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NYC Medicaid Fraud Lawyers

One of the biggest concerns in healthcare today, Medicaid fraud is a growing problem in many states. According to the Government Accountability Office, in 2015 alone improper payments for services not covered by Medicaid or for services that were billed but never rendered totaled more than $29 billion. Because of this, funds that could otherwise be used for legitimate services are instead wasted on these fraudulent claims, which results in increased costs for many services. More information about this can be found at www.ncsl.org/research/health/medicaid-fraud-and-abuse.aspx. If you find yourself being charged with Medicaid fraud, it’s a serious matter that could lead to significant financial penalties as well as jail time.

Defining Medicaid Fraud
The basic definition of Medicaid fraud is knowingly using false information to apply for and receive Medicaid benefits. Because eligibility for this program revolves around a person’s level of income, this is usually the area that is most often misrepresented. However, failing to disclose assets such as real estate is also considered fraud, as is failing to notify your Medicaid office of any changes to your financial or living situation. Even if you simply forget to make the notification, you can still be accused of fraud.

What are the Penalties?
Since Medicaid fraud falls under welfare fraud, there are varying types of offenses depending upon how much money was received. For lesser amounts that total no more than $1,000 dollars, it would be classified as a misdemeanor. However, anything above that amount becomes a felony, with the most serious being a first-degree felony, which is receiving fraudulent Medicaid benefits totaling more than $1 million. Needless to say, the higher the amount of fraudulent benefits you received, the more severe the penalties. In most cases you are fined and required to pay back any funds you obtained under false circumstances, but are rarely sentenced to prison for your offense. This is due to the large number of pending Medicaid fraud cases, which leads many prosecutors to be willing to negotiate a plea agreement with defendants, resulting in lesser penalties.

Are There Mitigating Factors?
When people hear of Medicaid fraud cases, most automatically assume the case is open and shut. However, that’s often not the case at all. In fact, there are numerous mitigating factors that usually come into play in these cases. When these emerge, a person who appeared guilty may all of a sudden be found innocent of all charges. This is due to being able to prove that the information provided on an application was complete and accurate, and is still accurate to the of their knowledge. However, if there is information on the application that is inaccurate, that doesn’t necessarily point to fraud. Instead, being able to prove an honest mistake occurred will resolve the situation, although it’s vital you be able to prove this. And remember, these fraud investigations usually result from tips provided by a whistleblower, who will usually be compensated financially for the information. Therefore, it’s quite possible mistakes can occur, so be prepared for this possibility.

How Do I Defend Myself Against These Charges?
While these cases can be intimidating to those being accused of Medicaid fraud, it doesn’t have to be that way. While you may receive a letter from Medicaid fraud investigators requesting your presence in their office to discuss the case, there are certain steps you can take. For starters, gather all documents you have related to the matter, make copies of everything, and take them with you to the meeting. However, it’s crucial that you not go to that meeting alone. Instead, contact a knowledgeable and experienced nyc medicaid fraud lawyer who specializes in Medicaid fraud. After doing so, discuss your case thoroughly and go over your options. In most situations, your lawyer will decide investigators lack the evidence needed for a conviction, or that they do have evidence which could result in a guilty verdict. In either case, have your medicaid fraud lawyer attend the meeting with you. If they do, they may be able to negotiate an agreement in your favor, especially if the evidence seems to be against you.

Don’t Go It Alone
Regardless of the circumstances in these cases, don’t choose to go it alone. Investigators often count on this, hoping you will be too intimidated to think clearly. Instead, schedule a consultation with an attorney as soon as possible after receiving notification from investigators. According to the website Healthresearchfunding.org, more than 40 percent of Medicaid payments in New York are deemed “questionable,” making it more likely that investigators will take a closer look at your application. So rather than let yourself be caught off-guard by zealous investigators who may be determined to find fault no matter the circumstances, hire an experienced and knowledgeable Medicaid fraud criminal defense attorney to help you navigate this complex process.

New York Medicaid Recipient Fraud Criminal Attorneys

You and your family rely on Medicaid to get the health care that you need. The Medicaid program is designed to help people like you when you need access to quality medical care. Millions of people depend on the Medicaid program for their health and well being.

