New York City Medicaid Fraud Attorneys
NYC Medicare Fraud Defense Lawyers
Our New York City criminal lawyers are often called upon by clients who are investigated for or charged with Medicaid fraud and Medicare fraud by federal or state authorities. We have represented a number of healthcare service providers, from physicians and dentists to home care agencies to ambulette companies at all stages of Medicaid or Medicare fraud investigations and prosecutions.
What are Medicaid and Medicare?
Medicaid and Medicare are governmental programs that provide medical and health-related services to eligible patients.
Both federal and state governments are involved in the Medicaid program. Health care providers bill the New York State Medicaid program directly. The state pays the providers based on a fee-for-service agreement or through prepayment arrangements such as HMOs. The federal government reimburses New York for its share of Medicaid expenses. This arrangement may place a Medicaid fraud investigation under state of federal jurisdiction.
In contrast, Medicare is an exclusively federal health insurance program that pays for hospital and medical care for elderly and certain disabled patients. Medicare fraud cases are generally prosecuted by the federal authorities.
What is Medicaid and Medicare Fraud?
There are several major scenarios for Medicaid/Medicare fraud that healthcare provides are accused of:
- Billing Medicaid for services that were not provided;
- Double billing (billing Medicaid and another insurance or the recipient);
- Upcoding. Upcoding is the illegal practice of using billing codes for more complex procedures than actually provided or more serious diagnoses than actually exist.
- Unbundling/Fragmentation.” Certain medical procedures that are done together are reimbursed at special rates. Unbundling is the illegal practice of billing separately for these procedures so that Medicare or Medicaid would pay for each procedure separately at higher rates.
- Billing for services provided by unauthorized or unlicensed staff;
- Illegal kickbacks, which includes providers referring patients to each other and paying or accepting payment from another provider for such referrals. Many providers set up their practices as if they rent medical office space and clerical services from a medical practice; however, in many cases, especially when the practice is owned by a non-physician, that results in illegal sharing of reimbursement paid by Medicaid.
- Billing for medical equipment that patient never received or that has been returned.
- Offering a Medicare drug plan that has not been approved by Medicare.
- Using false information to mislead patients into joining a Medicare plan.
What triggers Medicaid Fraud or Medicare Fraud Investigations?
In our experience, there are three factors that are most likely to trigger a criminal investigation of Medicaid or Medicare fraud. The first or foremost factor is an unusually high level of billing activity by a service provider. An unusually high billing pattern, when compared with other providers, will automatically raise a red flag.
In a recent case, a New Jersey physician was investigated and prosecuted after he billed Medicaid to the tune of $13 million a year, the next highest biller in the state only reaching a $6 million mark. The second common factor is fraud reported to the authorities by third parties or discovered by investigators during an unrelated probe. The third factor is discovery of fraud during a routine audit.
What to do when you are investigated for Medicaid or Medicare Fraud?
Most providers are not aware that they are targets of a criminal investigation. However, if you believe that you are under investigation, whether because you have been approached by agents or your billing documents have been subpoenaed, you must consult an attorney immediately, before discussing anything with authorities or disclosing any documents.
The benefit of retaining a competent criminal defense lawyer at the early investigative stage could literally secure your freedom in the not so distant future.
Because Medicaid and Medicare fraud investigations are based on billing patterns, and because many providers employ third party billing companies, mistakes do occur. Our New York City Medicaid and Medicare fraud lawyers have dealt with cases when provides accused of stealing huge amounts of money were eventually exonerated.
We employ highly skilled private Medicaid and Medicare auditors and investigators who are able to examine the records and determine whether the government numbers match the real numbers.
What to expect when my office has been raided or documents subpoenaed?
The answer is simple: you must seek legal consultation immediately. Do not settle for just any criminal attorney; always ask what part of the attorney’s practice is devoted to Medicaid and Medicare fraud defense work.
We will be able to assess your case and determine the strategy of your defense. If you are target of a criminal Medicaid or Medicare fraud investigation in New York City, call us for an immediate consultation.
