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NYC Medicaid Fraud Lawyers

new york medicaid fraud criminal lawyers

The Medicaid program is intended to provide medical care to those with low incomes. Misuse of this program is considered Medicaid fraud, and in New York, that would fall under the category of welfare fraud. If you’re being accused of Medicaid fraud, here’s what you need to know.

What Is Medicaid Fraud?

A simple definition of Medicaid fraud is that it’s any use of false information to receive Medicaid benefits. The most obvious examples of this would be providing false information when applying for Medicaid in order to qualify for benefits.

George FernandezGeorge Fernandez
14:16 30 Apr 24
Excellent 10 out of 10, Helped resolve my case. Jeremy explained everything and made everything easy to understand.
21:33 24 Apr 24
If you are looking for a lawyer that listens, is aggressive where needed, and holds his word above all else, Todd is the best pick. I had hired multiple attorneys prior to hiring the Spodek Group for a white collar case. The first thing that stood out to me was the cost, as anyone going through the process and dealing with the system, money was tight at that time - especially after hiring and firing multiple lawyers. The cost was not as high as others which was definitely a plus. Todd's intake process was also unlike other attorneys. He took the time to actually listen. He cared. He was trying to put himself in my shoes while I was explaining the situation to him and he really took the time to understand the whole situation. Other lawyers will give you 15 mins and send you a retainer agreement. Not Todd, I think he spent almost two hours with me as I was explaining everything.Not only was he great during the onboarding process, he was supportive and very informative through the entire plea process and eventually sentencing. After hiring him, I asked if I should hire a prison consultant, he told me to save my money as he would do everything they would. He was right and held up to his word. Later on I would hear from others that went with the prison consultants that they were a waste of money - I am glad I listened to Todd!When it came time for sentencing, two days prior to sentencing, the prosecutor tried increasing my proposed prison time by almost double - apparently a normal move. Todd and his team worked with me non-stop through the weekend prior to sentencing to ensure that I was not given additional prison time. Again, he took the time to listen and came up with a strategy to explain the case with great detail.Unfortunately, I did plead guilty as that was my best option. Todd and his whole team wrote up nearly 300 pages of a summary of what happened and why I should not be given prison time. If I breakdown the amount I spent with Todd versus the amount of work that I saw being done, I am shocked I was not charged four times as much. The other benefit was, a lot of criminal defense lawyers were just a single attorney with a paralegal or two. Todd had a team of people that I dealt with (5-7 people that I interacted with), but he was ALWAYS accessible. It would never take him more than an hour to reply unless he was in court.I was sentenced to prison and I was emotionally distraught. Todd and his team did whatever they could even after sentencing to make sure I was alright. He personally stayed in touch with my family to ensure I was doing alright and offered support to them. Most lawyers would consider the job complete at sentencing, not Todd.After prison, Todd still spent time with me to make sure I was on the right track and avoiding any potential risks in the future. He has also been giving advice on how to navigate probation etc and has not been looking at the clock for billing.Although I wish I had never been arrested in the first place, I am glad I had Todd and his team in my corner. Without them I likely would have had to spend a lot more time in prison than I did.Thank you, Todd, and the entire Spodek Law team, for helping turn what was a nightmare into a manageable situation!
Yelva Saint-PreuxYelva Saint-Preux
19:26 19 Apr 24
I am immensely grateful to the entire team at Spodek Law Group for their unwavering dedication and exceptional expertise throughout my case. From our initial consultation to the final resolution, their professionalism and tireless advocacy made all the difference. Their strategic approach and attention to detail instilled confidence in me every step of the way.Thanks to their hard work and commitment, we achieved a truly favorable outcome that exceeded my expectations. Not only did they navigate the complexities of my case with precision, but they also provided invaluable support and guidance during what was undoubtedly a challenging time. I cannot recommend Spodek Law Group highly enough, especially attorneys Todd Spodek and Claire Banks; they are beacons of excellence in the legal profession.YSP.
Katherine SunKatherine Sun
18:08 18 Apr 24
my lawyer is Alex Zhik. Efficient, patient and professional
Nun yaNun ya
17:48 18 Apr 24
Todd, Ralph and Alex are amazing. Helped my husband get from a double digit number with multiple charges to a single digit, by the time I blink he will be out. They very professional and help with all your needs. They dealt with my anxiety and worry very well and they understand that your family member needs to get home as soon as possible.
Keisha ParrisKeisha Parris
20:45 15 Mar 24
Believe every single review here about Alex Z!! From our initial consultation, it was evident that Alex possessed a profound understanding of criminal law and a fierce dedication to his clients rights. Throughout the entirety of my case, Alex exhibited unparalleled professionalism and unwavering commitment. What sets Alex apart is not only his legal expertise but also his genuine compassion for his clients. He took the time to thoroughly explain my case, alleviating any concerns I had along the way. His exact words were “I’m not worried about it”. His unwavering support and guidance were invaluable throughout the entire process. I am immensely grateful for Alex's exceptional legal representation and wholeheartedly recommend his services to anyone in need of a skilled criminal defense attorney. Alex Z is not just a lawyer; he is a beacon of hope for those navigating the complexities of the legal system. If you find yourself in need of a dedicated and competent legal advocate, look no further than Alex Z.
Taïko BeautyTaïko Beauty
16:26 15 Mar 24
I don’t know where to start, I can write a novel about this firm, but one thing I will say is that having my best interest was their main priority since the beginning of my case which was back in Winter 2019. Miss Claire Banks, one of the best Attorneys in the firm represented me very well and was very professional, respectful, and truthful. Not once did she leave me in the dark, in fact she presented all options and routes that could possibly be considered for my case and she reinsured me that no matter what I decided to do, her and the team will have my back and that’s exactly what happened. Not only will I be liberated from this case, also, I will enjoy my freedom and continue to be a mother to my first born son and will have no restrictions with accomplishing my goals in life. Now that’s what I call victory!! I thank the Lord, My mother, Claire, and the Spodek team for standing by me and fighting with me. Words can’t describe how grateful I am to have the opportunity to work with this team. I’m very satisfied, very pleased with their performance, their hard work, and their diligence.Thank you team!
K MarK Mar
01:37 25 Jan 24
I recently had Spodek Law Group represent me for a legal matter in NYC and I am thoroughly impressed with their services.Alex Zhik secured the best possible outcome for my case.It was a seamless journey from the initial consultation to the resolution of my legal matter. From the moment I spoke to Todd about my case, his enthusiasm to help was evident, setting a positive tone for the entire experience. The efficiency and professionalism displayed by the team is commendable.A particularly noteworthy aspect of their service is their user-friendly portal to upload your documents/evidence. This not only simplified the process, but showcases their commitment to streamline the client experience.Lastly, in an industry where legal fees can often be a concern, I found their pricing to be very reasonable, making needing legal assistance feel accessible and stress-free.I am grateful for their support and wouldn't hesitate to turn to them again in the future.