Because Medicaid is so important to you and your family, allegations of Medicaid fraud can be hard on you and your family. Aggressive investigators want to make their numbers look good by accusing as many people as possible of abusing the Medicaid system. If they accuse you of wrongdoing, you may find yourself cut off from benefits and even facing criminal charges.

New York’s health care fraud laws

Medicaid fraud charges fall under New York’s health care fraud laws. These are state laws that are criminal. The laws prohibit purposefully doing things to try to get more benefits than you deserve. Intentional dishonesty to get benefits that you don’t deserve is called fraud.

Different charges for different amounts of money

There are several different charges available for health care fraud. All of them require you to purposefully say something that’s false in an attempt to get what you aren’t otherwise eligible for under the Medicaid system. Then, the severity of your charges depend on how much money you actually gain from the fraud.

If less than $3,000 is involved, you can face charges of only Medicaid fraud in the fifth degree. New York classifies health care fraud in the fifth degree as a Class A misdemeanor. The maximum time you can spend in jail is one year in addition to other penalties like fines. The amount of money involved is measured in a year’s time. If you get $2,999 in benefits in one year and then $1.00 more in benefits the next day, you can still only face charges in the fifth degree.

For more amounts of money, the charges get progressively more serious. In cases where you receive more than one million in benefits in a year’s time, you find yourself facing charges in the first degree. Fifth degree charges are the only misdemeanor charges for health care fraud. All of the other charges are felonies.

How can I defend myself?

If investigators accuse you of committing Medicaid fraud, their goal is to prove you guilty. They aren’t interested in working things out, and they aren’t interested in hearing that it was an honest mistake. That means, you shouldn’t assume that the investigator is your friend or that they want to work with you.

If you’re accused of Medicaid fraud, your bet is to refer any questions about the investigation to your nyc medicaid fraud lawyer. If you talk to the investigators yourself, you can expect them to turn around and tell the jury. Of course, their version of events might be very different than yours. Your attorney can help you understand how the law applies to your case and help you handle any tense conversations with investigators.

Honest mistakes aren’t against the law

It’s important to remember that it isn’t against the law to make an honest mistake. If you forget that you have an account somewhere or the number of people living in your home isn’t accurate, it’s up to the state to prove that you made a misrepresentation on purpose. You have a right to a fair trial, and it’s up to the state to prove the charges against you. Your New York Medicaid recipient fraud criminal attorneys can help you tell your story to the jury in a way that helps them see that you just made an honest mistake.

Preparing your defense

An experienced New York Medicaid recipient fraud criminal attorney can help you understand how New York law applies to your Medicaid case. Medicaid fraud cases are often built on complicated evidence and a great deal of paperwork. You and your attorney can work together to create a plan to defend yourself. That might mean approaching investigators to give them the information that can help them see the truth. In other cases, you may need to present your evidence to the jury instead.

Your Medicaid fraud attorneys can help you in the event that state attorneys extend a plea offer. They can help you understand what the plea offer means and what the likely consequences would be. A plea offer might clearly be in your interests, or it might not be so simple. In either case, your attorney can help you weigh the pros and cons.

If you’re facing Medicaid recipient criminal charges, your attorney is your advocate and teammate. The sooner you begin working with an experienced attorney, the sooner you can begin to unravel the mistakes and make a plan for your defense. Having the right advocate on your side can help you prepare a defense that’s effective and help you address the charges in the possible manner.

Because Medicaid is a public program, if officials accuse you of fraud, it can mean having to answer to criminal charges. Often times, a misunderstanding can lead to big trouble for you. Officials are often quick to judge what might be an innocent situation. Fortunately, if you’re accused of New York Medicaid fraud, a New York Medicaid recipient fraud nyc criminal lawyer can help you address the charges and protect your interests.

Types of Medicaid fraud charges

The severity of the Medicaid fraud charges that you face depend largely on the amount of money involved. New York law looks at the amount of payments that you improperly receive in a year’s time. If the payments are a low amount, you may face a misdemeanor.

Medicaid fraud requires intent. The law says that Medicaid fraud can only occur “knowingly and willfully.” You don’t have to know how much money you’re getting improperly, but you have to know that you’re providing false information on purpose. If you just make a mistake, you haven’t committed a crime. You might have to pay back the improper payments, but if you make an honest mistake, you haven’t committed willful fraud.

