Medicaid Fraud Defense in New York

Medicaid fraud cases are pursued by the Medicaid Fraud Control Unit (MFCU) of the Office of the Attorney General, the Office of the Medicaid Inspector General (OMIG), HRA, and federal prosecutors when the conduct touches the federal share. Recipients and providers face different but parallel exposure.

Recipient Fraud

The typical recipient case alleges that the applicant failed to disclose income, assets, household composition, or a parent's whereabouts when applying for Medicaid. Charges are usually brought as welfare fraud under Penal Law Article 158 and as offering a false instrument for filing under PL §§ 175.30 or 175.35. The administrative side runs in parallel: overpayment recoveries, fair-hearing rights, and disqualification.

Provider Fraud

Provider cases against doctors, dentists, home health agencies, pharmacies, durable-medical-equipment suppliers, and behavioral-health providers are larger and more document-intensive. The MFCU subpoena typically demands billing records, patient charts, and personnel files. Issues include:

• Upcoding and unbundling under CPT-coding rules
• Phantom services and rendered-by mismatches
• Kickbacks under the federal Anti-Kickback Statute, 42 U.S.C. § 1320a-7b
• Stark Law self-referral issues, 42 U.S.C. § 1395nn
• Excluded-provider issues under 42 U.S.C. § 1320a-7
• False Claims Act exposure (civil) under 31 U.S.C. § 3729

Home-Care Aides and CDPAP

The Consumer Directed Personal Assistance Program (CDPAP) has produced its own wave of Medicaid-fraud prosecutions, with aides accused of submitting timesheets for hours not worked. We defend aides and consumers in these cases by attacking timekeeping records and the procedures used by the fiscal intermediaries.

Settlement and Negotiation

Many provider Medicaid cases resolve through civil settlements, corporate integrity agreements, and exclusion negotiations rather than indictments. Early lawyering preserves those options.

If you are being investigated for Medicaid fraud as a recipient, provider, or employee, call us at 212-233-1233 or email [email protected].