Hospice Fraud Defense
Former DOJ Fraud Section Prosecutors. Nationwide Defense for Hospice Owners, Medical Directors, Nurses, Executives, and Healthcare Professionals Facing Federal Hospice Fraud Investigations and Charges.
Based in Washington, D.C., Armstrong & Bradylyons PLLC defends hospice company owners, certifying physicians, medical directors, nurses, marketers, healthcare executives, and other professionals in federal hospice fraud investigations and cases nationwide.
The firm’s healthcare fraud defense practice is built on nearly a decade of combined experience at the nation’s preeminent healthcare fraud enforcement unit: the Healthcare Fraud Unit of DOJ’s Fraud Section. Scott Armstrong, Drew Bradylyons, and Andrea Savdie tried 17 federal jury trials in healthcare fraud cases at DOJ’s Fraud Section involving over $2.8 billion in alleged false and fraudulent claims to federal healthcare programs. The firm uses that experience to defend hospice owners, medical directors, and healthcare professionals at every stage of a federal case: from the first CMS audit or grand jury subpoena, through federal indictment, and at trial.
The firm defends individuals in the districts where hospice fraud enforcement is most active: the Central District of California, the Southern District of Texas, the District of Arizona, the District of Nevada, and Strike Force districts including the Southern District of Florida, the Eastern District of Michigan, and the Northern District of Illinois. The firm also defends hospice providers in states newly subject to CMS’s Provisional Period of Enhanced Oversight, including Georgia and Ohio.
Armstrong & Bradylyons PLLC defends every hospice fraud case from the start as if it will go to trial. That is not a slogan. It is the operating principle of the firm, grounded in 25 federal jury trials in complex fraud cases in federal courts across the country.
Trial experience drives results at every stage. Hospice fraud cases are factually complex and emotionally charged. They involve terminal illness certifications, medical necessity disputes, patient recruitment practices, and allegations that providers enrolled patients who were not dying. The firm builds the factual record from the first day of engagement: analyzing claims data, retaining clinical experts, identifying and preparing witnesses, and developing a case theory that can withstand the government’s scrutiny.
The firm’s attorneys know how federal prosecutors build healthcare fraud cases because they built them. Scott Armstrong served for nearly a decade at DOJ’s Fraud Section, where he served as lead trial counsel in 16 federal jury trials, including complex healthcare fraud cases involving Medicare, Medicaid, and Tricare. Scott also directed DOJ’s Appalachian Regional Prescription Drug Task Force. Drew Bradylyons served as Chief of EDVA’s Financial Crimes and Public Corruption Unit and, before that, supervised the Healthcare Fraud Unit’s Miami Strike Force at DOJ’s Fraud Section. That combined experience provides the firm with an unmatched understanding of how federal healthcare fraud cases are investigated, charged, and tried.
The firm relishes the opportunity to try cases. Its willingness to go to trial and its proven skills at trial provide significant leverage in negotiations with federal prosecutors at every stage of a hospice fraud case.
Hospice fraud is a top federal enforcement priority. The government is investigating and prosecuting hospice owners, medical directors, and healthcare professionals at an unprecedented pace. CMS, DOJ, and HHS-OIG have publicly declared that hospice fraud enforcement is intensifying. The enforcement wave is here.
The hospice industry has experienced explosive growth. The number of Medicare-enrolled hospices increased significantly in recent years, with swarms of new operators entering California, Arizona, Nevada, and Texas. CMS identified these four states as hotbeds for hospice fraud, waste, and abuse. In response, CMS launched the Provisional Period of Enhanced Oversight (PPEO) in July 2023, subjecting all newly enrolled hospices and ownership changes in those states to prepayment medical review. By December 2025, 817 hospices had been subject to PPEO review. CMS revoked the Medicare enrollment of 181 of them. That is a 22% revocation rate. CMS expanded the PPEO program to Georgia and Ohio in December 2025.
Los Angeles County alone accounts for approximately 18% of the nation’s total home health and hospice Medicare billing. The region has seen a seven-fold increase in hospice billing activity. In January 2026, CMS Administrator Dr. Mehmet Oz and First Assistant U.S. Attorney Bill Essayli held a joint press conference announcing deepened investigations of hospice billing fraud in California. CMS referred 343 cases to law enforcement for suspected fraud in 2025, representing $3.4 billion in fraudulent billing activity.