Charges of Medicaid fraud in New York are divided into degrees. First degree is the most serious and fifth degree is the least serious. Fifth degree is a Class A misdemeanor. It can involve any amount of money. If your offense involves $3,000 or more, it’s a fourth degree offense. That’s a Class E felony. Third, second and first degree health care fraud offenses involve progressively more amounts of money. A first-degree offense is a Class B felony offense that requires fraudulent payments of more than one million dollars over the course of a year.

Possible Penalties

The penalties that you face for Medicaid fraud depend on the specific circumstances of the offense. It’s up to the judge to decide your sentence based on what happened in your case. One penalty that you might face is time in jail. The penalty for a Class A misdemeanor is not more than one year in jail. The judge can give you the entire year, or they can give you no time at all.

If you’re facing Medicaid fraud in the first, second, third or fourth degree, there’s a chance that you could spend time in prison for the offense. Whether you spend time in prison depends on your criminal history, the specific circumstances of the case, your positive contributions to society and even your remorse. Your New York Medicaid recipient fraud criminal lawyer can help you create a plan to put your foot forward at sentencing.

If you’re convicted of Medicaid fraud, you may have to pay back the amount that you were paid in error. You’ll likely also have to pay fines to the court. In addition, you may lose your eligibility to receive benefits in the future. Your conviction may stay on your criminal record which may have an impact on your employment.

What defenses can I raise?

If you’re facing an allegation of Medicaid fraud, your bet is not to talk to any investigators. Instead, your attorney can speak on your behalf. When you talk to investigators, they might try to admit what you say in court. They may or may not remember or honestly report what you exactly said. This can create a mess for you to try to get a fair day in court. Remember that you have the right not to incriminate yourself.

Because Medicaid fraud requires you to act purposefully, your defense might be that the fraud didn’t happen on purpose. The government might assume that everyone’s guilty, but the jury might take an honest look at your story and agree that your mistake was accidental. Depending on the situation, your New York Medicaid fraud lawyer might even present the information to the state’s attorney and ask them to dismiss the charges before trial.

How an nyc medicaid fraud attorney can help?

Your attorney can help you evaluate your case in order to determine your defenses. The first thing you should do is look to see if there are defenses that can allow you to confidently take your case to trial. Then, your Medicaid attorney can work with you in order to determine the plan for you to present your case.

You can also discuss whether it’s in your interests to take your case to trial. You might choose to consider non-trial offers like a plea agreement. While a plea agreement isn’t in your interests in every case, a plea offer may be a way to lessen your jail exposure and other related penalties. Your attorney also helps you put your foot forward if you ultimately have a sentencing hearing. At each stage, your attorney helps you advocate for your interests and fight for a fair result.

Medicaid fraud is a serious crime in the United States. Each year, Medicaid fraud costs the country an estimated $140 billion, an amount that is equivalent to more than 3 percent of the nation’s total tax revenues.

Because Medicaid fraud is such a widespread and serious problem, state and federal agencies have been given a broad mandate to combat it. Increasingly, state and federal agencies are deploying state-of-the-art means to fight against those who would take advantage of the U.S. healthcare system to unfairly enrich themselves at the expense of their fellow citizens’ health. But this increase in enforcement efforts has also led to a wide net that often captures those who may not deserve the harsh penalties and life altering criminal convictions that they are facing.

If you find yourself under investigation or formally charged with Medicaid fraud, the most important thing to remember is that you should always get the help of a competent attorney on your side. Hiring the right attorney, with the knowledge, skills and experience to successfully bring your case to a satisfactory resolution, can make the difference between paying a small fine and some restitution versus being sent to state prison.

With toughened enforcement measures, even small mistakes can get you in hot water

The increased prevalence of Medicaid fraud has caused a backlash by law enforcement across the country. Unfortunately, many people who don’t really have any intention of committing fraud are often swept up in these efforts. The truth is that even minor oversights, such as not reporting income from a side job, can very quickly land you hot water with the Human Resource Administration, the state body responsible for investigating cases of welfare fraud in New York State.

