Various Practices That Can Trigger A Medicaid Fraud Investigation For Providers and Recipients

This article is about what triggers Medicaid fraud investigations for NY healthcare providers and recipients. If you are a Medicaid Services Provider, here are some of the reasons you can be investigated for Medicaid fraud:

  • Billing Medicaid for services that have never been provided;
  • Falsifying patients diagnosis to justify tests or other procedures that aren’t medically necessary;
  • Misrepresenting procedures performed to obtain payment for non-covered services;
  • Upcoding: billing for a more costly service than the one actually performed;
  • Unbundling: billing each stage of a procedure as if it were a separate procedure;
  • Filing claims for fake services and medical conditions;
  • Filing claims for fake and staged car accidents in NY;
  • Coverage claims for non-existent illnesses;
  • Filing claims for medical care coverage for staged, fraudulent auto accident injuries;
  • Illegal kickbacks;
  • Illegal fee sharing
  • Billing for services provided by unlicensed personnel in violation of Medicaid rules.

Who Investigates Medicaid Fraud?

Investigations and prosecutions can be conducted on state and federal levels.

On federal level, you can deal with the Office of Inspector General, the FBI, and other federal law enforcement agencies.

On state level, cases are handled by numerous organizations:

  • The Medicaid Fraud Control Unit of the NY Attorney General’s Office
  • The Office Of Medicaid Inspector General
  • Local District Attorneys

What Are The Basics Of Investigations?

Your practice might have come under the law enforcement radar in many ways. Once a NY practice is flagged, an investigation will begin and it can continue for months or even years. In many cases investigation targets don’t even know that they are being watched. The agents will review your billing records, subpoena your bank records, speak with your patients or employees. Often, undercover agents would come in to your office hoping that you would conduct some illegal transaction with them. On some occasions, agents may simply raid your office and seize your files and computers.

What Should You Do If You Are Under Investigation?

When you realize that you are subject to a government investigation, talk to a fraud defense lawyer before talking to the investigators! If you are under investigation, the “do-it-yourself” approach is wrong. How the case in handled in the early stage often determines the outcome, including the likelihood of whether criminal charges are filed against you. That is why a consultation with a NY Medicaid fraud lawyer is absolutely critical before you discuss anything with the investigators.

If you are a healthcare practitioner targeted by an investigation, you should never do the following:

  • Discuss the case with anyone
  • Allow anyone to review or remove any documents or files from your office unless they have a warrant
  • Alter any documents
  • Instruct your staff to lie

These actions will compound your problems and make your defense more difficult.

Your chances of a favorable outcome increase dramatically if you begin your defense early in this or other type of health care fraud case. The government authorities have already invested considerable time and resources in gathering evidence and building the case against you. They are ahead of the game – and the sooner your defense team gets involved the better your chances. You need an experienced and dedicated legal team of New York Medicaid fraud lawyers to beat the fraud investigators at their own game.

Here are some of our representative cases in the area of Medicaid Fraud

  • Routinely represent Medicaid providers investigated by the Medicaid Fraud Control Unit. In a recent case, we represented several providers each accused of stealing over a million dollars from Medicaid. We settled the case administratively, and the clients were not charged.
  • Successfully represented a defendant in NY federal court in a multi-million Medicaid fraud conspiracy case, securing a non-prison sentence.
  • Represented home care agencies, transportation companies, and medical practices in fraud investigations by state and federal authorities.
  • Represented Medicaid providers in administrative actions taken by the Office of Medicaid Inspector General. In a recent case on appeal we convinced the OMIG to reverse its decision to exclude our client, a healthcare provider, from participating in Medicaid Programs.

Use our efficiency and expertise to your benefit and call us today! Contact us today to talk to a NY Medicaid fraud lawyer.

Our lawyers have represented hundreds of clients investigated and prosecuted for health benefits fraud such as Medicaid Fraud or Family Health Plus Fraud.

If you are a Medicaid Recipient here are some of the things that can trigger Medicaid fraud investigation:

  • Providing false information on the Medicaid application (lying or concealing information about income, assets, etc.)
  • Altering or forging prescriptions
  • Re-selling medicine and products obtained through the program
  • Receiving services for which you are not eligible by means of intentional misrepresentation
  • Allowing another person in NY to use your Medicaid card to obtain services
  • Receiving and using several Medicaid Cards.

If you received a letter from the Bureau of Fraud Investigations, or a phone call from a detective regarding your benefits, I urge you read on.

Who Is NOT Eligible For Medicaid and Family Health Plus

In a nutshell, to be eligible for Medicaid in the city, you and all your family members who receive the benefits must live in one of the boroughs. Many recipients apply for benefits after they move out of the city to places such as Long Island and New Jersey, automatically disqualifying them from receiving Medicaid.

The other eligibility criterion is income. You must disclose all types of income, earned (from your job), unearned (such as rental income, alimony, child support, workers’ comp., etc), and all contributions (money others give you) from any source. Countless of individuals faced legal problems because they did not disclose their income.

