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NYC Medicaid Fraud Lawyer | Medicaid Fraud Attorney NYC

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 law24/7

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. Our NY medicaid fraud law firm can help ensure you don’t make any harmful statements. 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. If you work with us, our NYC medicaid fraud lawyers can help you during the 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.

NYC Medicaid Fraud Attorneys – 24/7 Help

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. Our NYC medicaid fraud lawyers can help prevent the investigators from overstepping and overreaching.

NYC Medicaid Fraud Lawyer

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.

Division of Claims and Collections

The Division of Claims and Collections is a revenue division within the HRA’s Investigation, Revenue and Enforcement division. The Division of Claims and Collections pursues the collection of money and monitors the repayment of money owed by the current and former HRA claimants who received benefits that they are now repaying. This could be cash assistance or medicaid.

The Division of Claims and Collections is located on the 12th Floor of 250 Church Street. They often send out target letters with the case number on the top right side. The letter will stat the following:
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.

Next, it will likely list the employer, that dates the claimant was initially employed and how much the claim amount is. The recipient of this type target letter must consider a few things:

  • 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?

The Human Resources Administration (“HRA”) will usually include an Agreement of Voluntary Repayment form (CC-112) and request that you either pay a lump sum or make monthly installment payments. If you are to repay it monthly, they will give you 12 month’s to repay the full amount. In the event that you are over 30 days late with any payments HRA reserves the right to initiate court action.

The target letter fails to mention that assigned HRA Investigator has the authority to work out the details of the monthly payment plan with the claimant. Depending on the facts and circumstances of your particular case you might be able to present mitigating factors which could reduce your liability or cancel any liability.

The Division of Claims and Collections will only accept a personal check, a cashiers check, a certified check or a money order. Checks or money orders should be made payable to Human Resources Administration and mailed to the following address:

New York City Human Resources Administration
Division of Claims and Collections
P.O. Box 414312
Boston, MA 02241-4312

A recipient of a target letter from the Division of Claims and Collections must be careful how they proceed upon receipt of this letter. There is a value to money in hand today, rather then money possibly in the future. Further, it is possible that their investigation was limited to a certain time period and that as their investigation continues further fraud could be recovered. Our NYC medicaid fraud lawyers can help investigate and understand all components of this.

Installment Note Financial Maintenance Form

NYC Medicaid Fraud Lawyer

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 our NYC medicaid fraud attorneys 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. Often, our NYC medicaid fraud lawyers see this as a possible fraud issue.

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. Here are some ways our NYC medicaid fraud lawyers have seen in the past.

  • 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 attorneys 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. Our New York medicaid fraud lawyers can help with all of these types of fraud.

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.

Upcoding

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.

Kickbacks

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. Our NYC medicaid fraud lawyers have experience handling kickback cases.

Unbundling

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. Our NY medicaid fraud law firm knows how to handle these cases.

Identify Theft

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. Our NYC medicaid fraud attorneys understand how to handle these cases.

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.

Civil Lawsuit for Medicaid Fraud – Our NYC Medicaid Fraud Lawyers Can Help

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.

Our NYC medicaid fraud lawyers are always available to help answer any questions you may have. Based out of New York, our medicaid fraud attorneys understand how to win tough cases.

What you should expect when trying to resolve a case with the HRA

Settlement Agreement
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

What is the 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.

Medicaid fraud in the United States is a serious crime. It is estimated that Medicaid fraud costs a massive $140 billion each year in the United States. That is money that comes directly out of the taxpayer’s pocket and accounts for a significant portion of the entire national budget.

For this reason, the pressure has been on state and federal governments to crack down on the waste cause by this out-of-control form of fraud. In the state of New York, medicaid fraud investigations are handled by the Human Resources Administration, which has been given broad latitude and a hefty budget to go after the worst cases of Medicaid fraud in the state. If you find yourself in the sites of Medicaid fraud investigators, it is imperative that you contact a competent law firm as quickly as possible. Medicaid fraud cases are often extremely complex. You need someone on your side with the knowledge, skill and experience to ensure that your case has the best possible outcome.

If you receive a letter from the Human Resources Administration, you’re under investigation

If you live in the state of New York and you receive a letter from the Human Resource Administration, make no mistake, you are under suspicion of having committed Medicaid fraud. Although these letters are often worded in banal-sounding language, once the letter is sent, it is a strong indication that you are already under investigation by an agent, and they have likely already spent a good deal of time amassing evidence against you. In short, if you are summoned to a so-called interview with the Human Resource Administration, one of its investigators strongly believes that you have committed fraud.

