More than seven million New Yorkers rely on Medicaid for prescription drugs and necessary medical care. Because this health care benefit program is so critical to so many people, police and district attorneys aggressively investigate allegations of fraud. Anyone accused of fraud risks high fines and potentially years in jail. If you are a medical professional or work in healthcare, you also stand a chance of losing your livelihood.
At ZMO Law PLLC, we take on challenging Medicaid fraud cases. We understand the risks you’re up against in this type of criminal matter and are ready to fight for your rights and your future. When healthcare allegations are involved, you need a criminal defense team that knows how to handle these cases and will stand by you with skill, determination, and a commitment to justice.
Why Hire ZMO Law for Medicaid Fraud Defense?
Defending against Medicaid fraud takes more than knowing the law. Attorneys need to be ready to push back against aggressive prosecutors. At ZMO Law PLLC, our Medicaid fraud lawyers have the experience, skills, and determination to help you address the charges with confidence.
- Experience in Health Care Fraud Cases: Medicaid fraud cases can be complicated. Federal agencies and prosecutors are often armed with complicated documentary evidence. Our job is to break down the prosecution’s case, find the weak points, and build a strong defense.
- Success in State and Federal Courts: Medicaid fraud cases don’t always stay at the state level. Because the health care programs involve government funding, they often get pushed into federal court. We are available to handle different types of healthcare fraud matters in both state and federal forums, so no matter where your case ends up, you’ll have a team that can navigate it.
- Prepared to Fight for You in Court: Many Medicaid fraud cases never go to trial, but if yours does, we’ll be ready. Our federal healthcare fraud attorneys have years of courtroom experience and know how to stand up to tough prosecutors. Being prepared for trial can give us an edge when negotiating for the best possible outcome.
We know this isn’t just about the criminal charges; it’s about your freedom. Whether you’re worried about keeping your professional license, avoiding financial ruin, or protecting your reputation, our Medicaid fraud defense lawyers are here to help you manage the bigger picture and get your life back on track.
New York Medicaid Fraud: What You Need to Know
Medicaid fraud occurs when someone intentionally makes false statements or hides important facts to obtain Medicaid or financial benefits. These cases are taken seriously, with federal and state agencies working hard to investigate and prosecute alleged offenders. It’s important to note that not every error is healthcare fraud – prosecutors are required to prove you acted with fraudulent intent, that your action was done on purpose to deceive a health care insurance program.
Examples of Medicaid Fraud
Common types of fraud include:
- Billing for services or supplies that were never provided (fraudulent claims)
- Misdiagnosing patient health conditions to justify unnecessary services
- Accepting money or other benefits (illegal kickbacks) for patient referrals to specific providers or health care facilities, in violation of the Anti-Kickback Statute
- Double billing Medicaid and a private insurer for the same treatment (duplicate claims)
- Billing for a more expensive service than the one administered (upcoding)
- Billing for unnecessary medical equipment
- Performing unnecessary treatments to inflate Medicaid reimbursement claims
- Billing for each step of treatment as if it were a separate procedure (unbundling)
Understanding what actions might trigger a government investigation is the first step toward protecting yourself or your practice from damaging allegations of health care fraud. If you have questions or are facing federal fraud charges, contact ZMO Law.
The Five Degrees of Medicaid Fraud in New York
Medicaid fraud in New York isn’t treated as a one-size-fits-all crime. Instead, the New York Penal Law divides it into five degrees, based on the financial value involved. This approach means that the more money allegedly at stake, the more severe the potential criminal penalties.
- Fifth Degree (Class A Misdemeanor): The fifth degree misdemeanor is the least serious charge, covering fraud involving up to $1,000. While it’s a misdemeanor, the criminal penalties can still be life-disrupting, including up to one year in jail, probation, and fines. For providers, even a misdemeanor conviction can lead to devastating professional consequences, including loss of medical license, or a ban preventing you from billing to Medicaid.
- Fourth Degree (Class E Felony): This category covers fraud valued between $1,000 to $3,000. As a felony, this charge is more serious and can lead to a prison sentence of up to four years, along with high fines. A conviction at this level can affect your ability to secure housing, employment, or loans in the future.
- Third Degree (Class D Felony): This charge applies to fraud involving $3,000 to $50,000. Criminal penalties include up to seven years in prison and mandatory restitution.
- Second Degree (Class C Felony): For fraud involving $50,000 to $1 million, the stakes get even higher. This felony conviction can result in up to 15 years in prison, along with fines and possible forfeiture of assets. This offense often involves more thorough healthcare fraud investigations, as the amount of money at stake makes it a priority for prosecutors.
- First Degree (Class B Felony): The B felony is the most severe Medicaid fraud charge because it involves losses of over $1 million. A conviction can lead to up to 25 years in prison, substantial fines, and asset seizures. Cases at this level typically involve providers or organizations rather than individuals, but the potential consequences are devastating regardless of who is charged.
Whether you are an individual accused of misrepresenting your income by thousands of dollars or a provider under scrutiny for improper billing practices, it’s critical to understand how this type of fraud is classified and prosecuted.
What Happens During a Medicaid Fraud Investigation?