For example, if you have multiple sources of income but you only list one on your Medicaid application, that would be Medicaid fraud, because you’re providing a lower income to meet the low-income threshold. Another common example of Medicaid fraud is failing to disclose certain assets, such as real estate, on the application.

Even if you provide accurate information on the Medicaid application, you could still commit Medicaid fraud if your situation changes and you don’t update your information with Medicaid. When you apply, you must agree that you’ll notify Medicaid of these changes. Potential changes Medicaid must know about includes a change in income or with your living situation. It’s easy to forget to do this, but it’s your responsibility when you’re receiving Medicaid benefits.

Possible Penalties for Medicaid Fraud

As mentioned, Medicaid fraud is a type of welfare fraud. There are multiple degrees of welfare fraud. Here is each offense and its class:
• Welfare fraud in the fifth degree is a class A misdemeanor
• Welfare fraud in the fourth degree is a class E felony
• Welfare fraud in the third degree is a class D felony
• Welfare fraud in the second degree is a class C felony
• Welfare fraud in the first degree is a class B felony

The degree of the fraud will depend on how much you fraudulently obtained in terms of benefits. Welfare fraud in the fifth degree applies if you fraudulently obtained Medicaid benefits for up to $1,000, whereas welfare fraud in the first degree would require that you fraudulently obtained Medicaid benefits for over $1 million.

