Medicaid is health insurance program provided by New York State for people who meed certain income and asset thresholds. In Brooklyn, Bronx, Queens, Staten Island and Manhattan there are facility enrollers who assist individuals and families with signing up for Medicaid. A facility enroller is a community agency that is trained to assist people with Access NY Health Care applications. The facility enroller is usually located centrally in the neighborhood and is staffed with agents who speak the local language. Further, they will have flexible hours and be open on nights and weekends.
Letter from Bureau of Fraud Investigation at Human Resource Administration
If you are the recipient of a target letter from an investigator at the Bureau of Fraud Investigators at the Human Resources Administration (“HRA”) for potential fraud this means that you have come on to one of the many Investigators radars for some reason. This could be for any of the following:
- Your name appears on the deed to real estate either in New York State or outside of New York State
- Your name appears on the title to a car or multiple cars
- Your children go to private school
- Your employer has reported your income that affects your eligibility
- You have bank accounts, stocks, bonds, 401K or other investment assets that affect your eligibility
- Another individual has reported you for fraud
If the case has started off at this level, the first letter that you will receive will be from the: Investigation Revenue and Enforcement Administration Bureau of Fraud Investigation either at the old office address: 250 Church Street, 3rd Floor New York, NY 10013 or from their new office address: 151 West Broadway, 7th Floor New York, NY 10013. The letter will state that Bureau of Fraud Investigation office is conducting an investigation into your eligibility for Medicaid and that an interview has been scheduled for you to come down to their offices to discuss this matter. The target letter fails to tell you that if at any point throughout their investigation it is apparent that there is criminal culpability they will likely refer the case out to the local District Attorneys office for prosecution or that if the civil liability is clear they might refer the case out to one of the law firms that represents the city in these matters. Recently, the firm of Leoopld Gross & Somers, P.C. at 16 Court Street has been handling the collection and litigation on the civil side for New York City.
Either way, whatever you say and do – will be held against you in court. The ideal situation for the HRA investigators is that you come down to the scheduled meeting, disclose all of your finances and provide them with all of the corroborating documentation to prove your ineligibility or worse that you intentionally committed fraud. Now, the investigators have leveraged the situation and they can demand an inordinate amount of money from you and leave you with few viable options.
The initial target letter itself itself will give you a good idea of the type of evidence that they already have against you and the stage of their investigation. Depending on the specific facts and circumstances of your case, the requested items will change. The target letter will generally ask for the some of the following documents when you come down for your interview.
- Photo ID, and a copy of the target letter
- Business bank book for the years under investigation
- Personal bank book for the years under investigation
- Drivers license
- Income tax documentation for the business for the years under investigation
- Income tax documentation for your personal returns for the years under investigation
- Last 4 pay-stubs
- Pension/401K/IRA Statements
- Utility bills
- Cell phone bills
- Business records
- Dissolution records
- All mortgage documents/applications for any properties
- Deed of any properties
- Letter certifying where your children attend school
- Marriage certificate/divorce papers
- Birth certificate for any children
- Vehicle registration/car payments/insurance
The issue with Medicaid fraud in New York is that often times applicants fail to realize that not only do you need to qualify when you initially applied, but you have an affirmative responsibility to update the appropriate agencies with any changes in your income and/or your assets. Every application you swear under penalty of perjury that your information is truthful and accurate. Often times, people forget that their income has gone up, or that they got married or any other factor that could effect their eligibility.
The Access NY Health Care application requests information for all members of the household. This includes the names and details of parents, step-parents and spouses. In a lot of cases, applicants will put a NYC address when they in fact live in New Jersey, or Long Island. In some cases, applicants put their NYC business address and they live elsewhere. The Access NY Health Care application also requires that the applicant detail the type of money and the amount received by all members of the household. Medicaid applicants are required to send in proof regarding their income. This is often where applicants get in trouble. Medicaid applicants under report their income, or have an individual state that they are an employee when they in fact own or operate the business. The Access NY Health Care application requires that applicants disclose all earnings from work such as wages, salaries, commissions, tips, overtime and money earned from self-employment. In addition, applicants must include “unearned income” such as social security benefits, disability payments, unemployment payments, interest and dividends, veterans benefits, workers compensation, child support payments/alimony, rental income, pension, annuities and trust income. The Access NY Health Care application requires details as to contributions such as money from relative or friends, roomers or boarders. This broad definition includes any money that was received to help meet living expenses. Lastly the application requires information regarding any temporary (cash) assistance, supplemental security income (SSI) payments, student loans or grants. If an applicants puts down that he or she and/or the household members have no income – then medicaid is going to want to know how you are living and supporting yourself. Are you living with friend or relatives? Did anyone recent quit their jobs? changed jobs? Is anyone a student in a vocational, undergraduate or graduate program? Are there child care expenses? What are your housing expenses? Is there rent, mortgage, and property taxes? Do you pay for water separately? The Access NY Health Care application requires that proof be sent in.
