Health Care Fraud Conspiracy Defense Lawyer: 18 U.S.C. § 1349

Federal prosecutors don't have to prove you committed health care fraud to convict you.

According to 18 U.S.C. § 1349, merely agreeing to participate in a scheme to defraud a federal health benefit program is a crime.

A billing coordinator who processed claims without knowing their source, a physician who signed referral forms for a clinic later found to be fraudulent, a recruiter who connected patients to a provider for a fee: all of them can face the same ten-year maximum sentence as the person who ran the scheme.

That is the feature prosecutors value most about § 1349. It casts a wide net, and it does not require them to prove you personally executed a single fraudulent act.

Eisner Gorin LLP can help you. Schedule your consultation by calling (818) 781-1570 or using the contact form.

Quick Reference Summary Chart: HC Fraud Conspiracy

At a Glance

Health care fraud conspiracy charges under 18 U.S.C. § 1349 enable federal prosecutors to broadly target individuals they suspect of knowingly participating in a fraudulent scheme, even if those individuals never submitted a false claim or received illicit funds.

Since the government does not need to prove an explicit act or successful fraud, these cases typically depend on whether a genuine agreement was present and if the defendant knowingly took part. Early involvement of skilled federal defense attorneys can be vital in safeguarding your freedom, professional license, reputation, and future.

What 18 U.S.C. § 1349 Actually Requires the Government to Prove

Under 18 U.S.C. § 1349, it is a federal crime to attempt or conspire to commit any fraud offense listed under Chapter 63 of the federal code, including health care fraud. 

The penalties for violating this statute are the same as the underlying offense. Unlike the general conspiracy statute at 18 U.S.C. § 371, § 1349 does not require proof of an overt act. Just agreeing to commit fraud is sufficient to convict.

To secure a conviction, the government must establish two things: that an agreement to commit health care fraud existed between two or more people, and that the defendant knowingly and voluntarily joined that agreement.

It does not matter whether any fraud was actually carried out. Health care fraud conspiracy does not require the fraudulent scheme to succeed. Just organizing or agreeing to engage in fraudulent activity, even if only in part, can lead to charges and significant criminal penalties.

Prosecutors often prefer these charges because they do not have to prove that a defendant sent a fraudulent claim or withdrew money.

Instead, they can link a defendant to the scheme through circumstantial evidence, such as emails, phone records, or financial transactions.

This can make it difficult for defendants to argue they were not involved, as even minor roles in the planning phase can lead to a federal indictment.

Who Gets Swept into These Cases

AS § 1349 does not require proof of an overt act, the relaxed burden of proof makes it dangerously easy for federal agencies to charge multiple individuals, sometimes based on flimsy or circumstantial evidence, sweeping up doctors, executives, billing clerks, and others into sprawling criminal cases.

The defendants in multi-party health care fraud indictments frequently include people who had limited, peripheral, or entirely innocent roles in the operations at issue, such as:

• A nurse practitioner who signed off on a high volume of orders without reviewing them. A practice administrator who managed payroll and contracts without knowledge of the billing irregularities.
• A sales representative who placed patients with a clinic in exchange for a fee, believing the arrangement was a standard referral program.

Each of these individuals can be named in a conspiracy count regardless of whether they touched a single fraudulent claim.

The DOJ's 2025 National Health Care Fraud Takedown charged 324 defendants, including 96 licensed medical professionals, across 50 federal districts in connection with over $14.6 billion in alleged fraud.

Coordinated takedowns of this scale do not involve individually tailored investigations for every name on an indictment.

They involve pattern recognition, co-conspirator cooperation agreements, and prosecutorial decisions made with incomplete pictures of each defendant's actual role.

Federal health care fraud investigations seldom rely on just one statute. What starts as a conspiracy claim under 18 U.S.C. § 1349 can quickly lead to additional charges, including substantive fraud, false statements, civil liability under the False Claims Act, and exclusion proceedings.

Having a comprehensive understanding of the legal landscape is crucial for creating a coordinated defense that safeguards your freedom, professional license, reputation, and future.

Penalties Under § 1349

A conviction for health care fraud conspiracy under 18 U.S.C. § 1349 can carry up to ten years in federal prison, along with fines and restitution.

That maximum mirrors the underlying § 1347 health care fraud statute. If the scheme caused serious bodily injury to a patient, the maximum penalty rises to 20 years. If a patient died, the statute authorizes life imprisonment.

Sentencing is driven largely by the total loss attributable to the conspiracy as a whole, not solely to the individual defendant's conduct.

A billing clerk named in a conspiracy that generated $40 million in fraudulent claims faces a guidelines range calculated on $40 million, even if their personal participation amounted to processing a few hundred transactions.

That sentencing dynamic, more than the conviction itself, is why experienced counsel matters so much in these cases and why it matters early.

Beyond imprisonment, a conviction under § 1349 triggers mandatory exclusion from Medicare, Medicaid, TRICARE, and all federal health programs, meaning a physician, nurse, or any licensed provider who is convicted effectively loses the ability to bill any government program for the rest of their career.