Fraudulent scheme investigations usually start with a trigger that raises suspicions. The trigger could be:
- A whistleblower, such as a former employee or patient, reporting suspected fraud
- A flagged discrepancy in Medicaid billing records or application data
- Findings from a routine audit conducted by Medicaid or associated agencies
- Unusual billing patterns, such as all patients of a provider receiving identical tests
Both state agencies, like New York’s Medicaid Fraud Control Unit, and federal agencies, like the Office of the Inspector General and the Federal Bureau of Investigation take the lead in these investigations for the prevention of fraud. If you are a provider, you might not even realize that you are under investigation at first. For individuals, the process could begin with a simple letter or phone call asking for clarification about your benefits or application.
Records Review and Subpoenas
Once government authorities suspect false claims, they get into the details. They’ll analyze financial and billing records to identify discrepancies, unusual patterns, and other fraudulent behavior. For providers, investigators might include examining medical codes, patient files, or payment records for things like double billing or treatments that lack medical necessity. For individuals, investigators could scrutinize their income statements, household information, and spending records.
If the initial review raises further questions, federal authorities may issue subpoenas. Subpoenas are formal demands for additional documents, such as:
- Medical charts or treatment logs
- Patient communications and provider contracts
- Employee emails or internal records
- Financial statements and bank account details
The investigators’ goal is to gather as much evidence as possible to either confirm or rule out fraudulent activities like accepting money in exchange for referrals or inflated reimbursements.
Interviews and Surveillance
As investigators dig deeper, they often conduct interviews with people connected to the case. They might talk to employees, patients, or even family members. They’re looking for additional context or firsthand accounts that could support their findings.
In some situations, investigators may use more covert methods, like undercover operations or surveillance. For example, they might send an agent posing as a patient to verify whether a provider is offering legitimate healthcare services or observe whether Medicaid funds are being used appropriately. For individuals, surveillance could involve tracking purchases or visits to healthcare providers to confirm whether benefits are being used as claimed.
Notification of Fraud Allegations
If investigators believe they have found enough evidence of fraud, they may demand records from you directly via subpoena, try to interview you, or execute a search warrant at your home or business. In other situations, you may not learn you are under investigation until you are arrested, after law enforcement agencies have filed healthcare fraud charges. If authorities suspect large-scale fraud, they may freeze your bank accounts or seize assets to prevent funds from being moved or hidden.
What to Do If You’re Accused of Medicaid Fraud
If you find yourself accused of Medicaid fraud, or if you believe you are under investigation for Medicaid fraud, your next steps are critical. First priority is to speak to a lawyer experienced in Medicaid fraud as soon as you become aware of an investigation. Do not attempt to resolve the issue on your own or speak to investigators without legal representation. Once you’ve retained counsel, take the following steps:
- Preserve Evidence: Retain all relevant documents, including correspondence, billing records, and contracts, and give them to your healthcare fraud defense attorney. Do not alter, destroy, or conceal evidence, as this could lead to additional charges.
- Avoid Discussing the Case: Limit discussions about the investigation to your healthcare fraud defense lawyer. Casual remarks to coworkers, friends, or family could be misinterpreted or used against you.
- Understand the Charges: Work with an experienced attorney to review the allegations, including the evidence against you and the potential penalties you face. An experienced criminal defense lawyer can help you proceed without risking accidental self-incrimination.
How We Defend Against Medicaid Fraud Charges
Charges of fraud often hinge on the details: Was there intent to deceive? Did the investigators follow proper procedures? Is the evidence accurate? By answering these questions, our criminal defense attorneys build a compelling strategy.
Proving Lack of Intent
Intent is a critical element in Medicaid fraud cases. The prosecution must show that you knowingly and deliberately tried to deceive the system. However, many fraud accusations arise from honest mistakes, such as misunderstanding the rules or unknowingly providing incorrect information. If your actions were unintentional, we work to show that there was no deliberate attempt to defraud a government program.
Challenging the Evidence
From billing records to patient files and financial documents, Medicaid fraud cases often involve mountains of paperwork. Mistakes in these records are not uncommon, and our experienced healthcare fraud defense attorneys know how to find them. We carefully review the evidence to identify inaccuracies, inconsistencies, or gaps that cast doubt on the prosecution’s claims.
Challenging Loss Amount
Even when people have some billing practices which are fraudulent, prosecutors often overestimate how widespread the fraud is. Our team can analyze billing data to challenge the calculations made by prosecutors. Analysis of the evidence can be crucial in negotiating plea deals and repayment of improperly received funds.
Highlighting Compliance Efforts
For providers, showing that you’ve taken steps to follow Medicaid regulations in good faith can be a powerful defense. If you have made an effort to stay within the rules and any errors were unintentional, we can present evidence to demonstrate your commitment to ethical practices. The goal is to shift the focus away from allegations of intentional fraud and toward resolving the issue with a non-criminal outcome.
Asserting Procedural Violations
Investigators don’t always play by the rules. If your rights were violated during the investigation (for example, if evidence of an alleged fraud scheme was obtained through an unlawful search, or if you were illegally pressured into making a statement without legal counsel), our criminal defense attorneys will fight to have that evidence suppressed.
Negotiating Settlements
Sometimes, resolving a Medicaid fraud case without going to trial is the best option. A resolution might involve negotiating a settlement where you agree to repay improperly received benefits or address false billing issues in exchange for avoiding criminal charges. This option can be especially beneficial for those in the medical field when it preserves professional licenses and avoids the publicity of a court trial.
Speak to Our New York Medicaid Fraud Lawyers Today
For doctors and other medical professionals, Medicaid fraud accusations can lead to life-changing consequences. ZMO Law PLLC is here to help. Call our law firm at (212) 685-0999 or fill out our online form to schedule a confidential consultation and let us put our extensive experience to work for you.