The criminal prosecutions are severe. In the Southern District of Texas, the owner of the Merida Group, which operated dozens of hospice locations across Texas, was sentenced to 20 years in federal prison for a $150 million hospice fraud and money laundering scheme. The CEO received 15 years. In the Central District of California, a hospice operator was sentenced to 12 years in prison for running sham hospice companies that defrauded Medicare of nearly $16 million. In Monterey County, the California Attorney General arrested seven individuals in January 2026 for a hospice fraud conspiracy involving false terminal certifications and patient transfers between three hospice companies. These are not outlier cases. They reflect a sustained federal enforcement campaign targeting every level of the hospice industry.
Hospice owners, medical directors, certifying physicians, nurses, marketers, and healthcare executives face real and immediate exposure to federal criminal and civil enforcement. False terminal illness certifications, kickback-driven patient recruitment, and billing for services not rendered are at the center of the government’s enforcement agenda.
The firm’s hospice fraud defense practice is built on healthcare fraud trial experience, deep knowledge of the Medicare hospice benefit and its regulatory requirements, and years of experience investigating and prosecuting complex healthcare fraud cases at DOJ’s Fraud Section. These tools are deployed at every phase of a case.
Challenging the Government’s Billing and Utilization Analysis
Federal hospice fraud cases are built on Medicare claims data. The government identifies providers with unusually long average lengths of stay, high live discharge rates, disproportionate enrollment of patients with certain diagnosis codes, and billing patterns that diverge from peer averages. The firm challenges the government’s data at every level: the selection of comparators, the statistical methodology, the assumptions underlying utilization analyses, and the conclusions drawn from aggregate billing patterns. A billing anomaly is not fraud. The firm ensures that distinction is drawn clearly and forcefully.
Terminal Illness Certification and Medical Necessity Defense
The government’s case often hinges on the claim that patients were not terminally ill when they were certified for hospice. The firm retains qualified hospice and palliative care physicians to review patient medical records, physician certifications, and clinical documentation. These experts can establish that the certifying physician’s clinical judgment was reasonable at the time of certification, that the patient met the applicable CMS Local Coverage Determination criteria for hospice eligibility, and that continued enrollment was supported by the patient’s clinical trajectory. Expert testimony on terminal prognosis is critical to rebutting the government’s hindsight-driven theory that patients who outlived their prognosis were never terminally ill.
Medicare Hospice Benefit Rules and Certification Requirements
The Medicare hospice benefit is governed by a complex regulatory framework. Eligibility requires a terminal illness with a life expectancy of six months or less if the disease runs its normal course. Certification requires the attestation of both the patient’s attending physician and the hospice medical director. Recertification is required at specific intervals. The firm analyzes the applicable certification requirements, LCD criteria, and CMS guidance to challenge the government’s interpretation of what constitutes a proper certification. Regulatory complexity and ambiguity in prognosis standards are powerful defense tools.
Challenging the Government’s Proof of Knowledge and Intent
Federal healthcare fraud requires proof of willful and knowing fraud. Terminal prognosis is inherently uncertain. Patients who outlive a six-month prognosis are not evidence of fraud. The firm builds the factual record to demonstrate that the provider acted in good faith, that certifying physicians exercised legitimate clinical judgment, and that the provider did not intend to defraud Medicare. Where the government relies on cooperating witness testimony to establish intent, the firm attacks the reliability, credibility, and motivations of those witnesses. The firm’s attorneys have extensive experience cross-examining cooperating witnesses in federal healthcare fraud trials.
Federal hospice fraud investigations target individuals at every level of the hospice industry: from the owners and executives who built and operate hospice companies, to the medical directors who certify patients, the nurses who deliver care, and the marketers who recruit patients. Armstrong & Bradylyons PLLC defends these individuals in federal investigations, after indictment, and at trial.
Defense of Hospice Owners and Operators
The firm defends the founders, owners, and operators of hospice companies in federal fraud, Anti-Kickback Statute, and money laundering investigations and prosecutions. Hospice owners are the primary targets of federal enforcement. Prosecutors pursue owners who allegedly directed or tolerated the enrollment of patients who were not terminally ill, designed compensation structures that incentivized false certifications, paid kickbacks for patient referrals, operated sham hospice companies, or engaged in license flipping to evade regulatory scrutiny. The firm defends hospice owners against these allegations by challenging the government’s evidence of personal knowledge, direction, and intent.
