Medicaid Fraud Defense Lawyer

A Medicaid fraud case can bring years in federal or state prison, full repayment with penalties, loss of your professional license, and exclusion from Medicaid, and in New York it is pursued aggressively by both the Attorney General's Medicaid Fraud Control Unit and federal prosecutors. Doctors, dentists, pharmacists, clinics, home health agencies, and billing companies can all become targets, often through data analytics or an audit that quietly turns criminal. Because Medicaid fraud turns on proving intent, these cases are frequently defensible, but only with the right lawyer and an early start. If you are under investigation or audit in New York City, an experienced Medicaid fraud attorney should be your first call.

Varghese & Associates, P.C. is a federal criminal defense firm on Wall Street, in the heart of the Southern District of New York. Medicaid fraud defense is a core part of our healthcare fraud defense practice, and the firm is led by Vinoo Varghese, a former prosecutor and one of the most recognized criminal defense attorneys in the country. Our Medicaid fraud attorneys handle these matters in house, from the first audit or subpoena through investigation, indictment, trial, sentencing, and appeal. Matters are not routed out to other firms.

Call now for a confidential consultation with a New York City Medicaid fraud lawyer. The earlier our Medicaid fraud defense lawyers are involved, the more they can do.

What Is Medicaid Fraud?

Medicaid fraud is the crime of knowingly using deception to obtain Medicaid payments a provider is not entitled to, such as billing for services that were not provided, billing for more than was provided, billing for medically unnecessary services, paying or receiving kickbacks, or billing for services by unlicensed or unqualified staff. It is prosecuted at both the federal and New York State level. The defining element is intent, meaning the government must prove a knowing scheme to defraud the Medicaid program, not a billing error or a good-faith coding mistake. That intent requirement is where an experienced Medicaid fraud attorney concentrates the defense.

Who Investigates Medicaid Fraud in New York?

Medicaid fraud in New York is investigated by the Attorney General's Medicaid Fraud Control Unit, which handles criminal cases, and the Office of the Medicaid Inspector General, which conducts audits and civil recovery, alongside federal agencies like HHS-OIG and the FBI. Many cases begin as an audit or a records request from the Office of the Medicaid Inspector General and turn criminal when investigators see signs of intentional fraud, or start with a whistleblower filing a False Claims Act suit. Because a routine audit can escalate into a criminal case, the response to that first audit letter or subpoena is critical, and it is the most valuable time to bring in a Medicaid fraud attorney.

What Are Examples of Medicaid Fraud?

Common examples of Medicaid fraud include billing for services never rendered, phantom or duplicate billing, upcoding to higher-paying codes, billing for medically unnecessary services, billing for services performed by unlicensed staff, and paying or receiving kickbacks for referrals. These allegations often arise from patterns in billing data, from a former employee, or from a patient complaint. In practice, Medicaid fraud is rarely charged alone, and prosecutors frequently pair it with the Anti-Kickback Statute, grand larceny, conspiracy, and money laundering, stacking counts to increase both the pressure and the potential sentence.

Medicaid Fraud and the Statutes Behind It

Medicaid fraud is charged under both federal and New York statutes, and prosecutors often use several at once. The charges most often in play include:

• Federal healthcare fraud (18 U.S.C. § 1347)
• Federal Anti-Kickback Statute, for paying or receiving value for referrals (42 U.S.C. § 1320a-7b(b))
• Conspiracy and false statements (18 U.S.C. §§ 1349 and 1035)
• The federal and New York False Claims Acts, which run civilly alongside criminal cases (31 U.S.C. §§ 3729 through 3733)
• New York health care fraud (N.Y. Penal Law Article 177)
• New York false statements to obtain Medicaid payment (N.Y. Social Services Law § 145-b)
• Grand larceny for the amounts obtained (N.Y. Penal Law Article 155)

What Is a Medicaid Audit?

A Medicaid audit is a review of a provider's claims and records by the Office of the Medicaid Inspector General or a managed-care plan to determine whether payments were proper, and it can lead to a repayment demand, referral for fraud prosecution, or exclusion. Auditors frequently review a small sample of claims and then extrapolate the error rate across all of a provider's billing, which can turn a modest sample into an enormous demand. How you respond to an audit, and how you challenge that extrapolation, can determine whether a matter stays civil or becomes criminal. Learn more on our Medicaid audit defense page.

What Are the Penalties for Medicaid Fraud?

Federal Medicaid fraud carries up to 10 years in prison per count, while New York health care fraud is graded by the dollar amount and rises to a class B felony punishable by years in state prison, and both bring restitution, fines, forfeiture, loss of licensure, and mandatory exclusion from Medicaid. Because each claim can be charged as a separate count, exposure can multiply quickly, and the civil False Claims Act can add treble damages on top. For most providers, exclusion from Medicaid is itself a practice-ending consequence. The severity of these penalties is exactly why an experienced Medicaid fraud attorney should be involved as early as possible.

How Does Sentencing Work in a Medicaid Fraud Case?

