As a result of the federal Affordable Care Act, the number of Medicaid beneficiaries continues to increase. Along with the increase in Medicaid beneficiaries and increases in health care costs has come an increased level of scrutiny by the New York state government and the federal government to identify providers who are committing Medicaid fraud.Because Medicaid is a jointly-funded program between the State of New York and the federal government, several entities are involved in fighting Medicaid fraud. The primary state entities are the Office of the Medicaid inspector General and the Attorney General’s Medicaid Fraud Control Unit. At the federal level, the Department of Justice through the United States Attorney’s offices investigates and prosecutes Medicaid fraud cases. The federal Inspector General and the federal Medicaid agency, the Center for Medicare and Medicaid Services (CMS), are also involved in fraud detection and prevention.

No provider is exempt from allegations of Medicaid fraud. Individual practitioners such as physicians, institutional providers such as nursing homes, and pharmacies serving Medicaid beneficiaries are all potential targets of the government’s fraud fighting efforts.

Medicaid fraud comes in many forms, including billing for services not actually provided, billing for or providing services that are not medically necessary, selling prescriptions to people other than the intended recipient, ordering unnecessary tests, and giving bribes in exchange for agreeing to get medical care from a particular provider. Federal law limits the ability of providers to make referrals for services to entities with which the provider has a financial relationship and also prohibits offering, paying, soliciting, or receiving kickbacks in exchange for recommending services under federal programs, including Medicaid.

Medicaid fraud is detected in several ways. A citizen may call in to one of the Medicaid fraud hotlines. An employee of a provider may report fraud observed in the provider organization. These “whistleblower” cases are particularly attractive for employees because the whistleblower may be able to receive part of the fines collected from the provider.

Some Medicaid fraud charges result from audits or other reviews of Medicaid claims. Sophisticated computer technology analyzes Medicaid claims to identify providers who are providing higher volumes of services than their peers. The Office of Medicaid Inspector General and CMS conduct audits to review medical records and claims to determine whether there is evidence of Medicaid fraud. Some providers who discover errors in billing or service provision self-disclose violations, hoping for reduced penalties.

A Medicaid provider may not know that a fraud investigation is underway. In other cases, auditors or investigators show up and ask seemingly innocent questions that later result in an audit alleging tens or hundreds of thousands of dollars in Medicaid fraud.

Penalties for Medicaid fraud range from suspension from the program, suspension of payments, exclusion from the Medicaid program (and other programs like Medicare), financial penalties, and in serious cases, prison sentences. When an investigation begins, you do not know what penalties may ultimately be imposed.

Because of the involvement of many different government entities, who often work in joint efforts, and the uncertainty regarding what ultimately penalty may be imposed, Medicaid providers who know they are under investigation should not attempt to handle the investigation on their own.

If Medicaid auditors or investigators give any indication that you are under investigation for Medicaid fraud, you should secure legal representation for you and your provider organization. Call us or fill out the information on our website to get our experienced attorneys working for you in dealing with the state and federal agencies. Your interests will be better protected, and you may be able to get a reduced penalty if the government knows you have your own experienced criminal defense attorney on the case.