Penalties obviously become more severe as the offense class increases. Any of the five degrees of welfare fraud can include jailtime and fines, and you could be barred from receiving any Medicaid benefits in the future. Jailtime is rare with cases of Medicaid fraud, especially when you have a skilled New York Medicaid fraud criminal lawyer to prepare your defense and possibly negotiate a plea deal for a lower class of fraud.

Potential Legal Mitigating Factors

Just because you’re being accused of Medicaid fraud doesn’t necessarily mean the fraud investigation unit has an airtight case against you. Medicaid fraud investigation often starts with a tip, as whistleblowers can receive financial compensation for tipping off investigators. This desire for a reward can lead to tips implicating people who actually haven’t committed any sort of fraud.

The best defense to allegations of Medicaid fraud is having proof that all the information provided on your application was and remains accurate. If there are any inaccuracies, proving that this wasn’t intentional could make all the difference. It’s only fraud if you intentionally used false information to obtain benefits. An honest mistake wouldn’t qualify, although you would need to be able to prove this.

Defending Yourself Against Charges of Medicaid Fraud

The most common way for a Medicaid fraud case to begin is with a letter from New York’s Fraud Investigation office. This letter will request that you come to an office to talk to investigators about the charges, and it may also request that you bring certain documents with you.

Your best bet is to contact a New York Medicaid fraud criminal lawyer as soon as you receive this letter. The fraud investigators are hoping that you come to the meeting alone, provide all the documents they wanted and answer all their questions. This is ideal for them, but not for your defense, because they will hold all the cards.

When you consult with a lawyer, your lawyer can go over the evidence against you and advise you on what to do going forward. They can go to the meeting with you, let you know what documents to bring, and tell you what questions you should and shouldn’t answer.

Depending on the circumstances of your case, your lawyer may feel that there’s insufficient evidence against you or that the fraud investigators could have a valid case. In the latter scenario, your lawyer can attempt to negotiate a favorable agreement for you. It may be possible for you to simply pay a settlement amount as restitution and close the matter without admitting any guilt.

Defrauding Medicaid services is a serious offense that could land you in prison. You will know that you are under investigation when you receive a letter from your local Department of Human Services stating so. Many people who receive this letter do one of two things, both equally incriminating: ignore the letter or go to the hearing without legal representation and say things that can be used against them. These are serious mistakes that can land you in hot water. If you receive notification that you are under investigation for Medicaid fraud, you should seek out legal representation as quickly as possible.

Never go into a situation like this alone. Federal investigators mean business. You could find yourself having to surrender to authorities. You need to find an attorney well before this situation occurs. A legal defense team can look over your case and offer you the proper defense.

If you are charged with Medicaid fraud as a recipient, it is usually due to the following:

  • Misrepresenting the family’s household income on application for services.
  • Not disclosing the income of all family members.
  • Allowing others to use your Medicaid services.
  • Receiving benefits from New York while living in another place.
  • Reselling services received through Medicaid.
  • Changing or forging prescriptions.

These are all very serious offenses. Most Medicaid benefit charges in New York are due to income discrepancies. Individuals don’t understand the serious ramifications this type of fraud. Not only can it cost you personally, it puts a strain on the Medicaid system. Each year, the Medicaid program is defrauded of millions of dollars. The trickle-down effect is that honest people who really need the services won’t receive everything they need.

Their are instances when honest mistakes can happen. Sometimes there can be small discrepancies that can be explained. Medicaid recipients should have accurate record-keeping. This includes check stubs, bills and other items that can help your case. Never attempt to answer to charges alone. If you have been charged with Medicaid benefits fraud, you should seek out an attorney with a solid background. This is your first line of defense.

Unfortunately, there are also cases where individuals who are not native to the U.S. get taken advantage of by unscrupulous people. If English is not your first language, this is something that can happen very easily. When you go to court, you will need a good advocate to fight for your rights. The federal government is very aggressive when handling benefit fraud cases. There is often a rush to judgement, even in cases where honest mistakes were made.