You are not required to go to the interview

It is important to know that, should you receive a letter requesting that you show up for an interview, you are not legally required to do so. You should instead immediately contact a competent lawyer and have them handle any interaction with the investigators.

There are many resources available on why you should never talk to the police without a lawyer present. In the case of talking to Medicaid fraud investigators, it is no different. There are three main reasons why you should not talk to fraud investigators or any other people in authority once you have been targeted for investigation in Medicaid fraud. Remember, once you receive a letter from the Human Resource Administration, no matter how nicely it’s worded, you are under investigation for fraud, and an agent does believe that you have committed a serious crime.

Let’s look at why you should not talk to the investigator or police without a competent lawyer present.

  • They are deliberately trying to trap you. The investigators for the HRA are trained professionals who already believe that you have committed a crime. They will use tricks to get you to contradict yourself and admit things that you otherwise may not have admitted to. They will use everything you say against you and, because you are not under arrest, they are not required to inform you that the real purpose of the meeting is to gather self-incriminating information.
  • Talking to investigators never helps you. In certain situations it may become necessary to talk to investigators. But these situations should be handled by your lawyer, who has thousands of hours of experience dealing with the process. If you are getting requests for interviews with investigators, they have found evidence against you already. Engaging with them, without the help of an attorney, has no upside potential at all but many serious risks.
  • You can’t beat investigators at their own game. HRA investigators are highly trained professionals working on teams that have hundreds of years of collective experience. There is no way you can outsmart them. The best you can do is to put on a good defense.

The stakes are high

Medicaid fraud is a serious crime. In New York State, the maximum penalties may be up to 25 years in prison. Most cases, especially those involving recipients, are much less serious and involve mitigating factors, such as innocent mistakes being made on forms or the inability of the recipient to understand the complex maze of laws that governs their eligibility for benefits. However, Medicaid fraud is still a serious crime that can result in hefty fines and jail time.

If you have been formally accused of Medicaid fraud or find yourself under investigation, it is absolutely crucial that you hire a good lawyer who specializes in Medicaid fraud. Medicaid fraud cases can often be successfully negotiated and jail time avoided. This is particularly true of those who do not have extensive criminal histories.

Medicaid Fraud Investigation Process and Medicaid Fraud Penalties

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.

Who Investigates Medicaid Fraud

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.

What Can Set Off Investigation

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.

Stages of Medicaid Fraud Investigation

Whatever are the reason and the cause of the investigation and whoever is in charge of it, they all start in a similar way.

  1. After receiving a lead, the agency allocates a team of agents to it and charges them with collecting the necessary evidence to prove that fraud took place. To achieve that, if the target is a provider, the agents may obtain data about the health care company’s financial transactions, come to the organization to ask its employees some questions, contact its patients, etc. If it is a recipient who is the subject of the investigation, then the investigators may get in touch with the person’s current and former employers and co-workers, keep a close watch on their place of residence to find out who is living with them, obtain financial information from banks about the person’s accounts, loans, mortgages, etc. In many cases, this phase of the investigative process does not require any participation of the targeted person or organization. Moreover, commonly the agents will do their best to make their presence unnoticed in order not to scare off the target.
  2. The next stage is contact with the targeted person or organization. As you see, by this time the agents most surely have already gathered enough information to bring the case against the person or company. Why do they still need to approach the recipient or the provider, you may ask. The answer is that the investigators may simply lack some document proof of the target’s guilt or they need some additional evidence – preferably the person’s own statements proving they are on the right track. They may send the person a letter to invite them to an interview and bring along some documents. They also have the right to issue subpoenas.
  3. Having gathered all the necessary information, the agency can now decide whether to drop or dismiss the case or to pass it on for further criminal proceedings. If the case is referred to court for prosecution, the person faces harsh administrative, civil and criminal penalties.

Consequences of Medicaid Fraud

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.

What to Do If Charged with Fraud

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:

  • Politely ask for a business card and tell the agents your legal counsel will get back to them shortly.
  • Don’t engage in any chit chats or conversations with the agents, whether on unrelated topics or about the case.
  • Don’t let the investigators in your apartment or office unless they have a warrant. Don’t give them any records or documents if they don’t have a subpoena. If they do, have your legal counsel check whether it is in order.
  • Immediately after the agents go, call a Medicaid fraud attorney to consult about the situation.

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