As part of their investigation, HRA fraud investigators will send out payroll inquiry forms to your employer. They do this to verify the employment information that an applicant supplied on the application. Since Medicaid is an income based program, an applicant’s earnings will determine eligibility. Many applicants under report their income in order to seem eligible and obtain benefits. The HRA will ask for payroll verification going back to the time that the applicant applied for benefits. Sometimes the HRA will ask for payroll verification going back 10 years. The HRA will also ask for payroll verification for all members of the household.
What if I lied about my earnings on my application?
-If you lied about your earnings on your application, the HRA will find out. It The HRA takes this offense very seriously and will flag your case for fraud. This happens very frequently and the Bureau of Fraud is well equipped to investigate each and every case. Since the threshold for eligibility for medicaid is very low, many people under report their income.
My earnings vary month to month – am I committing fraud?
-Many medicaid recipients have earnings that vary from month to month. This is common among hourly employees, freelancers, day laborers etc. You may be eligible for medicaid one month because you worked very little and earned very little. The next month, you may pick up extra shifts and work overtime and so you may be ineligible for that month. The reality is that earnings can change from week to week or month to month. The HRA expects you to inform the center of any changes in earnings. Most benefit recipients are unaware of this obligation, or find it too burdensome to follow up on. When a case like this gets sent to the Bureau of Fraud, they review the earnings on a month to month basis when reviewing the claim.
The Payroll Inquiry Form will come from the Investigation Revenue and Enforcement Administration, Bureau of Fraud Investigaiton located at 250 Church Street, 3rd Floor New York, NY 10013. The subject of the payroll inquiry form wil be Authorization To Release Information to HRA Bureau of Fraud Investigation. The name and address of the recipient of medicaid benefits will be listed along with the HRA case number. The letter will be addressed to the payroll manager and read as follows:
The Human Resources Adminstration, Bureau of Fraud Investigations is investigating an alleged case of fraud, involving the above named client. In order to complete our investigaiton, is is necessary for us to obtain a certified copy of the following documents you have on file. The letter will state the target of the fraud investigation along with the period that they recieved medicaid benefits. The request will also ask that this request be confidential.
The payroll inquiry form will be made in accordance with the following laws:
New York State Social Services Law 132
1. When an application for assistance or care is received, or a social services official is informed that a person is in need of public assistance and care, an investigation and record shall be made of the circumstances of such person. The object of such investigations shall be to secure the facts necessary to determine whether such person is in need of public assistance or care and what form thereof and service he or she should receive. Information shall be sought as to the residence of such person, the name, age, religious faith, physical condition, earnings or other income, and ability to work of all members of the family, the cause of the person’s condition, the ability and willingness of the family, relatives, friends and church to assist, and such other facts as may be useful in determining the treatment which will be helpful to such person. However, nothing in this subdivision or elsewhere in this chapter contained shall be construed to require a social services official to communicate with or require assistance from any person or persons liable by law to contribute to the support of a woman pregnant with, or the mother of, an out of wedlock child, in need of care away from home during pregnancy and during and after delivery, in the case where the surrender of the child to the social services official is under consideration, for such period as may be necessary for such mother and official to decide whether the child will be surrendered for adoption to such official, which period shall not extend beyond ninety days after birth of the child. Except where the welfare official is in possession of positive proof that the applicant is receiving or is eligible to receive unemployment insurance benefits and the amount thereof such investigations shall include written request to the commissioner of labor or his or her duly authorized officer charged with administration of the unemployment insurance law for information as to the status of such person in respect to unemployment insurance benefits.
2. (a) All applications received by a town social services officer shall be forwarded to the county commissioner immediately and all such applications shall be investigated by the staff of the county commissioner. After investigation the county commissioner shall return to the town social services officer every application for safety net assistance made by a person residing or found in such town, together with his or her recommendation as to the eligibility ofthe applicant and the amount of assistance to be granted, if any. In addition thereto, the county commissioner shallkeep the town social services officer currently informed of persons residing in his or her town who are receiving any form of public assistance and care other than safety net assistance.