Individuals who receive Medicaid are advised of the facts when they apply. Case workers are required to explain the ramifications of benefits fraud. Despite this, some individuals still believe they are able to beat the system. Sadly, many find out sooner or later that fraud will eventually be discovered. Regardless of the situation, the ramifications can be severe. If you are convicted of Medicaid fraud, you will be suspended from the program. Depending on the severity of the fraud, you will face hefty fines and jail time. And regardless of your economic status over the years, you will likely never be able to receive Medicaid benefits again. This is why individuals should always trust the advice of a seasoned New York City attorney.

Going to court when you are under investigation can be a very scary experience. Federal prosecutors will likely have a long list of individuals testifying against you. Don’t despair. Your Medicaid fraud attorney knows every trick of the trade. They have likely defended hundreds of individuals against similar charges, so they know the ends and outs.

Your Medicaid fraud defense attorney will already have a plan mapped out to offer you the best defense possible. In most cases, a person never intends to violate the Medicaid laws. A skilled attorney can prove to the court that you committed an honest mistake.

If you live in New York City and need a Medicaid fraud attorney, call for legal representation now. In most cases, the consultation is free of charge. Do not risk your future. Let an attorney help you today.

Each year in New York State, thousands of people are investigated for potential Medicaid fraud. This process can often cause serious interruptions to the lives of those being investigated. It can be a scary process, with the prospects of jail or prison time looming over the heads of everyone who is forced to comply with such investigations.

The recent uptick in Medicaid fraud investigations has been a response to a surge in Medicaid fraud, not just in the state of New York, but throughout the entire country. It is estimated that in the United States, Medicaid fraud is responsible for more than $140 billion each year in losses. This makes it a major source of losses to the healthcare system and an epidemic problem. As a result, the heat is being turned up on those who even appear as if they may be skirting the rules of the Medicaid system.

One result of this has been an explosion in the number of cases that the court systems across the country process. Unfortunately, people who had no real intention of doing anything wrong often end up caught in the wide net that is cast by these sustained governmental efforts to stomp out Medicaid fraud wherever it is found.

Regardless of whether or not you have actually committed a crime relating to Medicaid fraud, the single most important thing you can do, should you find yourself the target of a Medicaid fraud investigation, is to put yourself in contact with a qualified and experienced lawyer. Hiring the right lawyer can make the difference between prison time and having the case against you dismissed.

The Human Resources Agency investigates all cases of potential Medicaid fraud

That’s right, the same agency that handled such things as distributing food stamps and providing babies with enough food to get by is also in charge of investigating major cases of Medicaid fraud. This is almost unique among criminal investigations in New York State, as nearly all crimes are investigated by sworn law enforcement officers. However, if you are the target of a Medicaid fraud investigation, the first clue you will get that you are under watch will likely be a bureaucratic-sounding letter on disarmingly plain HRA letterhead.

Don’t let that fool you. If you have gotten a request from the Human Resources Administration to come in for an interview regarding Medicaid benefits, you are currently being investigated for serious Medicaid fraud. This means that the investigators have probably spent tens of hours and have accumulated a great deal of potential evidence against you. They know far more about you and your case than they will let on.

Furthermore, these investigators, while not sworn detectives, might as well be. They are trained in eliciting incriminating responses from suspects and have collectively spent hundreds of man-years handling thousands of fraud cases. You do not stand a chance against these professionals and should hire a lawyer at once.

Usually, you are not under any legal obligation to cooperate with these HRA investigators. Not doing so may result in charges being brought against you faster. But if you’re already under investigation and it’s reached the point where you are being solicited for an interview, the chances are high that they would have brought charges anyway. The upside to attending such an interview is virtually zero, while the risks are enormous. The only move you should consider is getting a competent lawyer on your side as soon as possible.

Don’t give the investigators or prosecutors the rope to hang you

For the same reason you should not talk to police without a lawyer, you should never talk to an HRA investigator by yourself. But if you follow this simple advice and hire a good lawyer as early in the process as possible, the chances that your case will have a favorable outcome are very good.

