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Medicaid Fraud FAQ

Why am I being targeted for a medicaid fraud investigation?

There are a number of reasons why a medicaid fraud investigation can be initiated. The Human Resources Administration (“HRA”) investigators have access to various databases of New York State records. The includes, but is not limited to, DMV records, NY State real estate records, NY State Division of Corporation records, NY licensing records, bank account summaries, etc. A recipient of medicaid may have conflicting information on their applications and recertifications when cross referenced with information an investigator gathered from other sources. Also, it is possible that a whistleblower called in the potential fraud. A whistleblower seeks to recover money for disclosing the fraud.

What is an enrollment agent?
An enrollment agent’s job is to market medicaid products to consumers.

What happens if the enrollment agent told me to lie on the application for medicaid benefits?
Nothing, the enrollment agent has no liability. You sign the application under penalty of perjury and swear that everything on the application is true and correct. It is your personal information that is submitted with the application.

Why did I receive a letter from an investigator with HRA?
The investigator believes that you are ineligible for medicaid and/or other benefits.

Is there any difference between receiving a target letter by mail or in person from an HRA investigator?
No, they have the same effect. If you receive the letter in person, a field investigation was also likely done.

What are my rights during a medicaid fraud investigation at the HRA?
As the target letter will state, you have the right to bring an attorney or other representative to the initial medicaid fraud investigation meeting and any subsequent meetings. You also have the right to consult with a lawyer about your rights prior to the meeting, and prior to submitting any documents for review. You can not be compelled to answer any questions at the meeting. As there is potential for criminal prosecution, you can assert your 5th amendment right to remain silent.

Can my benefits be canceled because I do not participate in the HRA meeting?
Your health benefits can be terminated if the investigator concludes that you are not eligible.

What is medicaid?
It is a joint program between the federal government and the individual states to provide low income families with health insurance. Medicaid is not an insurance company.

What is family health plus?
Family Health Plus is for people ages 19–64 without health insurance coverage who are not eligible for Medicaid.

What is child health plus?
Child health plus is a subsidized health insurance program for children who are not eligible for Medicaid.

Should I go to the meeting with the Investigator from HRA?
No. If you have been targeted for a medicaid fraud investigation there was at least some evidence that you were ineligible for benefits. Depending on the facts and circumstances of your particular case, there could be a civil or criminal prosecution forthcoming. What you say during the meeting will be used against you.

Should I cooperate with an investigator from HRA?
The answer to this question depends on the facts and circumstances of your particular case. Generally, you only want to cooperate if it is in your best interest and is the only avenue to closing out the investigation and resolving it favorably.

Should I Answer the Questions at the HRA Interview?
It depends on the facts and circumstances of your case. It may be in your interest to answer questions, or it may be best to remain silent.

What are the possible penalties and consequences of an HRA investigation?
The penalties vary depending on where the investigation goes. If the case remains with HRA, and is administrative in nature, then there could be full restitution of premiums paid on your and your family’s behalf. There could be fines, interest and additional monetary penalties. If the case winds up in civil litigation then there can be a judgement which will earn interest annually at 9% and can be enforced against any real estate, other assets you own and your paycheck can be garnished. If criminal charges are brought, there can be devastating consequences. Including monetary fines, penalties, and restitution orders. You can wind up with a possible jail or prison sentence. Your professional license can be suspended or revoked completely. If you are in the US illegally, you could be deported.

Will the investigator negotiate a settlement?
Generally, the earlier you start dealing with a medicaid fraud investigation the better result you can get. In certain medicaid fraud investigations, there will be an opportunity to negotiate a resolution without a finding of fault and settle the financial claim.

Should I got to the meeting first by myself, and if it does not go well then hire a lawyer?
No, by the time the meeting is setup on the target letter the investigator has gathered sufficient evidence against you that they are calling you in to corroborate information and strengthen the case against you. If you don’t cooperate with the investigation, they won’t reveal the pertinent details to you. If you do cooperate, everything you say will be used against you.

What is recipient medicaid fraud?
If you are the recipient of family health plus or medicaid and your eligibility for benefits is investigated, the investigator has targeted you because they believe that you failed to disclose material information on your initial application for health benefits and any renewal applications. This can also be intentionally providing false or misleading information and/or concealing assets you or your family own and/or control.

What are the duties of a medicaid fraud investigator?
The medicaid fraud investigators are broken up into different levels. Each level has varying degrees of difficulty and responsibility. Initially investigators will review applications for public assistance. This can be applications for any number of the welfare programs that HRA administers which can include any number of different welfare programs. This will include rent subsidies, food stamps, Medicaid, and cash assistance. The fraud investigator will determine whether an applicant is eligible for public assistance by reviewing an applicant’s application and supporting documentation, interviewing the applicant, and verifying whether the applicant’s information is correct by calling landlords and/or employers.