By signing the Access NY Health Care application you sign right under a disclaimer that states:
I understand this information is being shared for the purpose of determining the eligibility of those individuals applying for Medicaid, Family Health Plus, Child Health Plus, or to evaluate the success of those programs. Every applying adult must sign the application in the space below. By singing this application, I understand that each person applying for Medicaid, Family Health Plus, Child Health Plus, will be enrolled in the appropriate program if eligible. I have also read and understand the Terms, Rights and Responsibilities included in this application booklet on the next page. I certify under penalty of perjury that everything on this application is the truth as best I know.
The Terms, Rights and Responsibilities of the Access NY Health Care Application state:
I understand that workers from the programs for which family members or I have applied my check the information given by me for this application.
I understand that anyone who knowingly lies or hides the truth in order to receive services under these programs is committing a crime and subject to federal and state penalties and may have to repay the amount of benefit received any pay civil penalties. The New York State Department of Tax and Finance has the right to review income information on this form.
Often times during the investigation, the bureau of fraud investigations will send out a team to investigate an applicant. The investigators will go out and do surveillance of the applicants house, work and even the school the children attend to. In certain situations, the investigators will interview neighbors, friends and associates in attempt to build their case.
The goal of resolving the case with the Human Resources Administration (“HRA”) administratively at this level is that you avoid further scrutiny and prevent civil or criminal prosecution. A settlement agreement is a 1 (one) page document that the The New York City Human Resources Administration enters into with the client or clients. The settlement agree will state that HRA wishes to settle this matter under its expedite enforcement procedures in order to settle its investigation of clients subject to the following terms and conditions.
- HRA will certify that they are accepting a payment of a set amount as restitution for the over payment of medicaid benefits.
- The payment by the client is not an admission of wrongdoing
- HRA will release the clients from all claims and actions
- HRA will not refer the clients case out to any other third party government agencies
- HRA will not refer the clients family’s cases to any other third party government agencies
- No claims will arise out of the applications that the client filed
- No claims will arise out of the statements that the client made
Human Resources Administration and the Department of Social Services provides short term assistance to New Yorkers with social service and economic needs. This includes various benefits: temporary cash assistance, medicaid, family health plus, child care, food stamps, home care for disabled individuals, home care for senior citizens, protective services for adults, domestic violence support, child support enforcement, and assistance for those who have HIV/AIDS. The programs of HRA are designed to assist those who qualify.
The Investigation, Revenue and Enforcement Administration (“IREA”) is the division that is responsible for supporting HRA and making sure that there is public trust in the benefits system. The IREA is divided further into three separate agencies, with three distinct roles:
- The Office of Investigation
- The Office of Medicaid Provider Fraud and Abuse Investigation
- The Office of Revenue and Administration
If it could not get any complicated, each one of these divisions has separate subdivisions.
The Office of Investigation has three subdivisions
1. Bureau of Fraud Investigation (BFI). The BFI is required by law to conduct investigations of individuals and organized groups allegedly attempting or committing to commit fraud against the various social service programs administered by the Human Resources Administration. These investigations can lead to administrative disqualification hearings, civil litigation, and/or referrals for criminal prosecution.
It has recently come to our attention that an incorrect payment of Medicaid payments was made on your behalf under the above referenced case number. The claim amount of $_______________ was an incorrect payment due to the employment noted below. This income rendered you ineligible for Medicaid services. Accordingly, the agency must recover the cost of services paid in error.
- Is this amount correct?
- Does this amount include late fees, penalties, interest?
- Were there period I was eligible, and periods I wasn’t eligible?
- Does this claim amount cover me, my spouse, my children?
- What about the time period before this claim? Or after this claim? Does this settlement cover the full time period I recieved benefits?
- In the event that I pay this amount, what am I admitting to if anything?
- In the event that I refuse to pay what will the next steps be?
- How will this affect any professional licenses I have?
If any of the above concern you, feel free to call us at (212) 300-5196 for a free consultation to discuss your rights.
Download the 2013 NY Medicaid Income and Assets Levels. Each year the income and resources level are adjusted. Medicaid recipients can own a car, a home, and have personal property to be eligible. The issue with Medicaid fraud on the applicant side is the disclosure. Additionally, not only is the income and resources level for the applicants counted but the income and resources of any legally responsible adults. This is another area where the problem lies. Applicants are often confused as to what “resources” are for medicaid purposes. Under the Medicaid guidelines resources is cash or any assets that can easily be liquidated into cash. Generally this would be bank accounts, life insurance policies, stocks, bonds, mutual funds, promissory notes and real estate.
Family Health Plus Fraud
The NY Medicaid fraud lawyers at Spodek Law Group P.C. not only represent applicants for medicaid in fraud charges, civil and criminal prosecutions but we also represent individuals who are charged with defrauding Family Health Plus. Family Health Plus is a public health program for adults are between 19 and 64 years only and income is above the threshold for medicaid.
Child Health Plus Fraud
Children are under 19 years old, residents of NY State . Depending on what the families income and size is will depend on the premium they are required to pay for child health plus. The income is $9, $15, $30, $45, or $60 per child per month.