This is because, without self-incriminating statements and outright confessions, Medicaid fraud cases can be extremely difficult to prove. This not only means that you will have a better chance at trial and will often get a lighter sentence due to mitigating factors, it also means that prosecutors will think long and hard about wasting hundreds of man-hours and thousands of dollars taking a case to court that they will be very likely to lose in the end. This is where a good lawyer can really pay off. The mere presence of a solid attorney who specializes in cases of Medicaid fraud is often enough for a prosecutor to decide not to take the case to trial, at almost any cost. This can give rise to particularly good plea bargaining opportunities, usually involving no jail time or community service and much reduced restitution amounts.

By following these simple pieces of advice, your Medicaid fraud case can almost always be resolved in a way that doesn’t involve crushing restitution or any jail time.

Each year in the United States, more than $140 billion is lost to Medicaid fraud. This problem has only grown worse over the last few decades. As a result, state and federal agencies have grown more zealous than ever in their effort to stomp out cases of fraud wherever they are found.

This means that more cases than ever before are being prosecuted, and more people than ever before are being accused of Medicaid fraud, potentially facing life-altering criminal convictions, huge restitution and fine amount and even the prospect of spending years in prison. If you ever find yourself the object of a Medicaid fraud investigation, the most important move you can make is to quickly hire an experienced and knowledgeable attorney. While Medicaid fraud is a serious crime, it is often one of the most highly defensible types of cases that lawyers handle. Getting a competent lawyer on your side early in the fight can make the difference between prison time and a dismissal of your case.

In New York State, Medicaid fraud is investigated by the Human Resources Administration

Unlike many other forms of crime, Medicaid fraud, at least in New York State, is investigated by a civilian agency, the Human Resources Administration, not the police. However, this does not indicate that being targeted for investigation by this agency is not serious. On the contrary, many cases of Medicaid fraud result in the perpetrators being sentenced to prison and having to pay hefty fines and restitution.

If you receive a letter from the Human Resources Administration regarding your Medicaid eligibility, it is highly likely that you have become the target of an investigation. In our experience, if you have received a letter from the HRA requesting that you come in for an interview, it is nearly certain that you are under investigation for serious Medicaid fraud. This means that the investigators will likely already have compiled significant evidence against you. It is imperative that, if you receive a request for an interview, you should immediately contact a qualified and experienced lawyer to help guide you through the investigatory process. Failing to get a lawyer at this crucial stage will almost certainly result in far worse outcomes than would have otherwise been possible, had you quickly hired a lawyer in the first place.

With qualified counsel, you can often get a significantly reduced sentence

The above considerations should not get you down. Medicaid fraud is a crime that is uniquely prone to being negotiated down to lesser offenses and relatively lenient sentences. But it is crucial that you contact an experienced lawyer who knows how to maximize your chances of a favorable outcome.

In cases of Medicaid fraud, there are often many potential mitigating circumstances. Because Medicaid fraud is usually treated as a criminal matter, rather than a civilian one, the prosecution often has a high bar of proof that they need to meet at trial. Simple oversights, such as the misreporting of income or failure to notify of new employer benefits may have no element of criminal intent. Even in cases where there may have been an intent to defraud, the prosecutor will often have a very difficult time showing that to be the case.

Many actions that may lead to a Medicaid fraud investigation can be easily explained away as simple oversights or accidents. Yet, in other cases, it may be possible to defend against accusations of fraud by demonstrating that the defendant simply could not or did not understand the often highly complex rules, regulations and laws that dictate benefits eligibility. These are just a few of the mitigating factors that may make the difference between a long sentence and a case dismissal.

But only a competent lawyer will be able to give you the best possible defense by making use of all mitigating factors that may apply to your case.

Medicaid fraud cases are particularly hard on the court system

Medicaid fraud cases are also unique because they carry specific collateral consequences for those convicted. For example, someone who has been convicted of Medicaid fraud in one state, even if the case was a mere misdemeanor, may not be able to ever work in the healthcare field in most other states. This is a severely harsh punishment for what oftentimes ends up being little more than a thousand-dollar oversight.

