Medicaid fraud investigations in New York typically begin when a Medicaid fraud investigator obtains information suggesting that a person is illegally receiving Medicaid benefits. This may involve false information on applications or reselling products acquired through the Medicaid program. Evidence can come from various sources, including business and payroll records or even insights from co-workers and neighbors.
Medicare vs Medicaid
Medicare is a federal program authorizing the financing of healthcare costs for the elderly. In the Medicare program, healthcare providers submit claims reimbursed by private insurance companies, which are then compensated from Federal trust funds.
Medicaid, in contrast, is a program assisting those with low income. In New York, the Medicaid program is managed by the Department of Health and local social services agencies.
Frauds against these programs are prosecutable under several federal criminal statutes, such as:
- Insurance fraud
- Healthcare fraud
- Mail and wire fraud
Both beneficiaries and providers may face federal court prosecution for fraud against Medicaid and Medicare. However, the likelihood of prosecution differs between the two groups:
- Beneficiaries: Commonly, those who commit fraud by falsifying income and resource information on their applications are not often prosecuted in federal courts in New York, with most cases handled by state courts.
- Providers: Medical professionals and health care facilities are more likely to be prosecuted federally for Medicaid and Medicare fraud for actions including:
- Material false statements
- Submitting fraudulent claims
- Engaging in kickback schemes
Notably, New York has established the Medicaid Fraud Control Unit to investigate and prosecute Medicaid fraud cases under the state Attorney General’s Office.
Defense against Medicare and Medicaid fraud allegations in New York demands an attorney versed in the intricacies of the reimbursement process. Our criminal defense lawyers represent New Yorkers accused of Medicaid fraud, Family Health Plus fraud, or healthcare fraud criminal charges, including:
- Medicaid Recipients
- Medicaid Providers such as doctors, dentists, clinics, nursing home managers, pharmacists, home care providers, and owners of ambulette transportation businesses are accused of administrative or criminal fraud violations.
Medicaid fraud includes actions or omissions that result in unauthorized benefit receipt. Examples of such fraud include:
- Income manipulation to qualify for Medicaid
- Failure to report existing insurance coverage
Allowing another person to use one’s Medicaid benefits
Medicaid Fraud Accusations
Accusations of Medicaid fraud can vary. Common reasons for investigation include:
- Providing false information on applications about income and assets.
- Reselling medicines obtained through Medicaid.
- Forging or altering prescriptions.
- Permitting others to use one’s Medicaid card.
Medicaid Provider Fraud
In more severe cases, provider fraud involves Medicaid providers, such as medical professionals or health care facilities, committing fraudulent activities like billing for services not provided. With the government intensifying crackdowns, those found guilty of Medicaid fraud face harsh penalties, such as:
- Temporary or permanent suspension of benefits
- Criminal and civil charges lead to imprisonment for individuals (up to five years) and hefty fines (individuals up to $200,000, corporations up to $500,000)
- Civil penalties, including fines up to $10,000
Convictions have long-lasting effects, such as future difficulties in obtaining government assistance or employment, and for corporations, loss of business and investors.
Medicaid Fraud Investigation Process
Individuals usually learn they are under investigation after receiving a letter from an investigator. This letter typically requests various documents and an interview to discuss the suspected Medicaid fraud.
Your practice or healthcare facilities 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. An agent conducts investigations by reviewing your billing records, subpoenaing your bank records, and speaking with your patients or employees. Often, undercover Medicaid fraud investigators can come into your office hoping you will conduct a criminal offense by performing an illegal transaction with them. Medicaid fraud investigators may occasionally raid your office and seize your files and computers.
Meeting with Investigators
During a meeting with a Medicaid fraud investigator, anything said can be used in future proceedings. Having legal representation during these meetings with Medicaid fraud investigators is crucial, as even innocent mistakes could lead to criminal charges under statutes like the False Claims Act. Before saying anything to the investigator or providing any documents, consulting an experienced Medicaid fraud attorney is essential.
If you are a healthcare practitioner targeted by a fraud 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
What Are Your Rights?
When facing a Medicaid fraud investigation, individuals have the right to remain silent and are not obligated to answer investigators’ questions. Benefits from programs like Family Health Plus or Medicaid will not be terminated for refusing to answer questions. However, the approach to an investigation can vary, and it’s crucial to handle document requests and inquiries properly, as some may be inappropriate.
An experienced Medicaid fraud attorney is instrumental in these situations, offering the right to legal representation, advising on whether to cooperate with the investigator and negotiating to protect the individual’s rights based on the unique facts of their case.
Possible Medicaid Fraud Penalties and Punishments
The range of punishments is extensive if you are found guilty of Medicaid fraud. Convicted individuals may be forced to reimburse Medicaid for any benefits wrongly received. In more severe instances, they could face imprisonment for up to ten years.
Additionally, offenders might be banned and considered ineligible for future Medicaid benefits. Some may confront civil judgments or have liens placed against their property.
For those with precarious immigration statuses, the stakes are even higher, as they may face deportation proceedings following a fraud conviction.
Medicaid Fraud Settlement: This occurs when a person or corporation settles a Medicaid fraud charge out of court, which may involve:
- Paying a fine to prevent business-disruptive proceedings
- Undergoing monitoring by a third party during a probationary period
- Deferred prosecution agreements to postpone the imposition of severe penalties
Medicaid Recipients in New York
If you are a Medicaid Recipient, here are some of the things that can trigger a 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 Medicaid 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.
Administrative Disqualification Hearing
In certain situations, the government may suspect that an individual has intentionally committed Medicaid fraud, but the amount may not be substantial enough to warrant criminal prosecution. As a result, the case is referred to the Office of Administrative Hearings (OAH), a division of the New York State Department of Social Services (NYSDSS).
An administrative disqualification hearing is held at OAH to determine whether or not the individual intentionally defrauded Medicaid and whether they should be banned from receiving benefits for a specific period or permanently.
When to Hire a Medicaid Fraud Attorney
In the case of a Medicaid fraud allegation, it is essential to have an experienced lawyer who knows what steps to take. They can defend the case in court or, if necessary, reduce the person’s criminal exposure. The attorney will gather all the required information to achieve the best possible outcome for the client. They will also know how to work with a particular judge or prosecutor.
At Norman Spencer Law Group, we understand that facing Medicaid fraud charges in New York often leads to serious felony allegations. The consequences of a felony conviction are severe, including a permanent criminal record. Our approach focuses on negotiating with district attorneys and judges to potentially reduce these charges to a misdemeanor or to reach a plea agreement. Such strategies aim to protect our clients from the lifelong repercussions of a felony conviction, helping them avoid a criminal record and the associated long-term impacts.