Defense of Medical Directors and Certifying Physicians
The firm defends hospice medical directors and certifying physicians in federal hospice fraud investigations and cases. Medical directors face severe criminal exposure when the government alleges that they certified patients as terminally ill without conducting adequate face-to-face evaluations, signed certifications and recertifications for patients who did not meet hospice eligibility criteria, or received kickbacks disguised as medical director fees in exchange for signing certifications. The firm defends medical directors by challenging the government’s clinical evidence and establishing the legitimate medical basis for the physician’s certification decisions. Terminal prognosis is a matter of clinical judgment. The firm ensures that distinction is at the center of the defense.
Defense of Nurses and Clinical Staff
The firm defends Directors of Nursing, registered nurses, licensed vocational nurses, and other clinical staff in federal hospice fraud investigations and cases. Nurses face criminal exposure when the government alleges that they fabricated patient assessments, documented symptoms or decline that did not exist, participated in falsifying plans of care, or submitted visit notes for visits that were not actually conducted. The firm defends nursing professionals by challenging the government’s evidence and establishing that the nurse’s clinical documentation was consistent with legitimate patient care.
Defense of Marketers and Patient Recruiters
The firm defends hospice marketers, community liaisons, and patient recruiters in federal investigations. Marketers face criminal exposure when the government alleges that they recruited patients who were not terminally ill, made false representations about hospice eligibility to prospective patients or their families, or received compensation tied to the volume of patient referrals in violation of the Anti-Kickback Statute. The firm defends marketers by challenging the government’s evidence of knowledge, intent, and the nature of the compensation arrangement.
Defense of Healthcare Executives and Investors
The firm defends healthcare executives, management company operators, and investors in hospice companies. Federal prosecutors and the False Claims Act are reaching individuals beyond the direct service providers: corporate executives, management services organization (MSO) operators, and investors who exercised operational control over hospice companies. The firm defends these individuals against fraud, conspiracy, money laundering, and kickback charges arising from the operations of hospice organizations.
Federal hospice fraud investigations follow a pattern. Understanding that pattern is the first step to defending against it. Scott Armstrong and Drew Bradylyons built these types of cases as senior prosecutors at DOJ’s Fraud Section. They know how federal investigators identify targets, develop evidence, and present cases to grand juries.
Claims Data Analytics and Utilization Review
The investigation typically begins with data. HHS-OIG, CMS, and the FBI use sophisticated claims data analytics to identify hospice providers with billing patterns that deviate from industry norms. They flag providers with unusually long average lengths of stay, high percentages of patients with certain diagnosis codes such as dementia or debility, disproportionate enrollment of patients who are subsequently live-discharged, rapid growth in claims volume, and per-patient reimbursement rates that far exceed peer averages. These data-driven flags trigger the deeper investigation.
Terminal Illness Certification Audits
The government reviews patient medical records to determine whether each patient met the criteria for hospice eligibility at the time of initial certification and at each recertification. CMS requires that a patient have a terminal illness with a life expectancy of six months or less if the disease runs its normal course. Auditors and medical reviewers examine whether the certifying physician conducted an adequate clinical evaluation, whether the documentation supports the terminal prognosis, and whether the patient’s condition and clinical trajectory justified continued hospice enrollment. Patients who lived for years beyond their initial certification are a primary red flag for investigators.
CMS Provisional Period of Enhanced Oversight (PPEO)
CMS launched the PPEO program in July 2023 for newly enrolled hospices and ownership changes in California, Arizona, Nevada, and Texas. The program subjects hospices to prepayment medical review, unannounced site visits, and heightened documentation scrutiny for up to one year. CMS expanded the PPEO to Georgia and Ohio in December 2025. Through December 2025, 817 hospices were subject to PPEO review. CMS revoked the Medicare enrollment of 181 of them. A failed PPEO review can result in revocation of Medicare billing privileges, denial of claims, and referral to law enforcement for criminal investigation. PPEO findings are increasingly used as a springboard for federal criminal prosecutions.
Patient and Employee Interviews
Federal agents interview current and former employees, patients, patients’ family members, and referral sources. They look for cooperating witnesses who can testify about the hospice’s actual operations: whether patients were actually terminally ill, whether certifications were signed without adequate evaluations, whether documentation was fabricated, whether marketers were paid kickbacks for referrals, and whether the owner or management directed or tolerated the fraudulent conduct. Cooperating witnesses are a cornerstone of federal hospice fraud prosecutions. They provide the narrative that connects data anomalies to individual intent.