Because of the severe penalties associated with pleading guilty to Medicaid fraud crimes, proportionally, far more defendants accused of Medicaid fraud will go to trial than for other crimes. This leads to a strain on the court system. As a result, Medicaid fraud is one of the crime categories that is most frequently pleaded down to a lesser offense. Because of the unwillingness of prosecutors to take these cases to trial, a good lawyer can very often arrange a favorable plea bargain.

Fraud, waste, and abuse of Medicaid costs the state billions of dollars annually. Fraudulent practices not only increase Medicaid costs, they also increase potential harm to patients exposed to inappropriate procedures. According to the Government Accountability Office, in 2015, improper payments for non-covered services, or services that were billed but not provided amounted to $29 billion.

What is Medicaid Fraud?

Medicaid fraud refers to the misuse of Medicaid benefits and funds. This can be done by either the medical facility or the patient. There are a variety of actions that amount to Medicaid fraud.

For providers, typical fraudulent actions include:

  • Falsifying claims: billing Medicaid for unnecessary equipment or services that have not been performed
  • Phantom billing: billing Medicaid for a doctor’s visit that never took place
  • Double billing: billing the patient and Medicaid
  • Drug substitution: providing patients with a generic drug but billing Medicaid for a brand name drug
  • Unbundling: billing services separately instead of combining them into one bill.
  • Falsifying expense reports: compiling an expense report that features expenses that are not related to Medicaid claims
  • Upbilling: billing for a service that is more expensive than the one deliveredFor patients, typical fraudulent actions include:
  • Giving a non-Medicaid participant their Medicaid card so they can get benefits
  • Failing to report about their source of income
  • Failing to return Medicaid benefits when a health insurance plan provides coverage

Laws Associated With Medicaid Fraud

According to OIG, the basic federal fraud and abuse laws that apply to physicians include: The False Claims Act; The Stark Law; Anti-Kickback Statute; and Civil Monetary Penalties Law.

False Claims Act:Submitting false statements knowingly or misrepresentation of facts for the purpose of obtaining federal health care payment that a health care provider should not receive amounts to false claims.
Stark Law: Making referrals for certain health services to an organization in which the practitioner’s immediate family owns or has a financial interest is covered by the Stark law. A typical example is a situation where a physician refers business to a clinic that his relative owns.
Anti-Kickback Statute:Knowingly paying, soliciting, or accepting any kind of payment to induce or reward referrals for products or services that are reimbursed by health care programs. A typical example is an arrangement which is not catered for by regulatory safe harbors and where money or other kinds of benefits are exchanged for referrals.
Civil Monetary Penalties Law: A typical example of civil monetary penalties is knowingly presenting a claim for a service or item that is false and fraudulent, or that is not covered by Medicare, or that violates the Anti-Kickback Statute.The government can subject a person or institution to a penalty of up to $50,000 for every false claim plus three times the amount claimed for every service or item.

How To Report Medicaid Fraud

Medicaid has an incentive reward program that aims to encourage people to report Medicaid fraud. According to medicare.gov, you stand to gain up to $1,000 if :

  • You report a suspected case of Medicare fraud.
  • The Medicare fraud is acknowledged as potential fraud by a recognized authority such as the Medicare Drug Integrity Contractor or a Zone Program Integrity Contractor.
  • You are eligible for Medicaid benefits and are not part of the offense being reported.
  • The organization or person who committed the fraud is not being investigated by law enforcement.
  • Your report will result in the recovery of a minimum of $100.

Penalties for Medicaid Fraud

  • Jail time: The defendant may face anywhere between five years and life imprisonment depending on the seriousness of the offense and whether it caused bodily injury or the death of a patient.
  • Probation: The defendant may be subjected to probation. During the probation period, the defendant will be required to abide by all probationary requirements including employment standards and regularly attending probation meetings.
  • Fines: Depending on the charges, a person facing fraud can be subjected to fines resulting to tens of thousands of dollars.
  • Restitution: If the fraud led to the loss of funds for a patient or insurance company, they may be required to pay restitution to the victim as reimbursement for the money lost.
  • Administrative sanctioning: If Medicaid fraud was caused by bad administration, the institution or practitioner will be subjected to administrative sanctions. The penalties include the revocation or suspension of the doctor’s license to participate in the Medicare program .