Regardless of whether or not you have any idea why you have come under HRA scrutiny, always remember that the first thing you should do is contact an experienced attorney.

An HRA letter means you are under investigation

Medicaid fraud cases often unfold very differently than other cases. For starters, almost all Medicaid fraud cases in the state of New York are handled by an agency called the Human Resources Administration. On top of this vanilla-sounding, bureaucratic name, the HRA begins almost all investigations by sending a banal-sounding letter. These letters may look little different from any other government correspondence and usually request that the recipient come in for an interview.

Don’t do it.

Once you receive an HRA letter, you should assume that you are under investigation for serious fraud. The agents handling your case will not let you know what evidence they have on you. But in our experience, once the letter is sent, agents from the HRA have likely already spent dozens of hours investigating your case. At this point, they have evidence against you and suspect that you committed serious fraud. The agents are not looking to casually chat with you. They will be using every trick in the book to get you to make an incriminating statement and impeach yourself.

This is why it is crucial to contact an experienced attorney the moment you receive an HRA letter. An experienced Medicaid fraud attorney knows the process inside and out. They know what information they will have to provide, which requests they must comply with, when to fight head on and when to wait for a better moment. In general, you are not compelled to cooperate with HRA investigators, as they are not fully sworn law enforcement officers. However, at some point, your nyc medicaid fraud lawyer may determine that it is advantageous to open negotiations with the HRA.

A good nyc medicaid fraud lawyer can minimize your penalty

The good news is that, once you have hired a competent attorney, there are many different mitigating factors and other means by which your lawyer can negotiate the possible settlement. In our experience, the vast majority of Medicaid fraud cases do not end in any prison time for the client. This is especially true where the client is a mere recipient and is not involved in the provision of medical services.

However, jail time is not the only thing to worry about. Without following the advice of a competent NYC Medicaid fraud lawyer, you may quickly find yourself facing a crushing choice – either go to jail for months or pay tens of thousands of dollars in restitution. Most people will choose the latter. But the prosecutor and judge will be looking to get as much of the perceived loss back as they can.

But with the help of a good lawyer, it is possible to dramatically reduce the fines and restitution that you may be forced to pay. The mere threat of a good lawyer taking a case to trial, tying up limited and expensive court resources for hundreds of hours, often provides enough bargaining power to reduce fines and restitution costs by 50 percent or more.

Allegations of Medicaid recipient fraud are common in New York City along with the rest of the United States, in no small part because whistleblowers can receive financial compensation if their tip turns out to be accurate. If you believe you’re being investigated for Medicaid recipient fraud or you’re currently dealing with a fraud charge, it’s in your interest to contact a New York City criminal defense attorney who can help you get the result.

What Happens with a Medicaid Recipient Fraud Case?

New York has a fraud investigation department that handles cases of potential Medicaid fraud. There are a few steps to any Medicaid fraud case.

There could be many reasons for why the department would choose to investigate you. They may have received a tip from one of those aforementioned whistleblowers, or they may have gotten ahold of information that conflicts with something in your original Medicaid application, such as proof of income that’s higher than the amount you listed.

In the first stage of the case, the fraud department will gather evidence against you. It may even send investigators to monitor you during the day. If you know about the potential Medicaid fraud charges at this time, it’s a good idea to get in touch with a lawyer already. A lawyer can advise you on what to do and ensure that any investigators follow the law.

The next stage of the case will be when the fraud department notifies you of a potential case of Medicaid fraud, usually with a letter that it mails to you. The letter will ask you to come talk to the fraud department and bring in certain documents, which will vary depending on the case. The documents requested can give you some indication of what evidence the fraud department has compiled against you.

After the meeting date, whether you attend or not, the fraud department will decide how to proceed with your case. It may come to a settlement agreement with you, or it could send the case over to the district attorney for prosecution.

How Can You Be Punished for Medicaid Fraud?

Since Medicaid is a program for people with low incomes, it’s considered a type of welfare, and that means in New York City, Medicaid fraud is filed under the broader category of welfare fraud, which has five degrees, the least severe being a class A misdemeanor and the most severe being a class B felony. The degree of your welfare fraud depends on how much you obtained in Medicaid benefits through the fraud.