Kickback and Patient Recruitment Analysis
The government investigates patient recruitment practices and referral relationships. In hospice fraud cases, federal prosecutors examine whether hospices paid cash kickbacks to marketers, physicians, assisted living facility operators, or other referral sources in exchange for patient referrals. They also examine whether medical director compensation was structured as a disguised kickback tied to patient certification volume rather than a fair market value payment for legitimate services. Kickback allegations under the Anti-Kickback Statute (42 U.S.C. § 1320a-7b) carry independent criminal penalties and also taint every claim submitted for patients referred through the kickback arrangement.
Search Warrants for Electronic Devices and Cloud Accounts
Federal agents routinely seek and execute search warrants for cell phones, laptops, tablets, and cloud-based accounts in hospice fraud investigations. These warrants target text messages, emails, iCloud backups, Google Drive contents, and messaging applications. The government is looking for communications between owners, medical directors, nurses, marketers, and billing staff that reveal knowledge of false certifications, directives to enroll patients who are not terminally ill, discussions about kickback payments, and efforts to conceal conduct from auditors or regulators.
Cloud account warrants are particularly powerful. A single iCloud or Google backup can contain years of text messages, photographs of documents, location data, and app data. Federal agents obtain these warrants under 18 U.S.C. § 2703 of the Stored Communications Act and serve them directly on Apple, Google, and other service providers. The target of the warrant may not learn of its existence until well after the government has obtained and reviewed the contents.
Search Warrants for Electronic Medical Records and Patient Files
The government also executes search warrants and issues grand jury subpoenas to seize electronic medical records (EMRs) and patient files directly from hospice providers, EMR vendors, and practice management platforms. Federal investigators use EMR data to reconstruct the hospice’s certification and documentation practices across the entire patient population. They compare physician certifications to patient clinical trajectories, analyze timestamps and metadata to determine whether documentation was created contemporaneously or fabricated after the fact, and identify patterns of templated or copy-and-paste notes that may indicate documentation was not individualized to the patient.
EMR metadata reveals when a certification or progress note was created, when it was modified, who accessed the record, and whether the note was backdated. The firm understands how federal agents extract and analyze EMR data and challenges the government’s interpretation of that data at every stage of the case.
Federal hospice fraud enforcement is concentrated in specific districts. CMS has designated six states for the Provisional Period of Enhanced Oversight. DOJ’s Medicare Fraud Strike Force operates in additional districts with deep healthcare fraud infrastructure. Armstrong & Bradylyons PLLC defends hospice providers in every one of these jurisdictions.
Central District of California
The Central District of California is the epicenter of federal hospice fraud enforcement. Los Angeles County accounts for approximately 18% of the nation’s total home health and hospice Medicare billing activity. The region has experienced a seven-fold increase in hospice billing. CMS and DOJ held a joint press conference in January 2026 announcing deepened investigations of hospice billing fraud in California. Multiple federal prosecutions have resulted in sentences ranging from 57 months to 12 years in prison for sham hospice operations and money laundering. California imposed a moratorium on new hospice licenses in 2021. The Central District is a PPEO state and a Strike Force district.
Southern District of Texas
The Southern District of Texas is the site of one of the largest criminal hospice fraud prosecutions in the history of the Department of Justice. The Merida Group case involved $150 million in false and fraudulent hospice claims submitted from dozens of locations across Texas. The owner received 20 years in federal prison. The CEO received 15 years. Medical directors received sentences of over four years. Texas is a PPEO state, and the Southern District has an aggressive healthcare fraud enforcement posture.
District of Arizona
Arizona is one of the four original PPEO states. CMS identified a significant increase in the number of enrolled hospices in Arizona, raising concerns about market oversaturation and fraud. Arizona hospice providers are subject to prepayment medical review, unannounced site visits, and heightened documentation scrutiny under the PPEO. Providers in Arizona who fail PPEO review face revocation of Medicare billing privileges and referral to law enforcement.
District of Nevada
Nevada is one of the four original PPEO states. The rapid growth of hospice providers in Nevada mirrored the patterns identified in California, Arizona, and Texas. Nevada hospice providers are subject to the same PPEO oversight regime. Federal enforcement in Nevada is coordinated between CMS, HHS-OIG, and the U.S. Attorney’s Office for the District of Nevada.