In addition to applicant fraud for Medicaid, Family Heath Plus and Child Health Plus applicants can commit frauds in other ways as well.
- Intentionally lying on your medicaid application regarding your income or assets
- Intentionally lying on your medicaid applications regarding your spouses income or assets
- Failure to report any material change in you or your spouses income during the fiscal year
- Obtaining prescription drugs via a valid medicaid card and then selling the drugs on the black market
- Loaning your medicaid card to a third party for them to receives medical services
- Illegally obtaining multiple medicaid cards, and using them for medical services
- Forging or altering a prescription
- Acting as runner on behalf of a clinic to obtain new medicaid patients
Provider Health Care Fraud
The NYC medicaid lawyer at Spodek Law Group P.C. also represent providers who are under investigation or being charged with medicaid fraud.
Billing for Services Not Rendered
A medical provider bills medicaid for services, treatment or procedure that was never done. This could be a doctors office billing for blood tests when no blood samples were actually draw. This could be a doctors office billing for x-rays when no x-rays were ever done. Dentists billing for dental fillings yet they were never done. Also, home health care is ripe with double billing.
Double billing occurs when a provider bills medicaid for services rendered, but also bills the patient directly and/or a third party insurance company for the same services. This also occurs when (2) providers bill for the same treatment that was performed on a patient on a certain date.
Substitution of Generic Drugs
A patient pays a premium for the brand name drug and a pharmacist provides generic drugs instead.
Billing for Unnecessary Services
A medical provider will create fake symptoms and provide a fake diagnosis in order to bill medicaid for unnecessary lab tests.
This is when a medical provider exaggerates the medical service provided. For example, a dentist sees a patient for a 15 minute meeting to see the progress of a root canal but charges for an hourly consultation for pain and discomfort that the patient is suffering. The Dentist has improperly billed for unnecessary charges by upcoding the charge.
A medical provider may conspire with another provider to give a kickback for a referral. The kickback can be in the form of money, gift, products or a cross referral.
This is when a medical provider breaks one medical event into separate components. This is done so that the medical provider can bill for unnecessary services.
This is when third parties sell their medicaid billing number to medical providers in order for them to bill for services that were not rendered.
Medicaid Fraud Control Unit
The MFCU is a division of the Attorney Generals Criminal Division that investigates and prosecutes New York State medicaid fraud cases. The MFCU focuses their investigations on medicaid frauds by hospitals, pharmacies, doctors, nurses, dentists and nursing home. Another target of the MFCU is organized crime medical mills.
New York State Office of the Inspector General
The New York State Office of the Inspector General is an independent entity created within the NYS Department of Heath.The entity is focused on combating fraud through various control activities for all of the state agencies that administer medicaid services.
Civil Lawsuit for Medicaid Fraud
In the event that you receive a target letter from Human Resources Administration and you either object or disregard the letter and there is no evidence of criminal culpability then you may be sued civilly. New York City hires various law firms in New York to bring civil suits to recover payment. Generally these are collection lawyers. Generally recipients will receive a boilerplate letter stating the following:
We are the attorneys for The City of New York. According to our clients records you received Medicaid Assistance to which you are not entitled. Therefore you are indebted to our client in the amount set forth above.
If you believe that you have a legal defense with respect to the debt or any portion thereof kindly contact the undersigned at once. Unless you notify this office within 30 days after receiving this notice that you dispute the debt or any portion thereof, we will assume the debt to be valid. If you notify us in writing within 30 days that the debt or any portion of the debt is disputed we will obtain verification of the debt or a copy of the Judgement and mail it to you.
In the event that you don’t move to validate the debt and you don’t answer the letter and surrender yourself to their demands you will likely be the subject of a civil lawsuit. You will be served with a Summons and a Verified Complaint. The Complaint will state the following:
- Plaintiff; The Commissioner of the Department of Social Services was and still is a municipal corporation with their principle place of business in the County, State and City of New York
- The Defendant resides in ______________ County
- That on or about a certain date that defendant was the recipients of Medicaid Assistance in the amount of $_____________.
- That Defendant was not entitled to receive Medicaid Assistance
- Demand for repayment was denied
If you receive a Verified Complaint you must immediately prepare and serve a Answer. This is done to avoid a default. You must also consider your options. In any lawsuit both sides are paying legal fees to litigate. How does this affect your ability to negotiate? How does this firm get paid? Is it a percentage of the amount collected? What evidence do they have against you? What happens if instead of you being on the defensive, you become offensive. You aggressively serve discovery and demand all documentation. You serve Notice to Admit and Interrogatories. You service Notice to Take Depositions. How will this change your position?
We have been assisting people going through Medicaid Fraud Investigations for over 36 years. Let our years of experience work towards your advantage. Call us at (212) 300-5196.
The NYC Medicaid Fraud Lawyers at Spodek Law Group P.C. are available 24/7 at (212) 300-5196.
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