Every case is different, and the circumstances of your case will determine what penalties you can receive. Any degree of welfare fraud has the possibility of time in jail and financial penalties. You could also end up disqualified from ever receiving Medicaid benefits again if you’re found guilty.

Although jailtime is possible with Medicaid fraud, it’s rare and probably won’t happen unless you fraudulently obtained a very high amount of benefits or have several prior offenses. A fine or restitution is much more likely. A lawyer can help you negotiate the deal to potentially avoid jailtime and get a lower fine amount.

How Can You Defend Yourself Against Charges of Medicaid Fraud?

One of the biggest mistakes people make when they’re charged with Medicaid recipient fraud is going in without figuring out their defense first. The fraud department loves this, and their goal is for you to come in, answer everything they ask and give them all the documents they requested. If you do that, you may voluntarily give them all the evidence they need against you.

Your defense starts the moment you learn there’s a case being built against you. You and your lawyer should go over the information you provided in your Medicaid application and see if any of it is no longer accurate. It’s your responsibility to keep that information updated with any life changes, such as a marriage or a new job.

If you’ve received a letter from the fraud department, you and your lawyer can use their requested documents to get an idea of the case being built against you. Your lawyer can then look for potential issues with the case and advise you on how to handle the situation. They can also accompany you to the meeting, tell you when you shouldn’t answer a question and represent you if the district attorney gets the case.

Our New York City law firm is full of experienced criminal defense lawyers who know how to handle charges of Medicaid recipient fraud. We can analyze your case, help you build your defense strategy and either try to get the charges dropped or negotiate a favorable deal for you.

Here’s an article by Alex Z, a member of the Spodek Law Group, a team of Long Island Divorce lawyers. Every year, New York State sees billions of dollars in losses due to Medicaid fraud. This represents a huge problem for the taxpayers of New York state and the United States as a whole. It has been estimated that over $140 billion is lost, nationally, each year to Medicaid fraud. This has made the problem a top enforcement priority, with the number of cases brought to court over the last decades expanding dramatically.

But with increased enforcement efforts come more people getting caught up in the wide net of the Medicaid fraud investigatory apparatus and the court system. If you have become the target of an investigation concerning Medicaid fraud, the first thing that you need to do is to contact a qualified and experienced attorney. The sooner in the process you contact an nyc medicaid fraud lawyer, the more likely it will be that your case will have a favorable resolution and that you will not be subject to jail or prison time.

If you receive an HRA letter for an interview, contact an nyc medicaid fraud lawyer at once

Unlike most other crimes, in the state of New York, Medicaid fraud is investigated by a civilian agency, the Human Resources Administration. Although this bureaucracy may send you letters that look similar to any you may receive concerning other government business, if you have been asked to come in for an interview, you should immediately contact a lawyer.

The HRA interview process is nearly unique in the criminal justice system of New York State because these interviews are little different from being interrogated by a detective. Because you are not under arrest, everything you say and do can and will be used against you, but the investigators are under no obligation to inform you of this fact.

Despite the friendly looking, boilerplate letter format and the banal language that these requests entail, if you have received an HRA request for an interview, you are already the target of a serious investigation. This means that investigators have already likely spend dozens or even hundreds of hours amassing information on your case. The sole purpose of conducting these interviews is to get the person being investigated to make self-incriminating or impeaching statements. You have absolutely nothing positive to gain by attending one of these interviews, and you should never interact with HRA investigators without a competent lawyer present.

If you don’t talk, you’re chances look good

For the same reason that a good lawyer will always tell you that you should essentially never talk to the police, a good Medicaid fraud lawyer will give you the same advice regarding HRA investigators.

If you follow that advice and the prosecutor decides to eventually charge you anyway, Medicaid fraud is actually one of the crimes you can be charged with. This is because there are a large number of potential mitigating factors, the charges are often hard to prove and Medicaid fraud cases impose a unique strain on the court system. These three factors can provide you and your lawyer with enough leverage to significantly reduce penalties, fines and restitution amounts.

Mitigating factors and difficult-to-prove elements

Many of the reasons that people first come under the scrutiny of the the Human Resources Administration have innocent explanations. For example, it is both common and easy to forget to report that you made a certain amount of money from a side job. Likewise, many people legitimately forget to declare that their new employer gives them certain health insurance benefits. Because mistakes in reporting these factors are often innocent in nature, they can provide powerful mitigating circumstances in negotiating plea deals or at sentencing in a trial.