Eventually, investigators will focus more of their investigations regarding the improper receipt, dissemination or appropriation of welfare funds. The investigators both work in their office, and in the field. They will locate and interview people suspected of welfare fraud, and analyze and evaluate their testimony. They will contact and interview individuals and representative of local businesses and government agencies to verify and obtain information.They will know the ins and outs of the appropriate provisions of law, and rules and regulations relating to welfare fraud. They will examine, review and evaluate a variety of records to secure information for prosecution for suspected violations of welfare law.

In cases which criminal charges are being brought, medicaid fraud investigators will confer with assistant district attorneys regarding trial strategy and the presentation of evidence. If need be they testify regarding investigative findings. They will conduct surveillance of schools. homes, businesses to create evidence for welfare fraud prosecutions and make applications for search warrants.

What Other Agencies Investigate Recipient Medicaid Fraud in New York?

  • NYC Human Resources Administration
  • Investigation, Revenue and Enforcement Administration (IREA)
  • Office of Medicaid Provider Fraud and Abuse Investigation
  • Bureau of Fraud Investigation
  • New York State Attorney General’s Office
  • Medicaid Fraud Control Unit
  • New York State Office of the Welfare Inspector General
  • Local District Attorney’s Offices
  • Office of Inspector General, U.S. Department of Health and Human Services
  • Federal Bureau of Investigation

What is the Investigation, Revenue and Enforcement Administration (IREA)?
The Investigation, Revenue and Enforcement Administration (IREA) has three subdivisions which assist the HRA and NYC social services. The three divisions are: the Bureau of Fraud Investigation, the Office of Medicaid Provider Fraud and Abuse Investigation, and the Office of Revenue and Administration. These units are all housed in 250 Church Street, down the block from our office at 100 Church Street.

What is the Office of Medicaid Provider Fraud and Abuse Investigation?
This office is part of the NYC Human Resources Administration. It conducts investigations and audits of Medicaid providers in New York City who are suspected of fraud, waste, or abuse of government healthcare programs. Investigators assigned to this office are located at 250 Church Street in Manhattan. If you are a Medical professional or Medicaid provider in New York City, and are the subject of a fraud investigation, it is likely the investigator is assigned to the Office of Medicaid Provider Fraud & Abuse Investigation.

What is the Bureau of Fraud Investigation (BFI)?
The Bureau of Fraud Investigation (BFI) conducts investigations of individuals and organized groups who are suspected of committing Medicaid fraud. It is part of the NYC Human Resources Administration’s Office of Investigation. Investigations by the BFI may result in Administrative Disqualification Hearings, lawsuits to recover money, or referrals to the District Attorney for criminal prosecution. BFI investigators work out of the NYC Human Resources Administration offices at 250 Church Street in Manhattan.

What is the Medicaid Fraud Control Unit (MFCU)?
The Medicaid Fraud Control Unit (MFCU) is a large scale broad unit which investigates and prosecutes Medicaid fraud and other healthcare crimes in New York State. It is part of the New York State Attorney General’s office.These investigations are done on a state level, rather than local level.

The MFCU targets large-scale frauds involving overbilling, kickbacks, substandard drugs and medical equipment, and “Medicaid mills” run by rings of organized criminals. The MFCU also prosecutes cases involving fraudulent billing practices by physicians, pharmacists, and other healthcare providers. The MFCU investigates and prosecutes Medicaid recipient fraud only in conjunction with provider fraud investigations and prosecutions.

MFCU investigators work out of seven regional offices in Albany, Buffalo, Long Island, New York City, Rochester, Syracuse, and Westchester-Rockland.

What is an Administrative Disqualification Hearing?
In certain cases, the HRA investigator will believe that your behavior has not risen to the level of criminal fraud and refers your case to the Office of Administrative Hearings (“OATH”) at the New York State Department of Social Services for an administrative disqualification hearing. This is an adversarial hearing in which they program will seek to disqualify you from receiving welfare benefits for a set period of time.

What do I need to disclose in order to be eligible for medicaid benefits?
Your address, where you live, the composition of your family, all household members’ income, all assets.

What are the most common types of medicaid fraud by recipients?
The most common types are unreported income and changes in household composition. There are some cases involving more sophisticated fraud where there is an uncompensated asset transfer. This is when one party transfers an asset out of their name without any compensation because the transfer is in name only. In reality, the original owner maintains the interest.

Can criminal charges be brought based on the application itself?
Yes, your intent to commit welfare fraud can be inferred from the details you submitted on your application.

How else can HRA investigators determine your intent?
Face to face interviews with the recipient and with third parties, supporting or conflicting documentation, and other factors rooted in common sense.

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Questions? Contact us today.

If you are the target of a medicaid fraud investigation, call our office 24/7 for a free consultation. We have offices in Brooklyn, Manhattan and Queens.

(212) 300-5196 or info@spodeklawgroup.com