A lot of NYC residents receive health care through the Medicaid program. By its nature, it is a complex mechanism that is hard to ensure and track compliance with, which results in billions of dollars wasted. To minimize this sum and recover at least some of it into the local and federal treasuries, the government sends its investigators to look into alleged Medicaid fraud. In this article, our lawyers explain how such investigations are carried out and what are their consequences.
There are several federal and state-level authorities charged with investigating into Medicaid fraud. And since most of the program’s expenses lie on the shoulders of state rather than the federal government, state authorities are becoming more active when fighting Medicaid fraud. Surely, New York State is no exception. Here, such investigations are handled by District Attorneys, the OMIG agents and MFCUs. Investigations into suspected recipient fraud are carried out by the Human Resources Administration.
There are a number of things that can trigger provider fraud investigations. Most commonly, it is upcoding and billing for services not provided. An agency may be routinely auditing an organization when it finds some discrepancy that may imply fraud and then it decides to investigate into it. Another reason is a whistleblower report which may be filed by a patient, the organization’s employee or just an outsider.
As for recipients, it turns out that a large share of them do not qualify for Medicaid for one reason or another. Two most common reasons for that are unreported income and residency discrepancy. Again, it may be a whistleblower who tips off that a Medicaid beneficiary has committed fraud, but this is very uncommon. Nowadays, state and federal agencies employ many analytical tools that allow its agents to sift through vasts amounts of data in a blink of an eye, detecting potential fraud cases that are worth looking into more carefully. The data may be property and car registrations, tax return information, business records, etc. The investigators may always use dedicated software to find unusual patterns in a provider’s coding practices.
Whatever are the reason and the cause of the investigation and whoever is in charge of it, they all start in a similar way.
People and organizations accused of Medicaid fraud may be sentenced on charges of grand larceny, welfare fraud, forgery, etc. Penalties include massive fines, jail time, probation, community service, conditional discharge. If the person can afford to pay restitution, the situation is much better, since it allows minimizing penalties. Nevertheless, a conviction means a permanent criminal record, which may influence the life of the person may years after the sentence is served.
Other consequences include a high probability that the person will lose access to public health care benefits (or the right to provide them) either for a very long period of time or permanently. Moreover, the provider may face medical license suspension or complete loss. Even if the person or organization accused of Medicaid fraud manages to avoid program exclusion and or license loss, chances are big that the public finds out about the case and the reputation will be hampered forever.
Besides that, permanent residents may lose their status and appear in jeopardy of deportation.
If you happen to face such a situation, knowing your rights can save you money, career and even freedom. The first thing you should know is that as either a Medicaid provider or a recipient, you have all chances to get audited or investigated one day. No one can be sure that this won’t ever happen to them. So stay alert for any signs that an investigation is underway. For example, your boss or colleague or a neighbor may tell you that someone has approached them and asked about you, and this isn’t something to be ignored. This is an opportunity for you to intervene early and hire a Medicaid fraud lawyer to handle the situation on your behalf.
When the agents approach you to either simply talk and pass you an interview letter, you should know that you are not obliged to talk to them. And don’t fall into the trap of thinking that this is not a big deal or that it’s not you who is targeted. The investigators are not here to work out a misunderstanding with you, they want to find proof that you are guilty.
Follow these guidelines to protect yourself:
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