Northern and Southern Districts of Georgia
Georgia was added to the PPEO program in December 2025. CMS identified significant hospice enrollment growth in Georgia and determined that the state warranted enhanced oversight. Newly enrolled hospices and ownership changes in Georgia on or after December 30, 2025 are subject to PPEO review. Georgia hospice providers should expect intensified scrutiny and potential criminal referrals as the PPEO program generates findings.
Southern District of Ohio
Ohio was added to the PPEO program alongside Georgia in December 2025. The Southern District of Ohio is also a Strike Force district. Ohio hospice providers face enforcement risk from both the PPEO program and the established Strike Force infrastructure in Cincinnati.
Southern District of Florida
The Southern District of Florida is home to one of the most active Medicare Fraud Strike Force teams in the country. South Florida has a long history of healthcare fraud enforcement, including hospice fraud, home health fraud, and behavioral health fraud. Hospice providers operating in South Florida face scrutiny from both the Strike Force and HHS-OIG.
Additional Districts
Hospice fraud enforcement is not limited to the districts above. CMS has signaled its intent to expand the PPEO program to additional states. Federal and state enforcement activity in this space is expanding rapidly. Scott Armstrong and Drew Bradylyons defend hospice providers in every federal district where DOJ, CMS, HHS-OIG, and state Medicaid Fraud Control Units bring hospice fraud cases.
Federal hospice fraud prosecutions draw on several criminal statutes. The charges carry severe penalties. Understanding the statutory framework is essential to mounting an effective defense.
Healthcare Fraud (18 U.S.C. § 1347)
The primary charging statute in hospice fraud cases. Healthcare fraud makes it a federal crime to knowingly and willfully execute or attempt to execute a scheme to defraud any healthcare benefit program. In hospice cases, this statute targets false terminal illness certifications, billing for services not rendered, enrollment of patients who are not terminally ill, and billing for hospice services that were not medically necessary. The penalty is up to 10 years of imprisonment per count. If the fraud results in serious bodily injury, the maximum increases to 20 years. If it results in death, a life sentence is possible.
Wire Fraud (18 U.S.C. § 1343)
The government frequently charges wire fraud alongside or as an alternative to healthcare fraud. Wire fraud applies to any scheme to defraud that uses interstate wire communications, which includes the electronic submission of Medicare claims. Wire fraud carries a maximum penalty of 20 years of imprisonment per count.
Anti-Kickback Statute (42 U.S.C. § 1320a-7b)
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce or reward the referral of patients for services covered by federal healthcare programs. In hospice cases, prosecutors target kickbacks paid to patient recruiters, marketers, assisted living facility operators, and physicians for patient referrals. Medical director fees structured as disguised kickbacks tied to certification volume are also a primary enforcement target. Violations carry up to 10 years of imprisonment per violation.
Money Laundering (18 U.S.C. §§ 1956, 1957)
Money laundering charges are common in hospice fraud prosecutions. The government charges money laundering when it alleges that defendants conducted financial transactions involving the proceeds of the hospice fraud scheme with the intent to conceal the nature or source of the funds or to promote the underlying fraud. Hospice fraud proceeds used to purchase real estate, luxury vehicles, or other assets are frequently the basis for money laundering charges. Money laundering carries up to 20 years of imprisonment per count.
False Claims Act (31 U.S.C. §§ 3729–3733)
The False Claims Act is the government’s primary civil enforcement tool. It imposes liability on any person who knowingly submits or causes the submission of false or fraudulent claims to the government. In hospice fraud cases, the FCA targets claims for patients who were not terminally ill, claims for services not rendered, and claims tainted by kickback relationships. Penalties include treble damages and per-claim penalties. FCA cases may be brought by the government directly or by private whistleblowers through the Act’s qui tam provisions.
Federal Program Exclusion and Collateral Consequences
Beyond incarceration and fines, a conviction or settlement in a hospice fraud case triggers mandatory exclusion from Medicare, Medicaid, and all federal healthcare programs under the authority of HHS-OIG. For physicians and nurses, exclusion effectively ends a career. State licensing boards may also initiate independent disciplinary proceedings. These collateral consequences are often as devastating as the criminal penalties themselves.
What Should I Do If My Hospice Is Under Federal Investigation?
