At Varghese & Associates, P.C., we understand the devastating impact that Medicaid fraud allegations can have on healthcare professionals and entities throughout New York City. As dedicated NYC Medicaid fraud defense lawyers, we provide vigorous representation for individuals and organizations facing government investigations, audits, and criminal charges related to Medicaid billing practices.

Contact Varghese & Associates, P.C. for a confidential consultation and let us put our experience to work for you.

What Are Medicaid Fraud Investigations in NYC?

Medicaid fraud investigations in New York are among the most aggressive in the nation. The New York State Office of the Medicaid Inspector General (OMIG) and the Medicaid Fraud Control Unit (MFCU) have significantly expanded their enforcement efforts in recent years, targeting healthcare providers across all sectors.

Medicaid Fraud Cases We Take

As NYC Medicaid fraud defense lawyers, we regularly defend healthcare providers against the following frequently prosecuted Medicaid fraud offenses under New York and federal law.

• Billing for Services Not Rendered: Prosecutors charge providers for submitting claims for appointments that never occurred or procedures never performed, violating NY Social Services Law § 366-b and 18 U.S.C. § 1347.
• Upcoding and Unbundling: Providers face charges for deliberately assigning higher-paying procedure codes than warranted or inappropriately separating bundled services to increase reimbursement.
• Kickback Arrangements: The government prosecutes providers for offering, paying, soliciting, or receiving anything of value to induce referrals of Medicaid patients, violating the Anti-Kickback Statute (42 U.S.C. § 1320a-7b).
• Phantom Billing: Healthcare entities face charges for submitting claims for deceased patients or for periods when patients were not under their care.
• Medical Necessity Fraud: Providers are prosecuted for ordering or billing for services that fail to meet Medicaid's medical necessity requirements under 18 NYCRR § 518.3.
• False Certifications: Physicians face charges for falsely certifying the need for services such as home health care or durable medical equipment when patients don't qualify.
• Self-Referral Violations: Providers are charged under the Stark Law (42 U.S.C. § 1395nn) for referring Medicaid patients to entities with which they have financial relationships.
• Documentation Falsification: Prosecutors pursue charges for altering medical records, forging signatures, or creating backdated documentation to support fraudulent claims.
• Identity Theft and Misuse: Providers face prosecution for using patient or provider identification information without authorization to submit fraudulent Medicaid claims.
• Conspiracy Charges: The government frequently adds conspiracy charges (18 U.S.C. § 371) when multiple individuals allegedly worked together to commit Medicaid fraud.

Our NYC Medicaid fraud defense lawyer team has successfully defended healthcare providers against all these charges, often achieving case dismissals or significantly reduced penalties through strategic legal intervention.

How a Medicaid Fraud Defense Lawyer Can Protect Your Rights and Practice

As experienced NYC Medicaid fraud defense lawyers, we implement strategic interventions that safeguard healthcare providers facing government scrutiny.

• Immediate Legal Shield: Our healthcare fraud defense attorneys establish attorney-client privilege from the first consultation, protecting sensitive communications and developing defense strategies away from government scrutiny.
• Investigation Management: Our NYC Medicaid fraud defense lawyers control the flow of information to investigators, preventing self-incrimination and ensuring proper context for all documentation.
• Regulatory Navigation: We guide clients through the complex web of Medicaid regulations, identifying compliance safe harbors and valid billing justifications.
• Administrative Advocacy: Our team represents providers in audits and administrative proceedings, often resolving matters before they escalate to criminal investigations.
• Strategic Documentation: We help assemble and present evidence of compliance efforts, good faith billing practices, and quality patient care that contradicts fraud allegations.
• Government Negotiation: Our NYC Medicaid fraud defense lawyers leverage relationships with regulatory authorities to pursue reasonable settlements when appropriate.
• Financial Protection: We work to minimize monetary penalties, prevent improper recoupment demands, and structure manageable repayment plans when necessary.
• License Defense: Our healthcare fraud defense lawyer team coordinates with licensing defense counsel to prevent adverse actions against professional credentials.
• Exclusion Prevention: We fight vigorously against potential exclusion from Medicaid and other government healthcare programs that could devastate your practice.
• Future Protection: After resolving current issues, we help implement compliance programs that reduce the risk of future investigations and demonstrate commitment to proper billing.

With timely engagement of our NYC Medicaid fraud defense lawyer team, healthcare providers can significantly improve their position against government allegations and protect what they've worked so hard to build.

Who Investigates Medicaid Fraud in New York?

As NYC Medicaid fraud defense lawyers, we regularly interact with multiple agencies that conduct Medicaid fraud investigations in New York State.

