Many New Yorkers who can’t afford to pay for their own medical care can receive benefits from a government program known as Medicaid. Each state in the United States designs its own Medicaid program. New York state is able to determine eligibility and other criteria for those who want to be on Medicaid. The current program is paid for by using funds from individual New York Counties as well as state and federal funding. This budget for the New York State Medicaid program is over $49 billion yearly.
Medicaid Fraud Schemes
There are a number of different Medicaid fraud schemes detected each year in New York.
*Medicaid Mills. These are companies started and designed to only get money by billing Medicaid programs. This is done without regard to the real medical needs of people within a community.
*Overbilling for Hourly Services. This includes such services as home health care and more. It involves submitting as well as approving time records for medical service providers that are false.
*Billing for Unnecessary Services. This involves submitting bills for payments of services not medically necessary.
*Upcoding or Billing for Services not Performed. This involves billing Medicaid for procedures that were more expensive than the services actually performed. It also involves billing for services not performed for a patient.
*Selling Prescriptions. This involves providing access to prescription drugs for the intentional misuse or abuse of them.
*Cash Payments. This happens when a Medicaid provider demands cash payment from a patient in addition to being paid by Medicaid.
*Double Billing. This results when a Medicaid provider bills a private insurance company as well as other service providers in addition to Medicaid for the same procedure.
*Employing Barred Health Professionals. It is against the law to hire healthcare professionals or any other type of staff who have previously been forbidden from working in government healthcare programs because of abusive practices or fraud.
*Kickbacks. This is when financial arrangements are made between service providers for some type of financial benefit so another provider can use their products or services. This often happens when unnecessary treatments are involved.
*Inflating Reimbursement Rates. There are some large institutions such as hospitals, clinics as well as nursing homes that will falsify their financial reports when rates are set. The goal is always to get more money than they are owed from Medicaid.
Medicaid Fraud Control Unit
The Attorney General in New York has a Medicaid Fraud Control Unit. It is responsible for investigating and prosecuting individuals and companies who engage in abuse and fraud of New York’s Medicaid program. This unit is the largest and oldest operating in New York dedicated to this purpose. It was created in 1975 and at that time was tasked with investigating New York’s widespread financial fraud associated with the state’s nursing homes. Today, the unit investigates and prosecutes all types of Medicaid providers including pharmacies, physicians, hospitals and more. During it first years in operation, the unit was able to convict nursing homes known for their fraud and abuse as well as recovering millions of dollars for the state in the form of restitution.
Experts estimate Medicaid fraud costs taxpayers in the state of New York hundreds of millions of dollars each year. It is a serious offense and could involve a person being prosecuted in a criminal and civil court. When it comes to criminal trials, the type of case will be determined by the prosecutors. The penalties a person or company may receive from a civil trial could involve repayment of fund wrongfully obtained, non-payment for future claims as well as being excluded from participation in the Medicaid program. The results of a criminal trial could be serious fines as well as incarceration. In some cases, individuals have been given ten years in prison for each fraud conviction. If a patient experienced serious bodily harm resulting from Medicaid fraud, the provider could be given a 20-year sentence for each incident. Should a patient die because of Medicaid fraud, the guilty party could spend the rest of their life in prison.
There are certain legal defenses an experienced attorney will know how to use to successfully defend their client against charges of Medicaid fraud.
*Lack of Intent. It is possible for honest billing errors to result in a person or company being accused of Medicaid fraud. A prosecutor must attempt to prove the actions were based on malicious intent or ill-will. It is possible to demonstrate errors were the result of a new staff not yet properly trained, insufficient supervision and more. The goal of the defense is to show the mistakes were accidental and intentional fraud was not involved.
*Statutory Exceptions. In some situations, there are statutory exceptions. It’s possible to show the exceptions contained within the Start Law’s prohibiting physicians owning an ancillary company where patients are referred. These exceptions have often been used to lessen or eliminate a case against clients.
*Government Errors. There have been errors made by the government that have resulted in individuals and companies being falsely accused of Medicaid Fraud. It’s possible for the government to have incomplete or inaccurate records and more.
Being accused of Medicaid fraud is a serious situation. It will require the help of knowledgeable and experienced legal professionals. They will know what is required to achieve the best possible outcome for an individual’s situation.