However, many of these same factors are even more powerful when seen as a deterrent to the prosecutor choosing to take the case to trial in the first place. The truth is that Medicaid fraud cases, especially those involving mere recipients, make it notoriously difficult for the prosecutor to prove that there was criminal intent to defraud beyond a reasonable doubt.

Just one example of this would involve someone who claims that they didn’t declare a certain amount of side income because they didn’t understand the dizzyingly complex laws surrounding benefits eligibility. Most jurors find these sorts of defenses completely convincing, as most normal people have a difficult time comprehending even the basics of healthcare laws.

This leads to what is, perhaps, the most powerful reason to hire an experienced attorney. A good lawyer can quickly make a prosecutor think twice before risking hundreds of man-hours and tens of thousands of dollars prosecuting a case that they will likely lose. This is one reason that Medicaid fraud cases are among the most easily negotiated and least likely to produce jail time.

With the right lawyer, your case will almost certainly have a good outcome.

Medicaid fraud in New York City can land you in a lot of trouble. The program was put in place to help families of limited means with healthcare and other services.

Sadly, there are occasions when Medicaid fraud is committed. This takes a toll of federal and state budgets, and it also results in a cut in services for honest recipients. If you have been charged with Medicaid fraud, you are dealing with a serious offense with serious ramifications. Trust the advice of a seasoned Medicaid fraud attorney who can help you with your situation.

Medicaid is a very complicated system and mistakes can happen. There are some doctors who have made honest mistakes in their accounting practices which lead to them being charged. On the other hand, Medicaid can lack the proper oversight, which can lead to abuse. Doctors and pharmacists are often accused of Medicaid fraud more than any other person. There are specific rules that must be followed to the letter. Any discrepancies in paperwork can be deemed suspicious. If you been indicted for Medicaid fraud on believe a charge is imminent, you will need to hire a highly-experienced Medicaid fraud lawyer to help you with your case.

Each year, the Office of Medicaid Management receives thousands of Medicaid fraud complaints. Many of them are picked up by criminal court. There are several instances in which you may be charged with Medicaid fraud:

  • Prescription falsification
  • Providing contraindicated services or supplies
  • Receiving money for services that were not performed
  • Intentionally falsifying service bills for jobs that were not performed
  • Prescription kickbacks
  • Multiple billings for same procedure
  • Billing for unnecessary procedures
  • Billing private insurance and Medicaid for the same services
  • Over billing or false billing

With the rise in Medicaid fraud cases, federal authorities are very aggressive in their handling and prosecution. Individuals convicted could face very stiff penalties including the loss of license, jail time and fines. The court will also order full restitution for monies illegally taken as a result of the fraud. If you are a medical professional who has been accused, find an experienced attorney with a solid and proven Medicaid fraud track record.

As previously noted, mistakes with Medicaid are common. There are times when something was listed unintentionally. The federal government will also look at a pattern of practice. If there are multiple billings or multiple instances of the same mistakes. This is something that can land you in a great deal of trouble. This is why doctors, hospital administrators, pharmacists and others who deal directly with Medicaid should keep and maintain good records. This could be the one thing that prevents you from being convicted. If you are dealing with a Medicaid fraud charge and believe the federal authorities are wrong, don’t delay. Get legal assistance as soon as possible. An attorney can look at your case and launch a proper defense.

A Medicaid fraud charge can have very serious implications on your life. In the last few years, a number of doctors, pharmacists and other health professionals have found themselves on the wrong side of the law regarding Medicaid fraud. A conviction could ruin your life. If you lose your license or have been jailed for Medicaid fraud, the chances of you retaining your license is very low. Medicaid can be very complex. The rules and regulations regarding the program can be confusing to say the least. It is imperative that all medical professionals do their in terms of documenting services and billing so no questions will be asked.

A New York City attorney can help you if you are charged with Medicaid fraud. Do not attempt to answer charges without an attorney present. You may put yourself in a precarious position. Let a seasoned attorney do the taking for you. Only an experienced Medicaid fraud attorney can lay out a plan of attack. They can help you win your case so that your practice and name remains in good standing. So if you need help, don’t wait until the last minute. Call and experienced New York attorney now.