In federal Medicaid fraud cases, sentences are calculated under the United States Sentencing Guidelines, where the biggest driver is the intended or actual loss, while New York cases are graded directly by the value of the fraud. In both systems, the dollar amount controls much of the outcome, and prosecutors often overstate it by treating every claim as fraudulent or by relying on aggressive extrapolation. One of the most valuable fights in a Medicaid fraud case is challenging that loss figure and the sampling behind it. Our Medicaid fraud attorneys contest the loss calculation, challenge enhancements, present detailed mitigation, and argue for the lowest possible sentence, including a non-custodial resolution where appropriate.

What Are the Defenses to Medicaid Fraud?

Medicaid fraud turns on intent, and that is where the defenses concentrate. Every case is different, but the strategies our Medicaid fraud lawyers commonly use include:

• No intent to defraud. Billing errors, coding mistakes, and good-faith disagreements about medical necessity are not crimes.
• Medical necessity. Showing the services were appropriate and supported by clinical judgment.
• Good-faith reliance. Reasonable reliance on billing staff, coders, or compliance advice can negate the required intent.
• Attacking audit extrapolation. Challenging the sampling and extrapolation methods that overstate the alleged overpayment.
• Documentation. Producing records that support the claims the government says were unsupported.
• Suppression. Where records were obtained through an unlawful search or subpoena, moving to suppress under the Fourth Amendment.

What Should You Do If You Are Under Investigation or Audit for Medicaid Fraud?

If you learn you are under investigation for Medicaid fraud, or receive an audit letter, subpoena, or visit from investigators, do not talk to them, do not turn over records without counsel, and do not alter or destroy any documents. Call a Medicaid fraud attorney immediately. Anything you say to an auditor or investigator can be used against you, and altering records after a matter begins can create a separate obstruction charge. You have the right to remain silent and the right to counsel. Preserve everything, say nothing without counsel, and let your lawyer engage the auditors and prosecutors.

How Our Medicaid Fraud Attorneys Can Help You

Our Medicaid fraud defense lawyers defend these matters at every stage, and they look for the earliest possible point at which the case can be won or shrunk:

• Early intervention. Responding to audits, subpoenas, and target letters to keep a matter civil where possible and to negotiate a declination or reduced charges before an indictment.
• Audit defense. Challenging the sampling and extrapolation that drive repayment demands and fraud referrals.
• Protecting your license and enrollment. Coordinating the criminal defense with licensing-board and Medicaid exclusion proceedings.
• Motion practice and trial. Moving to dismiss defective counts, suppressing unlawfully obtained evidence, and trying cases before federal and New York judges and juries.
• Fighting the loss. Using forensic and clinical experts to challenge the government's damages methods.
• Sentencing and appeal. Challenging the loss calculation, arguing for variances, and pursuing appeals and post-conviction relief.

Is Medicaid Fraud a Felony?

Yes. Medicaid fraud is a felony under both federal law and New York law when the amount involved is significant, though small New York cases can be charged as a misdemeanor. Federal healthcare fraud is punishable by up to 10 years per count, and New York health care fraud rises from a misdemeanor to a class B felony as the dollar amount increases. Beyond prison, a conviction brings restitution, forfeiture, loss of licensure, and exclusion from Medicaid, which can permanently end a healthcare career. That is why every Medicaid fraud allegation should be treated as serious from the start.

How Much Does It Cost to Hire a Medicaid Fraud Lawyer in New York City?

The cost of a Medicaid fraud lawyer in New York City depends on whether the matter is a civil audit or a criminal case, the volume of billing and medical records, whether a parallel False Claims Act case exists, and whether it resolves before or goes to trial. These cases involve extensive record review, forensic and clinical analysis, and detailed motion practice, so they require real work. Our Medicaid fraud attorneys are transparent about fees from the first conversation and structure the representation to fit the matter. Given the prison exposure and the threat to your license and livelihood, the more important question is usually what an inadequate defense can cost you.

A Medicaid Fraud Attorney the National Media Turns To

When the biggest federal cases in the country are in the news, networks and newspapers call Vinoo Varghese to explain what is really happening in the courtroom. That is the same judgment and credibility our Medicaid fraud attorneys bring to your case.

Vinoo Varghese has provided legal analysis and commentary for CBS News, Fox News, Fox Business, CNN, MSNBC, Court TV, HLN, BBC, Inside Edition, i24 News, Sky News Arabia, and Nancy Grace's Crime Stories, and has hosted true-crime legal analysis for Vanity Fair. He has been quoted as a legal authority by The New York Times, The Wall Street Journal, the New York Law Journal, Law360, the New York Daily News, and the New York Post. A former prosecutor from the Brooklyn District Attorney's Office, he is a nine-time National Trial Lawyers Top 100 honoree, an eight-time New York Metro Super Lawyer, rated AV Preeminent by Martindale-Hubbell, and has served on the visiting faculty of Harvard Law School's Trial Advocacy Workshop.

Contact a New York City Medicaid Fraud Lawyer Now

If you are under investigation, are facing an audit that may be turning criminal, have received a subpoena, or have been charged with Medicaid fraud anywhere in New York City, do not wait and do not talk to anyone but your lawyer. Medicaid fraud defense is part of our broader healthcare fraud defense practice, and a Medicaid fraud attorney who has stood in the courtroom and tried the cases can change what happens next.

Call Varghese & Associates, P.C. for a confidential consultation. Our office is located at 2 Wall Street, Suite 310, New York, NY 10005, steps from the federal courthouses of the Southern District of New York.