Why am I being investigated?
Medicaid fraud investigations
usually start because of the following factors: an unusually high number of
Medicaid claims, a computer-generated analysis of Medicaid claims and billing codes,
an anonymous call to a Medicaid fraud hotline, or a whistleblower who hopes to
get a financial reward.
What are my rights during the investigation?
You have the right to bring an
attorney or other representative with you to any interviews or meetings with
the investigator. You also have the right to consult with your lawyer before
providing any documents or answering any questions.
You have the right to remain
silent. You do not have to answer the investigator’s questions. If you are a
Family Health Plus or Medicaid recipient, your benefits cannot be stopped
solely because you refuse to answer.
Should I answer the investigator’s questions?
How you respond to the
investigation depends on your particular facts and circumstances. Some
questions and requests for documents are appropriate; others may be improper.
Sometimes it makes sense to cooperate with the investigator and negotiate a
resolution; other times you must fight to protect your rights.
What are the possible penalties and consequences?
Medicaid fraud penalties range
from restitution or repayment of what you received from Medicaid to harsh
prison sentences. Some of the possible consequences include:
• monetary fines, penalties, and
restitution orders
• disqualification from receiving
Medicaid benefits
• civil judgments and liens on
any real property you own
• garnishment of your wages
• criminal prosecutions and a
possible prison sentence
• suspension or loss of
professional licenses
• exclusion from participating in
Medicaid as a provider
• depending on your immigration
status, you could be deported
Will the investigator negotiate a settlement?
Depending on the nature of the
investigation, the investigator may be willing to negotiate a financial
settlement to avoid any court cases or criminal prosecutions. If you cannot pay
the full amount of the settlement at once, the investigator will ask you to
sign an installment note. You will receive a statement every month until the
settlement amount is paid in full.
A Medicaid fraud attorney can
help you by negotiating a settlement that reduces or eliminates penalties and
interest – and, most importantly, by negotiating an agreement that your case
will not be referred for criminal prosecution.
What is Medicaid fraud and abuse?
Medicaid fraud and abuse may
involve either recipients or providers. When a recipient of Family Health Plus
or Medicaid benefits is investigated, the investigator may suspect that the
recipient did not tell the truth or failed to disclose important information
about their income and assets when they applied for benefits. Some common types
of Medicaid fraud and abuse involving recipients include:
Who is a Medicaid Provider?
Medicaid providers include any
individual or company that is paid by Medicaid for providing services,
treatment, or products to beneficiaries. Examples of Medicaid Providers
include:
• doctors
• dentists
• pharmacists
• nurses
• occupational and physical
therapists
• hospitals and nursing homes
• home health care agencies
• ambulance, ambulette and other
medical transportation companies
• diagnostic testing labs
• durable medical equipment suppliers
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