Last Updated on: 28th July 2023, 08:57 pm

The rate of health care fraud cases keeps going up as unscrupulous practitioners and recipients seek to capitalize on government programs like Medicaid and Medicare. For this reason, Medicaid audits and investigations have become increasingly common. New York has the Medicaid Fraud Control Unit, which is under the office of the Attorney General, to deal with providers and recipients who abuse the program.

As with all other government initiatives, Medicaid has its rules and regulations, which can be difficult to keep up with. Some individuals, practitioners, and health institutions get accused of fraud without even being aware that they were in violation of certain rules. When charged with Medicaid fraud in Long Island, your first response should be to get an attorney who specializes in this particular type of health care fraud case. Our lawyers have defended numerous clients with different types of Medicaid fraud cases.

Understanding Healthcare Fraud in New York

Under Article 177 of NY penal law, health care fraud refers to any attempt to defraud a health plan; in this instance, Medicaid. Health care fraud is classified into five degrees. A person could be charged with fifth-degree health care fraud if he/she provided false information or omitted details in order to receive services or products. This offense is a Class A misdemeanor.

Fourth-Degree health care fraud is a Class E felony, and it applies to a person who is accused of committing fraud more than once. The fraudulent payments received must be within a period of one year and more than three thousand dollars. If a person is found guilty of getting payments from Medicaid that exceed ten thousand dollars, then that is third-degree health care fraud and a Class D misdemeanor.

Second-degree fraud, which is a Class C felony, applies to payments received within one year and over fifty thousand dollars. If the fraudulent Medicaid payments received are over one million dollars, then that is first-degree health care fraud and a Class B felony.

These offenses come with severe penalties for both service providers and private individuals. For this reason, the expertise of a Medicaid fraud Lawyer in long island is recommended. An attorney will analyze your case to see the merits of it.

Medicaid Investigations

To guarantee quality health care services to the public, the Medicaid Fraud Control Unit conducts audits to ensure that service providers and recipients don’t defraud the system. The agency prosecutes private citizens and companies accused of Medicaid fraud and recovers stolen money. Medicaid allows individuals without the means to afford healthcare products and services. Recipients can find themselves under investigation for submitting false data on their applications. Medicaid eligibility has strict requirements, and some people offer false or inaccurate information to qualify.

Healthcare providers can find themselves dealing with Medicaid audits for prescribing unneeded services, ordering unnecessary tests, or overbilling services. Cases of fee-sharing among practitioners are also wildly common and therefore a big focus of these investigations.

Medicaid integrity contractors are responsible for conducting audits in instances where a service provider is accused of incorrect billing or other forms of fraud. Cooperating with the investigation is advisable but ensure that a legal professional is present to oversee the process. Before you can present all your documents to the MICs, consult one of our attorneys in Long Island regarding your rights.

Triggers of Medicaid Investigations and Audits

Medicaid recipients and providers should be knowledgeable about some of the reasons authorities may call for investigations. With this information, you can avoid getting into similar situations. One misconception is that Medicaid investigations and audits are a result of anonymous reports. However, in most cases, investigators may come calling because some discrepancy in the data triggered the computer system.

One example is when a Medicaid recipient fails to disclose accurate income when applying for benefits. If the Department of Labor has different information from what is stated in your application, the system that tracks unreported income will flag it. Another situation that can lead to a Medicaid fraud investigation is failing to report your spouse’s income because you are separated. Some of these mistakes occur unintentionally, but the investigators are not inclined to believe you. Therefore, before answering questions from a Medicaid investigator, call an attorney.

For service providers such as clinics, laboratories, and hospitals, Medicaid audits are largely triggered by incorrect billing. When the coding system detects discrepancies, the state sends in professionals like recovery audit contractors to figure out where the fraud is. The audit processes used by RACs vary widely, which means you can’t be sure what they will find. Note that some investigators get paid on a contingency basis meaning they are motivated to find proof of fraud.

Whether you are a recipient or service provider of Medicaid, always seek legal representation when accused of fraud. Even the most innocent mistake in the application or billing services can land you in jail or incur astronomical monetary penalties. Our Long Island Medicaid fraud lawyer should be with you from the beginning so don’t wait to call.