Retain experienced federal defense counsel immediately. Do not speak with federal agents, CMS auditors, HHS-OIG investigators, or anyone else about the investigation before consulting a defense attorney.
Federal hospice fraud investigations frequently begin with a CMS PPEO review, a grand jury subpoena, agent contact from the FBI or HHS-OIG, a state Medicaid Fraud Control Unit inquiry, or the suspension or revocation of Medicare billing privileges. What you say and produce in the early stages of an investigation shapes the entire case.
An experienced defense attorney will communicate with the government on your behalf, advise on the scope of any subpoena or audit, protect privileged information, and develop a defense strategy before charging decisions are made. Scott Armstrong and Drew Bradylyons defend hospice owners and medical professionals at the investigation stage and at trial, drawing on years of experience as senior prosecutors at DOJ’s Fraud Section.
What Is the CMS Provisional Period of Enhanced Oversight (PPEO) for Hospices?
The PPEO is a CMS enforcement initiative targeting newly enrolled hospices and ownership changes in designated states. CMS launched the program in July 2023 for California, Arizona, Nevada, and Texas and expanded it to Georgia and Ohio in December 2025.
During the PPEO, hospices are subject to prepayment medical review, additional documentation requests, and unannounced site visits for up to one year. Reviewers examine certifications, plans of care, clinical documentation, and billing records. Through December 2025, 817 hospices were subject to PPEO review and 181 had their Medicare enrollment revoked. That is a 22% revocation rate. A failed PPEO review can result in revocation of Medicare billing privileges and referral to law enforcement for criminal investigation.
What Are the Penalties for a Federal Hospice Fraud Conviction?
The penalties are severe. Healthcare fraud (18 U.S.C. § 1347) carries up to 10 years of imprisonment per count. Wire fraud carries up to 20 years per count. Money laundering carries up to 20 years per count. Anti-Kickback Statute violations carry up to 10 years per violation.
Beyond incarceration, defendants face substantial fines, restitution orders, and forfeiture of assets. Federal law mandates exclusion from Medicare, Medicaid, and other federal healthcare programs upon conviction. For physicians and nurses, exclusion effectively ends the ability to practice. Recent hospice fraud sentences include 20 years for a hospice company owner in Texas and 12 years for a sham hospice operator in California.
Can a Medical Director Be Charged with Hospice Fraud for Signing Certifications?
Yes. Medical directors and certifying physicians are high-priority targets in federal hospice fraud prosecutions. The government charges medical directors who allegedly certified patients as terminally ill without conducting adequate face-to-face evaluations, signed certifications and recertifications for patients who did not meet hospice eligibility criteria, or received compensation that was structured as a kickback tied to the volume of certifications signed.
In the Merida Group prosecution, a medical director was sentenced to over four years in federal prison for certifying patients who were not terminally ill in exchange for luxury trips and other perks. A defense attorney experienced in hospice fraud understands how to challenge the government’s clinical evidence and establish the legitimate medical basis for the physician’s certification decisions.
What Hospice Documentation Does the Government Scrutinize?
Federal investigators focus on specific documentation in hospice fraud cases. The government scrutinizes the initial certification of terminal illness, including whether the certifying physician conducted an adequate clinical evaluation and whether the documentation supports a terminal prognosis. Recertifications are reviewed to determine whether the patient’s continued enrollment was clinically justified at each required interval.
Investigators also examine comprehensive assessments, individualized plans of care, physician and nurse visit notes, interdisciplinary group (IDG) meeting notes, and documentation of symptoms and functional decline. The government looks for templated or copy-and-paste notes, inconsistencies between clinical documentation and billing records, documentation that does not reflect the patient’s actual condition, and notes that were created or modified after the dates of service.
Election statements, revocation documents, and discharge records are also scrutinized. The government examines whether patients and their families were properly informed about hospice, whether elections were voluntary, and whether patients were unknowingly enrolled in hospice care.
What Defenses Are Available in a Federal Hospice Fraud Case?
The available defenses depend on the specific allegations. Common defenses in hospice fraud cases include the following:
Legitimate clinical judgment. Terminal prognosis is inherently uncertain. The government must prove that the certification was knowingly false, not merely that the patient outlived the prognosis. A physician who exercised legitimate clinical judgment in certifying a patient is not committing fraud.