Before getting into the crimes associated with Medicaid, it may help to briefly explain Medicaid itself. Only those claiming Medicaid benefits or those familiar with other recipients of the program might really understand what it entails. We know it provides for medical care for those unable to afford commercial health insurance, but where does the funding come from? It’s actually a cost-sharing initiative in which the federal government contributes to state programs. As such, healthcare providers are answerable to both the federal and state governments.

What Constitutes Medicaid Fraud?
There isn’t just one type of criminal fraud associated with Medicaid, according to the Office of Inspector General. Healthcare providers from hospitals to physicians have been known to commit various types of Medicaid fraud. To begin with healthcare providers, doctors have been known to bill Medicaid for X-rays, blood tests, and other diagnostic tests that were never actually performed. A more common practice, however, is to submit patients to those tests unnecessarily to pad the bill and therefore boost their income. Some doctors may also prescribe a generic drug to a patient, while billing Medicaid for the name brand drug.

Another practice common among physicians is to provide a disabled patient with a motorized scooter, but telling Medicaid it was actually an electric wheelchair. The latter can be as much as triple the cost of a scooter. Inappropriate billing such as this may be a common practice, but it’s also illegal.
Additionally, healthcare providers may bill Medicaid programs for care not given, either by billing deceased or fictitious patients or by billing patients no longer under the facility’s care. Along similar lines, a healthcare facility may compel patients to be transported unnecessarily by ambulance, which is a costly expense for Medicaid and patients.

A practice seen more commonly in the news of late is the practice of asking vendors for kickbacks. In exchange for referring patients to a specific vendor (such as particular pharmaceutical companies), the physician receives a kickback in the form of a cash bonus, aid vacation, or free merchandise.

Medicaid Fraud Control Units Seek To Stop Abuses
The Medical Fraud Control Unit in each state investigates cases that involve the abuses mentioned above, as well as other allegations of misconduct. Additionally, cases of physical abuse and criminal neglect of patients in Medicaid licensed healthcare facilities are also investigated. These agencies also investigate fraud committed by individuals within the Medicaid organization.

If a prosecutor can prove Medicaid fraud was intentional, a conviction carries very stiff penalties, reports AAPS Online. In cases where an individual healthcare provider filed false information, which covers many of the aforementioned issues, he can receive a prison term of up to five years and a fine of up to $250,000. A corporation would be subject to a fine of up to $500,000 for the same type of felony conviction.
There are also misdemeanor Medicaid fraud charges that carry slightly less severe consequences. An individual can be fined as much as $100,000, while a corporation would receive a maximum fine of $200,000.

Additionally, healthcare providers can be charged with violating The False Claims Act. Under this act, the state must be able to prove that the physician or institution knowingly submitted false statements and that the healthcare provider knew the information to be false at the time it was submitted. A third component of this law requires that the false information was intended to influence the actions of the agency to which it was submitted.

A conviction for violating The False Claims Act also carries a five year imprisonment term. The fine assigned to a convicted defendant can be as much as $10,000.

Whether a felony or misdemeanor, these penalties are per occurrence. In a case where a doctor routinely falsifies his patient’s records, for example, and submits false claims for 10 patients, he might be facing felony charges that will result in a fine up to $2,500,000. If the doctor in this example is also charged with violating the False Claims Act, he might also be fined an additional $100,000.

If you suspect a healthcare provider of falsifying documents to defraud the government, contact your area Medicaid Fraud Control Unit. Abuse can take many forms from theft and larceny to physical abuse and the negligence of patients. In many states, it is also a crime to fail or neglect to report such abuses. Typically a Class A misdemeanor, failure to report abuse to the government can result in a penalty of up to one year of imprisonment.

Only by eliminating misconduct can we reduce the costs of healthcare on all of us. Even state and federally funded programs are financed by the people through taxes, so ignoring instances of misconduct ultimately affects everyone’s financial standing. A dishonest healthcare provider isn’t just stealing from the government. They’re also lining their pockets with your tax money. Stand up for Medicaid, for patients, and for yourself by putting a stop to fraud.

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