• New York State Office of the Medicaid Inspector General (OMIG): This agency conducts audits, identifies improper payments, and investigates potential Medicaid fraud, waste, and abuse throughout the state healthcare system.
• Medicaid Fraud Control Unit (MFCU): Operating within the New York State Attorney General's Office, this specialized unit investigates and prosecutes healthcare providers suspected of defrauding the Medicaid program or abusing patients in healthcare facilities.
• U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG): This federal agency conducts nationwide Medicaid fraud investigations, often partnering with state authorities on complex cases involving multiple jurisdictions.
• Centers for Medicare & Medicaid Services (CMS): The federal agency that administers Medicaid conducts program integrity activities and may initiate investigations based on data analysis of billing patterns.
• Federal Bureau of Investigation (FBI): The FBI's Healthcare Fraud Unit often becomes involved in complex Medicaid fraud investigations, particularly those with interstate components or organized criminal elements.
• U.S. Attorney's Offices: Federal prosecutors from the Southern and Eastern Districts of New York pursue Medicaid fraud cases that violate federal law, often seeking substantial penalties and prison sentences.
• New York City Human Resources Administration (HRA): This local agency investigates recipient fraud and may coordinate with other agencies on provider investigations within NYC.
• Medicaid Fraud Data Mining Units: Specialized teams use sophisticated analytics to identify statistical anomalies in billing patterns that often trigger investigations of NYC providers.
• Unified Program Integrity Contractors (UPICs): These CMS contractors conduct audits and investigations to identify improper payments and potential fraud in both Medicare and Medicaid.
• Healthcare Whistleblower Programs: These programs encourage and facilitate insiders to report suspected fraud, offering financial incentives that can trigger intensive investigations.

Our NYC Medicaid fraud defense lawyer team has extensive experience dealing with each of these investigative bodies and understands their distinct approaches, priorities, and procedural requirements in defending healthcare providers against fraud allegations.

Consequences and Penalties of a Medicaid Fraud Conviction in NYC

As NYC Medicaid fraud defense lawyers, we inform clients about the severe repercussions that can result from Medicaid fraud convictions under both state and federal law.

• Criminal Sanctions: Convictions can result in substantial prison sentences, with federal healthcare fraud carrying up to 10 years imprisonment and up to 20 years if patient harm occurred.
• Financial Penalties: Courts may impose massive fines, often reaching hundreds of thousands or even millions of dollars depending on the scope of the alleged fraud.
• Treble Damages: Under the False Claims Act, providers may be required to pay three times the amount of the government's loss plus penalties for each false claim submitted.
• Professional License Revocation: State licensing boards typically initiate disciplinary proceedings upon conviction, often resulting in license suspension or permanent revocation.
• Program Exclusion: Convicted providers face mandatory exclusion from participating in Medicaid, Medicare, and other federal healthcare programs for a minimum of five years.
• Civil Monetary Penalties: The government may impose additional civil penalties of up to $50,000 per violation plus three times the amount claimed for each service.
• Corporate Integrity Agreements: Organizations may be required to operate under burdensome federal monitoring with extensive compliance obligations for years.
• Reputational Damage: Public reporting of fraud convictions can cause irreparable harm to professional reputation and practice viability.
• Civil Liability: Beyond government action, providers may face civil lawsuits from patients or private insurers affected by the fraudulent conduct.
• Asset Forfeiture: The government may seize property and assets connected to fraudulent activities or purchased with proceeds from fraud.

Our NYC Medicaid fraud defense lawyer team emphasizes that these consequences underscore the critical importance of engaging qualified healthcare fraud defense lawyers at the earliest indication of an investigation to protect your practice, professional standing, and personal freedom.

When To Contact Our Healthcare Fraud Defense Lawyers

As NYC Medicaid fraud defense lawyers, we urge healthcare providers to seek legal counsel at the earliest signs of potential investigation.

• Document Requests: Contact us immediately upon receiving unusual or extensive requests for patient records or billing documentation from Medicaid, OMIG, or other government entities.
• Audit Notifications: Reach out when you receive notice of a Medicaid audit, as early legal intervention can shape the process and improve outcomes.
• Whistleblower Concerns: If you suspect a current or former employee is making allegations to authorities, our NYC Medicaid fraud defense lawyers can help you prepare proactively.
• Billing Discrepancies: Consult us when internal reviews reveal potential billing issues that might trigger government scrutiny.
• Investigator Visits: Contact our healthcare fraud defense lawyer team immediately if investigators arrive at your practice location asking to speak with you or your staff.
• Subpoena Receipt: Seek immediate legal counsel upon receiving any subpoena related to your healthcare practice or billing procedures.
• Suspension Notices: Reach out promptly if you receive notification of payment suspension or prepayment review status from Medicaid.
• Colleague Investigations: Consider consulting our NYC Medicaid fraud defense lawyers if others in your practice area are under investigation, as enforcement actions often target multiple providers.
• Compliance Uncertainties: Contact us when facing unclear regulatory requirements or complex billing scenarios that could create liability.
• Self-Disclosure Considerations: Consult before self-reporting potential violations, as our team can help structure disclosures to minimize negative consequences.

Waiting until formal charges are filed significantly limits our ability to protect your interests; our NYC Medicaid fraud defense lawyer team can achieve the best results when engaged early in the investigative process.