Medical necessity. Defendants can challenge the government’s claim that hospice services were not medically necessary. Clinical documentation, patient records, and expert testimony from hospice and palliative care physicians support this defense.
Good faith reliance. Reliance on the advice of compliance programs, legal counsel, or clinical guidelines can negate the element of intent.
Challenging data analysis. The government relies heavily on statistical methodologies. Aggregate data showing long average lengths of stay or high live discharge rates does not prove fraud at the individual patient level.
Scott Armstrong and Drew Bradylyons leverage their significant federal trial experience as former prosecutors to anticipate the government’s trial strategy and develop an aggressive, evidence-based defense.
What Triggers a Federal Hospice Fraud Investigation?
Federal hospice fraud investigations are typically triggered by claims data analytics identifying billing outliers, CMS PPEO review findings, qui tam whistleblower lawsuits filed under the False Claims Act, complaints from current or former employees, complaints from patients or their families, and referrals from state Medicaid Fraud Control Units or other regulatory agencies.
Common red flags that trigger investigations include unusually long average lengths of stay, high percentages of patients with dementia or debility diagnoses, disproportionate live discharge rates, rapid growth in patient census, billing patterns that diverge significantly from peer providers, and geographic clustering of hospice providers in areas identified by CMS as oversaturated.
What Is the Difference Between a Civil and Criminal Hospice Fraud Investigation?
Civil hospice fraud investigations focus on recovering money. These may involve False Claims Act actions, Civil Investigative Demands (CIDs), and penalties including treble damages and per-claim fines.
Criminal hospice fraud investigations focus on proving intentional and willful fraud beyond a reasonable doubt. Criminal cases carry the possibility of imprisonment, criminal fines, and restitution.
The government frequently runs civil and criminal investigations in parallel. The same conduct can expose a provider to both civil liability and criminal prosecution at the same time. Statements and concessions made in a civil matter or audit response can be used to build a criminal case. Scott Armstrong and Drew Bradylyons have years of experience navigating parallel civil and criminal healthcare fraud cases at DOJ’s Fraud Section and as defense attorneys.
Can a Hospice Owner Be Held Personally Liable for Fraud by Employees?
Yes. Federal prosecutors regularly pursue hospice owners and executives for fraud committed within their organizations. The owner does not need to have personally certified patients or submitted false claims. If a provider causes another person to submit a claim with knowledge that the claim is false or fraudulent, a criminal case against that provider may be viable.
The government relies on theories of conspiracy (18 U.S.C. § 371) and aiding and abetting (18 U.S.C. § 2) to reach individuals beyond those who directly submitted the false claims. Prosecutors examine whether the owner had knowledge of, directed, or willfully ignored the allegedly fraudulent conduct.
Why Is Hospice Fraud Under Intensified Federal Scrutiny Now?
Several factors converged. The number of Medicare-enrolled hospices surged in recent years, particularly in California, Arizona, Nevada, and Texas. CMS identified these states as oversaturated and launched the PPEO program. HHS-OIG and CMS identified patterns of fraudulent enrollment, false terminal certifications, kickback-driven patient recruitment, and license flipping by unscrupulous operators.
In January 2026, CMS and DOJ held a joint press conference announcing deepened investigations of hospice billing fraud. CMS referred 343 cases to law enforcement in 2025. The combination of massive federal spending, rapid industry growth, high-profile criminal prosecutions with lengthy prison sentences, and public attention to the issue has made hospice fraud a top enforcement priority for the foreseeable future.
Does Armstrong & Bradylyons PLLC Handle Hospice Fraud Cases Outside of Washington, D.C.?
Yes. Armstrong & Bradylyons PLLC defends individuals in federal hospice fraud investigations and prosecutions nationwide. The firm can practice in every federal district court in the country.
Hospice fraud enforcement is concentrated in the six PPEO states (California, Arizona, Nevada, Texas, Georgia, and Ohio) and in Strike Force districts including the Southern District of Florida, the Eastern District of Michigan, and the Northern District of Illinois. Prosecutions also originate from U.S. Attorney’s Offices in districts beyond the PPEO and Strike Force footprint.
Scott Armstrong and Drew Bradylyons have tried healthcare fraud cases and handled investigations in Strike Force districts and federal courts across the country. The firm is based in Washington, D.C. and represents clients in every jurisdiction where DOJ, CMS, and HHS-OIG investigate and prosecute hospice fraud cases.