Responding to a Medicaid Fraud Control Unit Investigation

The Medicaid Fraud Control Unit is part of the New York State Attorney General’s office.  It is charged with identifying, investigating, and prosecuting Medicaid fraud by physicians, nurses, dentists, pharmacists, physical therapists, durable medical equipment suppliers, hospitals, nursing homes, and other healthcare providers.

Medicaid fraud is the largest unit inside the Attorney General’s office, and it is staffed with some of the most experienced lawyers, auditors, and investigators.  Every year, the unit recovers hundreds of millions of dollars from healthcare providers in the form of restitution and fines.  It also receives 3 to 1 matching funds from the federal government.  As a result of the money available, the unit is constantly adding more prosecutors, auditors, and investigators.

The Medicaid Fraud Control Unit is very aggressive.  It does not focus only on so-called “Medicaid mills,” where organized criminals set up sham entities for the sole purpose of billing Medicaid.  The unit also targets legitimate healthcare professionals. 

In fact, the Medicaid Fraud Control Unit frequently targets physicians, pharmacists, and other healthcare professionals who run legitimate practices.  Many of the unit’s prosecutions are for using the wrong billing codes, failing to maintain adequate records, or having business relationships that violate the anti-kickback and physician self-referral laws.  

What may seem like a technical violation can result in felony charges and a prison sentence.  Even if you avoid a criminal conviction, your career can be ended by the loss of professional licenses or exclusion from the Medicaid and Medicare programs. 

Responding to a Medicaid Fraud Control Unit investigation requires highly specialized legal advice.  It is not enough to retain a capable criminal defense lawyer.  You need a lawyer who understands the constantly changing Medicaid rules, and who understands how the Medicaid Fraud Control Unit conducts investigations and makes decisions. 

Early intervention is your best chance of avoiding a criminal prosecution or reducing the charges.  If you are innocent, the investigation stage is your last chance to convince the investigators before criminal charges are filed against you.  If you made mistakes, the investigation stage is your last chance to negotiate a financial settlement or favorable plea agreement.

Most Medicaid fraud cases are won (or lost) at the investigation stage, before the prosecutors have decided to file any criminal charges.  By working with Medicaid Fraud Control Unit investigators early in the process, your lawyer can help you develop a strategy to respond to their concerns. 
 
It is, therefore, critical to retain an experienced Medicaid fraud defense lawyer as soon as you have any indication that you are under investigation.

To schedule a free and confidential consultation with an experienced Medicaid fraud lawyer, call John Howley, Esq. at (212) 601-2728.