Summing It Up

Medicare fraud is a serious offense that can cause the perpetrator’s license to be revoked and subject them to huge fines and jail time. There are various laws that come to play in cases of Medicare fraud hence the need to involve a seasoned criminal defense attorney. If you or a loved one has been accused of Medicare fraud, it is advisable to seek legal counsel to have the charges reduced or withdrawn altogether.

Health costs have been soaring in the United States since the early 1970s. One source of the uncontrolled increases in medical costs for U.S. citizens has been the steadily increased incidence of fraud that has taken place over the last 30 years. In particular, Medicaid fraud is a tremendous problem that has strained the healthcare system, directly contributing to higher costs for all patients and worse outcomes as a result of unnecessary treatments and ineligible parties being treated, tying up valuable and limited medical resources.

In fact, it has been estimated that Medicaid fraud alone costs more than $140 billion each year. This staggering sum represents over 3 percent of the total revenue that the federal government takes in. At the end of the day, such astonishing levels of fraud make it more expensive for everyone to receive the healthcare they need.

As a result of all of the fraud taking place throughout the Medicaid system, state and federal governments have begun cracking down on cases of fraud. The number of investigations in states like New York has exploded over the last decade, yielding much higher rates of conviction for Medicaid fraud but also catching many small fish in its wide net.

Even though you may not think you have done anything wrong, simple oversights, such as not fully declaring income or assets, can put you in the sights of over zealous enforcement agencies. In New York State, the agency that investigates cases of Medicaid fraud is the Human Resources Administration. Even if you believe that you have done nothing wrong, if you are contacted by the Human Resources Administration, you should immediately contact an experienced, qualified lawyer to help you navigate the investigation process. Medicaid fraud is a serious crime with serious penalties. You need to have an expert by your side to help you through the difficult process of clearing your name.

If you receive an HRA letter, you are a target of an ongoing investigation

The Human Resources Administration may sound like a boring bureaucracy. They will also send benign-sounding, boilerplate letters to residents, disarming any sense in the recipient that something is wrong. But make no mistake, if you receive a letter from the HRA, no matter how banal it sounds, it means that investigators have already built a strong case against you and believe that you have committed a serious crime.

Unlike most other crimes, Medicaid fraud cases are not handled by the police. However, this should not trick you into complacency. If you receive a letter asking you to come in for an interview, you should realize that it is a legal proceeding that will likely result in you making incriminating statements that will later be used against you. It is absolutely imperative to understand that if you are summoned to an interview with the HRA, you must immediately contact a lawyer.

You are not always required to attend meetings with HRA agents. And a lawyer’s presence can mean the difference between a slam-dunk case, resulting in serious prison time, and having the case completely dismissed.

For the same reason that you should never talk to police without a lawyer present, you should not talk to investigators from the HRA. Going in for an interview with investigators carries great risk but virtually no reward. They employ expert investigators with years of experience in eliciting incriminating statements and confessions. You should not play their games if you don’t have to.

Medicaid fraud cases often have lots of mitigating factors and choke points

Even if you have done something that you know you shouldn’t have, the chances are that any Medicaid fraud case that can be built against you will give you opportunities to dramatically reduce the penalty. One way this can be accomplished is through mitigating factors.

In the case of Medicaid fraud, simple oversights like incorrectly reporting income usually do not rise to the level of criminal intent. Regardless of the circumstances that led to these mistakes, the prosecution may often find it difficult or impossible to prove that there was actually intent to defraud. This can drastically reduce the potential penalties involved. In particular, it can take the possibility of prison time off the table.

Additionally, Medicaid fraud cases are brought to trial at far higher rates than other criminal proceedings. All prosecutors understand that, due to the collateral consequences involved in convictions, such as medical personnel having licenses revoked, many defendants will fight their cases to the bitter end, duking it out in court rather than accepting a career-ending plea bargain.

