud is a crime where a person will come up with a scheme to get illicit gains from insurance companies. This can also be done against government programs such as Medicare and Medicaid. Typically, these crimes deal with a person charging too much for services. It may also deal with charging for services that were not rendered. It can even cover providing medical services that are not needed. Rest assured, the federal government will hammer someone hard if they think you are ripping off Medicare or Medicaid.
Another area where Health Care Fraud is found a lot is in health care facilities that take care of the elderly and disabled. The typical allegations of fraud at these facilities include elder abuse, child abuse, billing fraud and vulnerable adult abuse.
Professionals Who Get Charged With Health Care Fraud Include:
- Dentists
- Chiropractors
- Doctors
- Laboratories
- Pharmaceutical Companies
- Clinics
- Nursing Homes
- Hospitals
Defenses
Attorney Shawn James Haff knows how to get results when it comes to these serious felony charges. These cases are complicated, extremely time consuming and require an expertise that other cases might not need to in order to get the best results possible. Shawn will examine all the records you may have to see if you had valid medically reasons for what you did. Shawn will review all the evidence to see if another member of your medical staff committed the crime. Shawn will go over the law to make sure the actions you are accused of committing are actually illegal. There are numerous times through out the year where we have watched prosecutors charge someone for a crime based on their false interpretation of the law.
Do not wait to talk to Shawn about your case. Call him now at 616-438-6719. The call is free so why not call him right now?
The Statute Michigan Actually Charges
Most state health care fraud prosecutions in Michigan run through the Medicaid False Claim Act. MCL 400.607 makes it an offense to:
- Make or present, or cause to be made or presented, a claim under the social welfare act that you know to be false;
- Make or present a claim that you know falsely represents that the goods or services were medically necessary in accordance with professionally accepted standards; or
- Knowingly make or use a false record or statement to conceal, avoid, or decrease an obligation to pay money or property to the state.
A violation is a felony punishable by up to 4 years in prison, a fine of up to $50,000, or both. Critically, the statute states that each claim violating the medical-necessity provision is a separate offense — which is how a billing dispute over a period of months becomes a charging document with dozens of counts. It also limits when a health facility itself is liable: not unless it acted pursuant to a conspiracy, combination, or collusion with a physician or other provider.
Depending on the facts, prosecutors also reach for embezzlement under MCL 750.174, larceny by false pretenses, uttering and publishing under MCL 750.249 where documents were altered, and Michigan's racketeering statute where a pattern is alleged.
State or Federal — It Changes Everything
This distinction determines who prosecutes you, where, and what you are facing:
| Michigan Medicaid | Federal (Medicare and beyond) | |
|---|---|---|
| Charging authority | Attorney General, Health Care Fraud Division | United States Attorney |
| Principal statute | MCL 400.607 | 18 U.S.C. § 1347 |
| Maximum | 4 years, $50,000 per claim | 10 years; 20 if serious bodily injury results; life if death results |
| Court | Circuit court | U.S. District Court, Western District of Michigan |
I defend the state cases. I do not practice in federal court, and I will not pretend otherwise to keep a file. If what you are facing is federal, the honest and useful thing I can do is tell you that early and connect you with a federal practitioner — that is what my page on federal charges is for.
The Investigation Usually Starts Quietly
Nobody gets arrested at the beginning of a health care fraud case. What happens first is one of these:
- A records subpoena to the practice, often broad and covering several years.
- A Medicaid audit that shifts in tone, and starts asking about intent rather than documentation.
- An unannounced visit to a provider's home, early in the morning, to ask questions before a lawyer is involved.
- A former employee who reports billing practices after a termination or a dispute.
Two rules from the moment any of that happens. First, do not give a statement. Providers talk themselves into these cases constantly, because they are confident the billing was proper and believe an explanation will end it. Second, preserve everything. Deleting a file or "cleaning up" a chart converts a defensible billing dispute into an obstruction charge, and obstruction is much easier to prove than fraud.
How These Cases Are Defended
- Error is not fraud. The statute requires knowledge. Upcoding by a billing service, a template error in an EMR, staff misapplying a modifier, and shifting guidance from the payer are all explanations that defeat the mental state.
- Medical necessity is a professional judgment. The statute measures it against professionally accepted standards. Where a treating provider's judgment is defensible within the field, a payer's after-the-fact disagreement is not a crime — and this is where a qualified expert earns their fee.
- Extrapolation. Audits routinely sample a handful of claims and extrapolate an overpayment across an entire population. The sampling methodology is attackable, and the loss figure drives both the charge and the restitution.
- Who actually submitted the claim. In a practice with billers, coders, and outside vendors, the provider whose NPI appears on a claim did not necessarily prepare or transmit it.
- Count structure. Because each claim can be a separate offense, how the counts are drawn matters. So does whether the alleged conduct falls inside the limitations period.
One more thing that gets overlooked: for a licensed professional, the licensing consequence often outlasts the criminal one. LARA and the relevant board proceed on their own track, and a plea that seems attractive in circuit court can be catastrophic before a licensing board. Those two outcomes have to be managed together, not sequentially.
Related reading: white collar crimes, embezzlement, theft and property crimes defense, and vulnerable adult crimes.
Frequently Asked Questions
What is the penalty for health care fraud in Michigan?
Under the Michigan Medicaid False Claim Act, MCL 400.607, making or presenting a claim known to be false — or falsely representing that goods or services were medically necessary — is a felony punishable by up to 4 years in prison, a fine of up to $50,000, or both. Each false claim is a separate offense, which is why these cases arrive as multi-count charges. Related conduct can also be charged as embezzlement, larceny by false pretenses, or forgery.
Is health care fraud a state or a federal charge?
It can be either. Billing to Michigan Medicaid is prosecuted by the Michigan Attorney General's Health Care Fraud Division under the Medicaid False Claim Act. Billing to Medicare, or a case involving a federal program or interstate conduct, is a federal matter under 18 U.S.C. § 1347 with far higher exposure. I defend the state charges. If your case is federal, I will tell you that directly and connect you with counsel who handles federal court — see my page on federal charges.
What triggers a health care fraud investigation?
Usually a billing-data outlier rather than a complaint: a provider whose coding pattern, service volume, or hours billed sits outside the norm for the specialty. Others start with a disgruntled former employee, a patient complaint, or a Medicaid audit that escalates. The first sign is often a records subpoena or an unannounced visit — not an arrest.
What should I do if investigators contact my practice?
Do not hand over records, and do not give an interview, before you have counsel. Investigators frequently arrive at a home or office without notice, specifically because it is easier to get statements that way. Preserving records is essential — destroying or altering anything turns a defensible billing dispute into an obstruction case. Call a lawyer the day it happens.
Is a billing error a crime?
No. The statutes require knowledge — a claim known to be false, or a knowing false representation of medical necessity. Coding errors, staff mistakes, ambiguous billing guidance, and honest disagreements about medical necessity are not crimes, and the difference between an error and a scheme is the central issue in most of these cases.
Talk to Me Before You Talk to the Police
I am Shawn Haff, and I defend theft and property crime cases across Kent, Ottawa, Allegan, Barry, Ionia, Muskegon, Newaygo, and Van Buren counties. The call is free, I answer my own phone, and in a property case the earlier I am involved the more room there is to work. Call 616-438-6719 or send me a message.