(b) In a city social services district, investigation of applications shall be made by the city commissioner of social services and his staff.
(c) In a city which is functioning under section seventy-four-a of this chapter, investigation shall be made by the county commissioner of social services and his staff.
3. The commissioner of the department of family assistance shall provide by regulation for methods of determining eligibility for public assistance and care, other than medical assistance, to be utilized by all social services officials. Such regulations shall provide for methods of verifying information supplied by or about recipients with information contained in the wage reporting system established pursuant to section one hundred seventy-one-a of the tax law and similar systems in other geographically contiguous states, and, to the degree mandated by federal law with the non-wage income file maintained by the United States internal revenue service, with the benefits and earnings data exchange maintained by the United States department of health and human services, and with the unemployment insurance benefit file.
4. (a) Investigation into the cause of the condition of a head of household or of any adult applicant or recipient and the treatment which will be helpful to such person shall include a screening for alcohol and/or substance abuse using a standardized screening instrument to be developed by the office of alcoholism and substance abuse services inconsultation with the department. Such screening shall be performed by a social services district at the time of application and periodically thereafter but not more frequently than every six months, unless the district has reason to believe that an applicant or recipient is abusing or dependent on alcohol or drugs, in accordance with regulationspromulgated by the department.
(b) When the screening process indicates that there is reason to believe that an applicant or recipient is abusing or dependent on alcohol or drugs, the social services district shall require a formal alcohol or substance abuse assessment, which may include drug testing, to be performed by an alcohol and/or substance abuse professional credentialed by the office of alcoholism and substance abuse services. The assessment may be performed directly by the district or pursuant to contract with the district.
(c) The social services official shall refer applicants and recipients whom it determines are presently unable to work by reason of their need for treatment for alcohol or substance abuse based on the formal assessment to a treatment program licensed or certified by the office of alcoholism and substance abuse services or operated by the United States office of veterans affairs and determined by the social services official to meet the rehabilitation needs of the individual. When residential treatment is appropriate for a single custodial parent, the social services official shall make diligent efforts to refer the parent to a program that would allow the family to remain intact for the duration of the treatment.
(d) A person who fails to participate in the screening or in the assessment shall be ineligible for public assistance. Other members of a household which includes a person who has failed to participate in the screening or assessment shall, if otherwise eligible, receive public assistance only through safety net assistance if they are otherwise eligible for public assistance.
(e) A person referred to a treatment program pursuant to paragraph (c) of this subdivision, and the household with which he or she resides shall receive safety net assistance while the person is participating in such treatment, if the household is otherwise eligible for public assistance. If a person referred to treatment cannot participate in that treatment because treatment is not presently available, that person and the household with which he or she resides shall receive safety net assistance if the household is otherwise eligible for public assistance.
(f) If an applicant or recipient is required, pursuant to paragraph (c) of this subdivision, to participate in an appropriate rehabilitation program and refuses to participate in such program without good cause or leaves such program prior to completion of the program without good cause, provided that program completion shall be solely determined by the guidelines and rules of such rehabilitation program, or if an applicant or recipient has been suspended from the receipt of social security disability benefits or supplemental security income benefits by reason of noncompliance with requirements of the federal social security administration for treatment for substance abuse or alcohol abuse, the person will be disqualified from receiving public assistance as follows: (i) for the first failure to participate in or complete the program, until the failure ceases or for forty-five days, whichever period of time is longer; (ii) for the second such failure, until the failure ceases or for one hundred twenty days, whichever period of time is longer; and (iii) for the third and subsequent failures, until the failure ceases or for one hundred eighty days, whichever period is longer. Good cause shall be defined in regulations by the commissioner. The household with which the person resides shall continue to receive safety net assistance if otherwise eligible.