Signs You're Being Investigated for Medicaid Fraud in NYC

As NYC Medicaid fraud defense lawyers, we help providers recognize the early warning signs that they may be under government scrutiny.

• Unusual Document Requests: You receive targeted requests for specific patient records or billing documentation from Medicaid, OMIG, or other regulatory agencies without a routine audit notification.
• Unannounced Site Visits: Investigators from the Medicaid Fraud Control Unit or other agencies appear at your practice without prior notice asking to interview staff or review records.
• Patient Interviews: You learn that your patients have been contacted by investigators asking detailed questions about the services they received from your practice.
• Extended Audit Timeframes: What began as a routine audit has expanded in scope or timeline without clear explanation from the auditors.
• Former Employee Contacts: Past employees report being approached by government investigators with questions about your billing practices or patient care.
• Payment Holds: You notice unexpected delays in Medicaid reimbursements or receive notification of payment suspension pending investigation.
• Subpoena Receipt: You receive a grand jury subpoena or civil investigative demand requesting extensive practice records or documentation.
• Data Analysis Notices: You receive communication mentioning that your billing patterns have been flagged as "outliers" compared to other providers in your specialty.
• Colleague Investigations: Other healthcare providers in your practice area or referral network have become targets of fraud investigations.
• Prepayment Review Status: Your practice is placed on prepayment review, requiring documentation submission before claims are processed.

Our NYC Medicaid fraud defense lawyer team strongly recommends immediate legal consultation if you notice any of these warning signs, as early intervention provides the greatest opportunity to protect your practice and professional reputation.

How Does the Medicaid Fraud Investigation Process Unfold?

As NYC Medicaid fraud defense lawyers, we guide clients through each stage of government investigations to protect their rights and interests throughout the process.

• Data Mining Phase: Investigations often begin invisibly when government algorithms flag unusual billing patterns in your Medicaid claims data for further review.
• Document Requests: The first tangible sign typically arrives as formal requests for specific patient records and billing documentation from OMIG or the Medicaid Fraud Control Unit.
• Desk Audit: Investigators conduct detailed reviews of the requested documentation, comparing your records against billing submissions and Medicaid requirements.
• Patient Interviews: Investigators may contact your patients to verify they received the services claimed and to gather information about the nature of care provided.
• Staff Questioning: Current or former employees may be approached for interviews about your practice operations, sometimes without your knowledge.
• On-Site Inspections: Investigators may conduct unannounced visits to your practice to observe operations, review original records, or interview staff members.
• Expert Analysis: Government consultants review your clinical documentation to evaluate medical necessity and appropriate coding of services billed.
• Administrative Hearings: If discrepancies are found, you may face administrative proceedings to determine overpayments or program violations.
• Settlement Negotiations: Our NYC Medicaid fraud defense lawyers can often negotiate resolutions before criminal charges are filed if engaged early enough.
• Criminal Referral: In cases where fraud appears intentional, investigators refer the matter for criminal prosecution at the state or federal level.

Our healthcare fraud defense lawyer team emphasizes that intervention at any stage can significantly impact outcomes, with early representation offering the greatest opportunity to address concerns before they escalate to criminal proceedings.

Protect Your Practice Today

Don't wait until charges are filed to seek legal help. Our NYC Medicaid fraud defense lawyers provide the strategic guidance and vigorous representation needed to protect your professional reputation, practice, and freedom. Contact Varghese & Associates, P.C. for a confidential consultation and let us put our experience to work for you.

Medicaid Fraud Defense Lawyer FAQs

As NYC Medicaid fraud defense lawyers, we address important questions about Medicaid fraud investigations.

Do I need a lawyer specialized in healthcare fraud? Our NYC Medicaid fraud defense lawyers bring essential knowledge of medical billing regulations and healthcare operations that general criminal attorneys typically lack.

Will my practice be shut down during an investigation? With proper legal representation, many providers continue operating during investigations, though payment suspensions may temporarily affect cash flow.

How are whistleblower claims handled in Medicaid fraud cases? Whistleblower claims under the False Claims Act can entitle informants to 15-30% of recoveries, making these cases particularly complex to defend.

What happens during the first meeting with a Medicaid fraud defense lawyer? Our initial consultation focuses on understanding the investigation scope, reviewing documentation received, and developing an immediate response strategy.

Can I handle document requests without legal counsel? Responding to document requests without legal guidance creates significant risks, as improper responses can expand investigations or inadvertently provide damaging evidence.

Are billing software errors a valid defense? Software errors may provide defense arguments, but our healthcare fraud defense lawyer team must carefully document the technical issues and demonstrate lack of fraudulent intent.

How does attorney-client privilege protect me during investigations? Communications with our NYC Medicaid fraud defense lawyers remain confidential, allowing candid discussions about billing practices without risk of disclosure to investigators.

Our NYC Medicaid fraud defense lawyer team provides strategic guidance tailored to your specific circumstances while protecting your professional future.