In some cases and during various time periods, excessive resources would also disqualify one from receiving Medicaid, although in most cases there is no resource test.

Who Gets Investigated for Medicaid Fraud in NYC

Most Medicaid and other public benefits recipients first learn that they are the targets of a NY State investigation when they receive a letter from New York Human Resources Administration, Bureau of Fraud Investigations. The Bureau of Fraud Investigations (BFI) is located at 151 W. Broadway, New York and at 250 Church Street, New York. The BFI is staffed with dozens of fraud investigators and its primary job is to investigate public benefits fraud such as Medicaid, Food Stamps., etc.

Once your case is flagged, an investigator is assigned to it and at some point you will receive a letter from the Bureau of Fraud Investigations that looks like this.

Most BFI cases involve situations where clients haven’t reported their income in some way, didn’t reside in NY State, or both.

What To Do If You Receive an Investigation Letter From The Bureau of Fraud Investigations

By the time you are called for a so-called “interview” there are two possibilities: either the investigation is in the very beginning but the agency doesn’t really have any solid evidence, and they need your statements to make their case easier, or the investigation is essentially over and they need your statements to make the case waterproof. Either way, speaking with the investigators will never help you and will only make your problem more difficult to resolve.

If you go to the “interview” and voluntarily submit requested documentation you may be implicating yourself and confessing to having committed a crime and in the event your case is referred to the District Attorney’s Office for criminal prosecution or to the NYC Legal Department for civil litigation, any information your provide will be used against you.

The bottom line is: speak to us as soon as you receive the letter. Do not contact the investigator under any circumstances, not by phone, not in person, not ever.

How Can My Medicaid Fraud Case Be Resolved?

We always try to resolve Medicaid fraud investigations before they are referred to the NY DA’s Office. Each Medicaid fraud case boils down to money: how much did the government pay for your healthcare services? The more people receive Medicaid in a family and the longer they are on the program, the larger the claim will be.

We always begin with verifying the numbers. We need to make sure that the government’s claim is correct. If not, we will press the agency to adjust it. The best-case scenario is when you are allowed to pay voluntary restitution to the City and the investigation is terminated.

What Is The Division of Claims And Collections?

Some Medicaid cases are handled differently and they are investigated by another HRA branch, the NY Division of Claims and Collections, instead of the BFI. Usually, the Claims and Collections investigators will send you a letter asking for a certain amount of money to be repaid. These cases are not generally prosecuted but could result in a civil action where the HRA will sue you in civil court. If you receive a letter like this, give us a call.

Will I Be arrested If I’ve Committed Medicaid Fraud?

Not necessarily. The vast majority of the cases we have handled were resolved administratively without criminal charged filed. Lately, however, there has been a significant shift in the HRA policy and we see more criminal prosecutions of individuals who received health benefits illegally. While a good lawyer should be able to help resolve your case administratively, there is always a potential that the case will be sent to the DA’s Office.

What Happens If I Am Arrested for Medicaid Fraud in NYC

If the HRA decides to press charges, the case will be referred to the District Attorney’s Office and you will be charged with several felony charges including Grand Larceny, Medicaid Fraud, and other charges.

Many clients found out that they had been targeted only upon receiving a call from the DA’s Detective Squad instructing them to surrender to their local New York DA’s Office and face the charges.

We have helped countless individuals investigated for Medicaid Fraud. In many cases, our lawyers have been successful in preventing criminal charges to be filed in the first place! If you or someone you know is targeted in a Medicaid fraud investigation in NY, do not be part of the statistics – call us today for a confidential consultation.

Here are some of our representative cases in the area of Medicaid Fraud:

  • Represented a wealthy business owner with multiple properties who was charged with receiving Medicaid in New York in the amount of $115,000. The client facing up to 7 years in prison. We convinced the New York District Attorney to agree to a conditional discharge with full restitution payment.
  • Represented several hundred clients investigated by the Bureau of Fraud Investigations for receiving Medicaid and Family Health Plus benefits to which they were not entitled. We have reached administrative settlement solutions in almost all of these cases, preventing criminal and civil charges.
  • Represented Numerous Medicaid Recipients whose cases were referred to the District Attorney’s Office. After meeting with prosecutors, we convinced them to send the cases back to the HRA for a civil resolution.

Use our expertise to your benefit and call us today! Contact us today to talk to a New York Medicaid fraud criminal defense lawyer.

Both providers and recipients of Medicaid funds can be accused of Medicaid fraud, with the risk of severe consequences. It is not uncommon to have two or more Medicaid Fraud Agents show up unannounced at your home or place of work and initiate an unpleasant interrogatory process. This is how most people find out that they are the subject of a Medicaid fraud investigation. Subjects of Medicaid fraud investigations frequently find themselves speaking with the investigator without an attorney and inadvertently incriminate themselves, even if they haven’t done anything wrong. Joseph Potashnik & Associates are a Medicaid fraud law firm that is on your side, every step of the way.

READ MORE: NYC MEDICAID FRAUD LAWYER