FREQUENTLY ASKED QUESTIONS

Below are some of the most frequently asked questions from our Medicaid fraud clients:

What is Medicaid fraud?

In simple terms, Medicaid fraud is the misuse of federal Medicaid funds and benefits. It can be committed by both  providers and beneficiaries.

What is the NYC Human Resources Administration (HRA)?

The NYC Human Resources Administration is a department of the government of New York City dedicated to fighting poverty and income inequality by providing New Yorkers in need with essential benefits through numerous social service programs.

What is the Bureau of Fraud Investigations (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.  

What is an Administrative Disqualification Hearing?

If the BFI does not categorize your case as a criminal offense, the investigator may refer your case to the Office of Administrative Hearings (OATH) at the New York State Department of Social Services for an Administrative Disqualification Hearing. The purpose of this hearing is to attempt to ban you from receiving benefits for a specific period of time.

Why did I receive a letter from the BFI?

Providing false income information on Medicaid applications/recertifications, duplicating or sharing Medicaid ID cards, requesting unnecessary medication or medical procedures, and/or other irresponsible utilization of Medicaid services may have sparked suspicion surrounding your eligibility for Medicaid benefits and made you a target of investigation.

How does the HRA find out that I provided false information?

The HRA has access to databases containing information about your employment, education, property, and banking records. In the event that the information you provided on your application/recertification does not match the information listed in the databases, you will be targeted for Medicaid fraud investigation.

What should I do if I received a letter from the NYC HRA?

If you received an HRA investigation letter, you should consider seeking the help of an experienced attorney who will represent you in your Medicaid fraud investigation case. He or she will help you gather all relevant documents and go through the investigation process in the most convenient manner in order to minimize your losses.

Who will investigate?

Medicaid fraud committed by participants is investigated by the Department of Social Services. The Attorney General’s Office and the Medicaid Fraud Control Units only have the right to investigate fraud committed by providers.

What are my rights if I am being investigated for Medicaid fraud?

During the interview, you have the right to remain silent. In addition, the HRA letter states that you have the right to bring an attorney to the initial meeting with an investigator. Prior to this meeting, you can, and should, meet with a qualified Medicaid fraud attorney to discuss your rights in detail and submit any necessary documents for review.

Should I answer the questions I am asked during my HRA interview?

If there is any potential criminal prosecution, you can exercise your right to remain silent. You do not need to respond to any of the investigator’s questions.

What process do the NYC HRA investigators follow specifically and what can I expect at each step?

1) The NYC HRA investigators begin an investigation because of inconsistencies in your bank or property records or tax returns, or a phone call from a Medicaid fraud whistleblower (a person who reports people that they suspect are guilty of committing Medicaid fraud).

2) You will receive a request from the HRA to authorize the release of your information to the HRA Bureau of Fraud Investigation and related third parties. The investigators will have the opportunity to conduct field visits which consist of taking photos of your house, your cars, and your workplace.

3) Once the field visits are completed, the investigators will send a letter requesting you to come to an interview and submit various documentation so that they may analyze your eligibility for Medicaid.

4) An experienced Medicaid fraud attorney will always want to review and analyze your Continuing Disability Reviews (CDRs). A CDR is a detailed form listing all payments made by the provider for the recipient in the Medicaid fraud case.

5) Finally, you and your Medicaid fraud attorney will meet with the HRA investigator for your interview.  From here, you will review your document, discuss any settlement options, and/or give in any evidence that may dismiss your case, or subject it to court prosecution.

What are the possible consequences of this investigation?

If you are convicted of Medicaid fraud, the legal consequences may include monetary fines, restitution orders, disqualification from receiving Medicaid benefits, wage garnishment, criminal prosecutions, prison sentences, suspension or loss of professional licenses, asset confiscations, and/or deportation.

What is the New York Medicaid Fraud Control Unit (MFCU) and how does it operate?

The New York Medicaid Fraud Control Unit (MFCU) is a law enforcement entity made up of investigators, auditors, attorneys, and administrative staff. It has the statewide authority to investigate, penalize, and prosecute individuals involved in criminal welfare cases in New York.

What types of medical providers are targeted for fraud charges?

Many medical providers and practitioners are targeted for fraud charges, including doctors, physician assistants, dentists, chiropractors, optometrists, clinical psychologists, optometrists, nurses, and more.

Do I need a Medicaid fraud attorney and how can they help my case?

It is highly recommended that you obtain an experienced attorney in order to avoid incriminating yourself and thereby undermining your case with any sensitive information you disclose. A qualified attorney will help you go through the investigation process as smoothly as possible while safeguarding your interests. They will help make sure you do not disclose any self-incriminating information, while providing all the appropriate documents required by the investigators, and possibly reducing any charges and punishments that you may be accused of.