This means that prosecutors are often especially willing to make generous plea deals in Medicaid fraud cases. Because they are afraid of tying up valuable criminal justice resources for hundreds of hours to prove a $5,000 Medicaid fraud case, they will often make generous plea deals. In most cases, serving no jail time will be on the table.

Medicaid fraud is a crime vigorously investigated and prosecuted in New York State. It is the job of the Office of the Medicaid Inspector General to represent the interests of taxpayers, medicaid recipients, and medical providers and to go after those who abuse the medicaid program. In fact, New York State has a very active campaign to encourage the public to report claims of waste or abuse of the medicaid program http://ag.ny.gov/comments-mfcu.

What is medicaid fraud?
According to New York Penal Law §177.00, medicaid fraud is defined as the act of defrauding a health plan, by willingly providing false, inaccurate or misleading information or documents with the specific intent of receiving payment or benefits for which that person or entity would not otherwise be entitled to receive.

Is medicaid fraud a serious crime?
Yes. Medicaid fraud can be classified as a misdemeanor or felony depending greatly on the circumstances of the case. Each State has its own strict laws regarding medicaid fraud, but medicaid fraud is also a Federal crime subjecting defendants to sentencing under more severe Federal laws. The medicaid program is run both by the State and Federal government and willful and/or intentionally defrauding this program can result in State and Federal charges being brought against a defendant, concurrently.

Can I go to jail?
Yes. A charge of medicaid fraud can lead to incarceration. Therefore, it is imperative that you speak with an experienced medicaid fraud criminal lawyer as soon as possible in order to immediately implement a strategy to prevent you from facing incarceration. Among your lawyers primary objectives should be to ensure that your rights are diligently defended, so that incarceration is not an option.

Are there other penalties or legal aspects associated with medicaid fraud?
Yes. A conviction of medicaid fraud can have other negative ramifications or legal aspects, including but not limited to restitution wherein the court requires a defendant to pay back the money or value of the benefits illegally obtained. Also, if you are a patient who has been convicted of medicaid fraud you may be permanently removed from participation in the medicaid program regardless of your legitimate future need or eligibility.

If you are a doctor, healthcare provider or insurer who has been convicted of medicaid fraud your professional licenses can be revoked or suspended, and you can be permanently restricted from participating in the medicaid program, and in many cases you can be restricted from ever participating in any State or Federally funded or run benefits program.

How can a medicaid fraud criminal lawyer help my case?
If you have been accused of medicaid fraud you need to speak with a lawyer right away. Delay in consulting with an experienced criminal defense attorney can result in serious-irreparable damage to your case. If you have been charged with medicaid fraud, that means that the District Attorney and/or Attorney General has already gathered enough information to determine that the charges against you are justified. Therefore, if you have been charged with medicaid fraud you will need an attorney on your side who will immediately get engaged in your case, in order to actively pursue your defense and seek a quick disposition or dismissal of your charges.

What are possible defenses?
It is important to remember that a required element to prove fraud, is a showing that the person or entity who is accused of the fraud acted with specific and willful intent to commit the fraudulent activity. It is imperative that you openly share all details and facts regarding your case with your attorney so that he or she can begin exploring affirmative defenses or mitigating factors that will help resolve your case.

What are possible mitigating factors?
Mitigating factors in your case can be evidence or information given to the court in order to lessen the charge or reduce penalties. For example, your attorney can present supporting evidence showing that the alleged fraud was the result of mistake or inadvertent error. Other mitigating factors your lawyer can explore is evidence that shows mental incapacity, retardation or an addiction to illegal substances or alcohol that lead to you engaging in the fraudulent activity. Whatever defense best suits your case, is a strategy that you must establish with your attorney.

Charges of medicaid fraud should be taken very seriously. The State and Federal government have all of the legal resources to pursue their charges against you. If you have been accused of medicaid fraud it is critical that you have all of the legal resources available to you in order to protect your rights and best interest.

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.

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