(g) Persons disqualified from receiving public assistance pursuant to paragraph (f) of this subdivision who would otherwise be eligible for public assistance and who return to required treatment prior to the end of the disqualification period and are receiving residential care as defined in paragraph (d) of subdivision three of section two hundred nine of this chapter shall be eligible for safety net assistance.
(h) Notwithstanding any inconsistent provision of section one hundred thirty-one-o of this article, if a recipient required to participate in an appropriate treatment program pursuant to paragraph (c) of this subdivision receives a personal needs allowance, such allowance shall be made as a restricted payment to the treatment program and shall be a conditional payment. If such recipient leaves the treatment program prior to the completion of such program, any accumulated personal needs allowance will be considered an overpayment and returned to the social services district which provided the personal needs allowance.
(i) Compliance with the provisions of this subdivision shall not be required as a condition of applying for or receiving medical assistance.
New York State Social Services Law 134(a)
1. In accordance with regulations of the department of family assistance, any investigation or reinvestigation of eligibility for public assistance and care, other than medical assistance, shall be limited to those factors reasonably necessary to insure that expenditures shall be in accord with applicable provisions of this chapter and the regulations of the department and shall be conducted in such manner so as not to violate any civil right of the applicant or recipient. Such regulations of the department shall provide that where inconsistencies and gaps in the information presented by a recipient or where other circumstances in the particular case would indicate to a prudent person, that further inquiry should be made, additional necessary information is to be sought except further that the department shall provide by regulations which are consistent with federal law for matching of data supplied by or about recipients with information contained in the wage reporting system established pursuant to section one hundred seventy-one-a of the tax law and similar systems in other geographically contiguous states, and such regulations shall further provide to the extent mandated by federal law for matching with the non-wage income file maintained by the United States internal revenue service, with the benefits and earnings data exchange maintained by the United States department of health and human services, and with the unemployment insurance benefits file. In making such investigation or reinvestigation, sources of information, other than records maintained by a public agency, shall be consulted only with the permission of the applicant or recipient. However, if such permission is not granted by the applicant or recipient, the appropriate social services official may deny, suspend or discontinue public assistance or care until such time as he may be satisfied that such applicant or recipient is eligible therefor. Nothing in this section shall be construed to prohibit activities the department reasonably believes necessary to conform with Federal requirements under section one thousand one hundred thirty-seven of the social security act. The activities authorized by this section may be initiated only with regard to those clients who have been given appropriate notice of verification activity under article six-A of the public officers law.
2. At the time he applies for public assistance and care, an applicant shall, as a condition of receiving such aid, present proof of his identity to the social services official as the department may by regulation require, and he shall provide such proof thereafter whenever required by such official.
3. The social services official shall require that persons applying for or receiving public assistance and care be interviewed personally at a time and in a manner provided by the regulations of the department. Applicants or recipients shall be excused from such requirements to avoid hardship, as defined by regulations of the department. Hardship shall include but not be limited to circumstances including infirmity, serious illness or physical disability.
4. Notwithstanding any other provisions of this chapter, the department may provide for a comparison of information identifying a recipient of benefits under any program authorized under this chapter with identifying information possessed by state agencies in other states administering programs similar to those authorized by this chapter regarding recipients of such programs. Such a comparison shall be authorized only with regard to clients who have received appropriate notice under the personal privacy protection law, which notice shall be deemed compliance with the provisions of subdivision one of this section. Should the comparison of identifying information indicate that the client in question is or has been simultaneously receiving benefits in both states, the department may, in its discretion, authorize exchange of income, benefit, and other case information with the state agency of the other state.
5. The social services official upon receipt of information concerning a sentence of imprisonment imposed upon a person receiving public assistance shall make a reinvestigation of eligibility.
If you or your employer recieve a payroll inquiry form, it is imperative to speak with a medicaid fraud lawyer as soon as possible. We have offices in Brooklyn, Manhattan and Queens are available 24/7 to discuss your options. Call us at (212) 300-5196
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.