Various Practices That Can Trigger A Medicaid Fraud Investigation For Healthcare Providers and Recipients
Medicaid Services Providers in New York
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:
If you are a Medicaid Services Provider, here are some of the reasons you can be investigated for Medicaid fraud:
- Bill Medicaid for services that have never been provided
- Falsifying patients’ diagnoses to justify tests or other procedures that aren’t medically necessary
- Misrepresenting medical procedures performed to obtain payment for non-covered services
- Upcoding: billing for a more costly service than the one performed
- Unbundling: billing each stage of a procedure as if it were a separate procedure
- Filing claims for fake services and medical conditions
- Coverage claims for non-existent illnesses
- Filing claims for fake and staged car accidents in NY
- 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.
You can deal with the Office of the Inspector General, the FBI, and other federal law enforcement agencies on the federal level.
On the state level, cases are handled by numerous government agencies and organized groups:
- The Medicaid Fraud Control Units of the NY Attorney General’s Office
- The Office Of Medicaid Inspector General
- Local District Attorneys
What Are The Basics of a Medicaid Fraud Investigation?
Your practice or health care 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. Oftentimes, undercover Medicaid fraud investigators can come into your office hoping that you will conduct a criminal offense by performing an illegal transaction with them. Medicaid fraud investigators may simply raid your office and seize your files and computers on some occasions.
What Should You Do If You Are Under a Medicaid Fraud Investigation?
When you realize that you are subject to a government fraud investigation, talk to a qualified Medicaid fraud attorney or fraud defense lawyer before talking to a Medicaid fraud investigator! If you are under investigation, the “do-it-yourself” approach is wrong. How the Medicaid fraud investigation case is handled in the early stages often determines the legal consequences, including whether criminal charges are filed against you. That is why a consultation with an experienced Medicaid fraud attorney is critical before discussing anything with the Medicaid fraud investigator.
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
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 types of health care or Medicaid fraud cases. The government authorities have invested considerable time and resources to gather evidence to prosecute fraud and build their fraud investigation 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 NY 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 cases administratively, and there were no criminal prosecutions.
- Successfully represented a defendant in NY federal court in a multi-million Medicaid fraud investigation and conspiracy case, securing a non-jail time 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 Office of Medicaid Inspector General to reverse its decision to exclude our client, a healthcare provider, from participating in a Medicaid Program.
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, Medicaid benefits fraud, and Medicaid provider fraud, such as Family Health Plus Fraud or Medicaid Fraud.
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.
If you received a letter from the Bureau of Fraud Investigations or a phone call from a detective regarding receiving benefits, I urge you to read on.
Who Is NOT Eligible For Medicaid and Family Health Plus?
To be eligible for Medicaid in the city, you and all your family members receiving benefits must live in one of the boroughs. Many recipients apply for benefits after moving 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 individuals face legal problems because they do not disclose their income.
In some cases and during various periods, excessive resources would also disqualify you from receiving Medicaid, although there is no resource test in most cases.
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 the New York Human Resources Administration (HRA) Bureau of Fraud Investigations. The Bureau of Fraud Investigations (BFI) is located at 151 W. Broadway, NY, and 250 Church Street, NY. 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 HRA investigator is assigned to it, and at some point, you will receive a letter from the Bureau of Fraud Investigations.
Most BFI cases involve situations where clients haven’t reported their income somehow, 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 an initial meeting, a so-called Medicaid fraud “interview,” there are two possibilities: either the investigation is in the very beginning stages, but the agency doesn’t 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 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 committing Medicaid fraud, 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 you provide will be used against you.
Bottom line: Speak to us as soon as you receive the letter. Do not contact the investigator under any circumstances – not by phone, not in person.
How Can My Medicaid Fraud Case Be Resolved?
We always try to resolve Medicaid fraud investigations before they are referred to the NY District Attorney’s Office. Each Medicaid fraud case boils down to money – how much did the government pay for your healthcare services? The more people who receive Medicaid in a family, and the longer they are on the Medicaid program, the larger the claim.
We always begin by 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 office, 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 civil lawsuits 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 in administrative hearings without criminal charges filed. Lately, however, there has been a significant shift in HRA policy, and we see more criminal prosecutions of individuals who received health benefits illegally. While a good Medicaid fraud attorney should be able to help resolve your case administratively, there is always the potential that the case will be sent to the District Attorney’s Office.
What Happens If I Am Arrested for Medicaid Fraud in NYC?
If the HRA decides to pursue a criminal investigation and 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 and Medicaid Fraud, among others.
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 their charges.
We have helped countless individuals investigated for Medicaid Fraud. In many cases, our experienced Medicaid fraud attorney has successfully prevented criminal charges from being 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 faced 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 charges and civil lawsuits.
- Represented numerous Medicaid recipients whose cases were referred to the DA’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! 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 they are the subject of a Medicaid fraud investigation. Subjects of Medicaid fraud investigations frequently speak with a Medicaid fraud investigator without an attorney and inadvertently incriminate themselves, even if they haven’t done anything wrong. Norman Spencer & Associates is a Medicaid fraud law firm on your side every step of the way.