Glossary: Understanding Your Federal Health Care Fraud Investigation -
WSJ logo
Forbes logo
Fox News logo
CNN logo
Bloomberg logo
Los Angeles Times logo
Washington Post logo
The Epoch Times logo
Telemundo logo
New York Times
NY Post logo
NBC logo
Daily Beast logo
USA Today logo
Miami Herald logo
CNBC logo
Dallas News logo
Quick Practice Area Locator

Glossary: Understanding Your Federal Healthcare Fraud Investigation

qui tam investigations

Is your business or practice being targeted in a federal healthcare fraud investigation? If so, the federal healthcare fraud defense team at Oberheiden, P.C., is here to help.

From acronyms to legalese, when you are facing a federal healthcare fraud investigation, you are likely to hear various terms with which you are unfamiliar. If you feel a bit lost, don’t worry – you are not alone. Even most lawyers who do not routinely practice in the area of federal healthcare fraud investigations will be unfamiliar with these terms.

Key Terms in Federal Healthcare Fraud Investigations

But, when you are being targeted by the federal government, the more you know, the better. With this in mind, here are brief explanations of the key terms you are likely to hear during your case:

Civil Assessments

If your investigation is civil in nature (healthcare fraud investigations can either be civil or criminal), one of the types of penalties for which you are at risk is “civil assessments.” In federal healthcare fraud cases, civil assessments are the government’s damages (i.e., the amount of the alleged overpayment). However, in many cases, laws such as the Anti-Kickback Statute, False Claims Act, and Stark Law call for providers to pay civil assessments of three times the government’s actual losses.

Civil Monetary Penalties

“Civil monetary penalties” are another type of penalty in civil healthcare fraud investigations. In addition to paying civil assessments, providers found liable for healthcare fraud can also be required to pay civil monetary penalties of anywhere from $15,000 to $50,000 per individual violation.

Department of Justice (DOJ)

The “Department of Justice” or “DOJ” is the federal government’s top law enforcement agency. It employs prosecutors and investigators across the country who are devoted to targeting healthcare providers suspected of fraud. It also houses the U.S. Attorney’s Office, which is responsible for prosecuting healthcare providers in criminal fraud cases.

Designated Health Services

Under the Stark Law, physicians are prohibited from referring Medicare patients to entities with which they have a financial relationship if those entities are to provide “designated health services” to the patient. Designated health services are:

  • Clinical laboratory services
  • Physical therapy, occupational therapy, and outpatient speech-language pathology services
  • Radiology and certain other imaging services
  • Radiation therapy services and supplies
  • Durable medical equipment and supplies
  • Parenteral and enteral nutrients, equipment, and supplies
  • Prosthetics, orthotics, and prosthetic devices and supplies
  • Home health services
  • Outpatient prescription drugs
  • Inpatient and outpatient hospital services

Drug Enforcement Administration (DEA)

The “Drug Enforcement Administration” or “DEA” is the federal agency that is responsible for enforcing the Controlled Substances Act and the multitude of other federal drug laws and regulations that apply to drug manufacturers, physicians, pharmacists, and patients. The DEA routinely gets involved in investigations targeting registration violations, prescription drug fraud, and opioid diversion.


In addition to financial penalties (and federal imprisonment in criminal cases), another penalty that is on the table in federal healthcare fraud investigations is “exclusion.” If an entity or individual provider is excluded from Medicare, Medicaid, or Tricare, this means that the provider is no longer eligible to provide program-reimbursed medical services.


In the context of federally-reimbursed healthcare services, “fraud” means billing the government in any circumstance in which such billing is inappropriate. Some of the most-common allegations in federal healthcare fraud investigations include:

  • Overbilling due to intentional or unintentional coding errors
  • Offering or accepting illegal referral fees
  • Billing for medically-unnecessary services or medications
  • Billing for services or medications not actually provided to patients
  • Improper physician certifications for hospice care and other practice-specific violations


A “kickback” is a form of unlawful referral fee for Medicare, Medicaid, or Tricare-reimbursed healthcare services. Providers who accept compensation from other providers, pharmaceutical manufacturers, or durable medical equipment (DME) companies to which they provide referrals can face civil or criminal penalties under the Anti-Kickback Statute.

Office of Inspector General (OIG)

The “Office of Inspector General” or “OIG” is the law enforcement division of the Department of Health and Human Services (DHHS). As such, it is responsible for investigating and prosecuting a broad range of healthcare fraud allegations – from overbilling Medicare for services to seeking reimbursement for diverted opioid medications.

Qui Tam

Qui tam” is a type of federal litigation in which a U.S. citizen files a claim on behalf of the federal government. These individuals (commonly referred to as “whistleblowers”) are often disgruntled former employees or competitors, and they can receive a substantial financial award for initiating a successful claim. The requirements to initiate a qui tam lawsuit are minimal, but these lawsuits can lead to substantial headaches and potential exposure for healthcare providers.


In addition to prohibiting kickbacks, the Anti-Kickback Statute also prohibits any and all other forms of unlawful “remuneration.” Remuneration is any form of incentive or inducement to provide a referral for program-reimbursed medical services or supplies. This includes cash, gifts, meals, travel, and other forms of monetary and non-monetary compensation.

Safe Harbor

The broad prohibitions of the Anti-Kickback Statute and Stark Law are tempered by a laundry list of statutory and regulatory “safe harbor” provisions. If a transaction or relationship qualifies for safe harbor protection, then it cannot serve as the basis for a federal healthcare fraud investigation.


A “subpoena” is a formal means for federal agents or prosecutors to obtain information during a healthcare fraud investigation. Authorities can subpoena witnesses or targets of federal investigations, and a subpoena can request documents, testimony, or both.

There are several different types of subpoenas. However, in the context of federal healthcare fraud investigations, two of the most common are OIG subpoenas and grand jury subpoenas.

Contact the Federal Healthcare Fraud Defense Team at Oberheiden, P.C.

The DOJ, DEA, and OIG are aggressively targeting healthcare providers in federal fraud investigations nationwide. If your business or practice is under investigation, it is imperative that you engage an experienced defense team immediately. To discuss your case with defense attorney, Dr. Nick Oberheiden, leader of our firm’s healthcare fraud defense team, call 888-680-1745 or request a free case assessment online now.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Merely reading this information does not create an attorney-client relationship. Prior results do not guarantee similar outcomes for any client or potential client in the future. Oberheiden, P.C. is a Texas professional corporation with its headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.

Contact Us Today

I accept the Terms and Conditions.(Required)
WordPress Lightbox