Medicaid Fraud Defense

Local governments have dedicated a considerable amount of resources to the investigation and prosecution of Medicaid fraud in recent years. Many states even award patients and staff who file Medicaid fraud Whistleblower lawsuits up to 30% of the recovered money. Unfortunately, this has caused many providers to be subject to investigations relating to smaller billing errors or discrepancies.

Medicaid Audits and Investigations

Medicaid audits are conducted by state agencies for purposes of determining compliance, potential overpayments, and to look for possible evidence of fraud. Often audits are conducted in response to a complaint received by the state from a patient, whistleblower, or Medicaid plan. Auditors may conduct an onsite audit or an offsite records audit (also called a desk audit). Auditors use several different fraud and overpayment detection methods. Common methods include data mining, where state analysists sort claims through statistical models to identify outliers. Other methods include evaluating a provider’s claims against similar providers within the same geographic region. If state auditors suspect fraud, they will refer the matter to the Medicaid Fraud Control Unit (MFCU). Audits can result in tens of thousands of dollars in overpayment demands, false claims charges, and anti-kickback actions.

Therefore, we advise that you seek assistance from an attorney if you are subject to a Medicaid audit or investigation. Our Medicaid fraud attorneys will work with you to prepare for the audit/investigation and work with the authorities during the investigation to protect your interests. We will work with you to ensure you submit sufficient information to support your claims and reimbursement to help avoid overpayment demands. Depending on the facts of the case, we may be able to prevent criminal charges from being filed and avoid licensing action or overpayment action.

Medicaid Fraud Actions

Providers suspected of fraud can face both criminal and civil charges for Medicaid fraud. Unlike other health law matters, Medicaid fraud cases often progress very quickly and have devastating consequences, if not handled properly and timely. Often Medicaid fraud cases are assigned to special prosecutors who are very experienced in fraud and abuse laws. Therefore, providers accused of Medicaid fraud should retain an attorney who is exceptionally experienced in handling Medicaid fraud matters at the earliest opportunity.

Our team of Medicaid fraud defense attorneys includes a former Medicaid fraud prosecutor who is exceptionally experienced in both criminal and civil Medicaid fraud matters. She is very knowledgeable in fraud and abuse laws and detection strategies. She assists providers with Medicaid audits, investigations, overpayment actions, and civil and criminal actions related to Medicaid fraud.Our Medicaid fraud team also includes a former Medicare attorney who is highly knowledgeable in Medicare audits, fraud detection, and overpayment actions. These attorneys are dedicated to assisting providers during audits, fraud investigations, and Medicaid fraud actions, and are capable of handling the most complex Medicaid fraud cases.

If charges of Medicaid fraud have been filed against you, our Medicaid fraud attorneys will work with you to prepare your defense and protect your interests. Depending on the facts of the case, we may aim to have the case dismissed, or if the evidence is against you, work to achieve a favorable settlement and limit the impact on your career.

Common Types of Medicaid Fraud

  • False Invoicing
  • Billing for services not provided
  • Billing for equipment not provided
  • Overutilization of certain medical procedures or services
  • Billing unbundled services

Possible Medicaid Fraud Sanctions

  • Criminal charges
  • Expulsion from Medicare / Medicaid Program
  • Licensing Action
  • Loss of Staff Privileges
  • Inability to collect outstanding invoices
  • Fines and costs

All Medicare and Medicaid fraud audits have the potential to evolve into criminal indictments, as well as civil recovery complaints and state professional licensing complaints. All of these potential situations have the capability of causing you long term harm, including jail time, large fines, professional license suspension and even revocation. Therefore, our team of Medicaid fraud defense attorneys work together with our licensing and health law attorneys to prevent and/or resolve subsequent matters following fraud allegations, such as licensing, credentialing, and CMS enrollment matters.

We are keenly aware of the negative impact a criminal indictment will have on your career, including your license, your standing with your employer, your reputation with your peers, your continued inclusion in the Medicaid and Medicare programs, etc. We not only work to defend you against Medicaid fraud charges, but also work to limit the impact that such charges will have on the many facets that affect your career.


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