Frequently Asked Questions (FAQs) 

Can I be convicted of health care fraud conspiracy if I never submitted a false claim?

Yes. Unlike substantive health care fraud charges, 18 U.S.C. § 1349 does not require proving that you personally submitted fraudulent claims or received illegal proceeds. Prosecutors only need to show that you knowingly and voluntarily agreed to participate in a health care fraud scheme.

Does the government have to prove that the conspiracy succeeded?

No. A conviction under 18 U.S.C. § 1349 does not require proving that the fraud was completed or successful. Even just agreeing to take part in the scheme might suffice if prosecutors can demonstrate the necessary intent and knowledge.

Can employees or lower-level workers be charged with conspiracy?

Yes. Billing coordinators, office managers, recruiters, nurses, sales representatives, and administrative staff may all face charges if investigators find they knowingly participated in the alleged scheme. However, simply working for an organization involved in fraud does not automatically classify someone as a conspirator.

What are the penalties for a conviction under 18 U.S.C. § 1349?

Health care fraud conspiracy carries the same penalties as the main offense. Convictions can lead to up to 10 years in federal prison, hefty fines, restitution, and mandatory exclusion from Medicare, Medicaid, TRICARE, and other federal health programs. Penalties may increase significantly if serious bodily injury or death results.

Can a health care fraud conspiracy case be resolved before an indictment is filed?

Yes. Many federal investigations take months or even years before charges are filed. Early involvement of experienced federal defense attorneys can help present evidence, question the government's assumptions, show a lack of criminal intent, and possibly prevent or limit criminal charges before an indictment is made public.

Defense Strategies That Isolate and Dismantle the Government's Case

Challenging Whether a Real Agreement Existed

Prosecutors must prove actual agreement, not mere association. While an agreement can be unspoken, prosecutors cannot rely on a person's mere association with criminals.

They must show through evidence that the defendant was a knowing participant in the plan. A defendant who worked alongside people engaged in fraud, received payments, or processed claims does not automatically become a conspirator.

The defense examines whether any communication, financial arrangement, or conduct actually constituted an agreement to defraud, rather than ordinary professional activity that intersected with someone else's scheme.

Attacking Knowledge and Intent

Defendants may have been unwitting participants or misled by others involved in the scheme.

A physician who signed referral documents based on representations by clinic staff, or a billing employee who processed submissions prepared by others, may have had no knowledge that those transactions were fraudulent.

The government must prove that the defendant knowingly joined the conspiracy, not merely that they worked in proximity to it.

Establishing the boundaries of what a defendant actually knew, when they knew it, and what information was available to them at the time is often the central task of the defense.

Severing the Defendant from the Larger Scheme

In multi-defendant cases, the government presents the conspiracy as a unified enterprise.

Defense counsel works to sever the individual client's conduct from the broader narrative, demonstrating that the defendant's role was limited, discrete, and separable from the core fraud.

This matters at both trial and sentencing. Even where liability is difficult to contest entirely, establishing that a defendant was a minor, peripheral participant rather than a knowing architect of the scheme produces materially different sentencing outcomes.

Engaging Before Indictment

Prosecutors are known to use 18 U.S.C. § 1349 as a leverage tactic in plea negotiations, even in cases where they know a jury would be unlikely to convict. That reality cuts both ways.

The threat of conspiracy charges pressures defendants to cooperate or plead. But it also means the government's conspiracy theory in many of these cases is more vulnerable at the margins than it appears.

Early engagement through prefiling intervention allows defense counsel to present a factual narrative before charges are locked in, potentially narrowing the scope of charges or removing a peripheral defendant from the indictment entirely.

Billing Supervisor Severed From Multi-Defendant Conspiracy

A billing supervisor at a multi-location physical therapy group was named as a co-conspirator in a federal indictment targeting the clinic's owners for submitting false claims to Medicare.

The indictment alleged a broad conspiracy involving upcoded services, phantom visits, and forged signatures on plan-of-care documentation.

The billing supervisor had processed claims during the relevant period and had access to the systems used to submit the fraudulent submissions.

Defense counsel was retained before the supervisor gave any statement to investigators.

A thorough review of the supervisor's employment records, internal communications, and claim submission logs showed that the supervisor had processed claims based on documentation provided by clinic directors, had no authority to alter procedure codes or approve treatment plans, and had flagged billing anomalies in internal emails on two separate occasions, both of which were overridden by clinic ownership.

Counsel presented this record to the DOJ's assigned prosecutor during the pretrial phase. The government agreed to sever the billing supervisor from the conspiracy count.

She was not required to plead to any charge related to the fraudulent scheme. The resolution reflected the factual record: a worker who processed what she was given, not a knowing participant in a fraud she had actually tried to flag.

If you are accused of health care fraud conspiracy under 18 U.S.C. § 1349, you need a strong defense. Contact the attorneys at Eisner Gorin LLP today for a consultation.

Related Legal Topics

• Laws Against Health Care Fraud
• Federal Healthcare Fraud CID
• Federal HC Lawyer for Patients
• Exclusion from Participation
• Defending Doctors Explained
• Defending Federal Conspiracy