Picture this: you're a health care provider. Your business largely depends on Medicaid billing. In fact, Medicaid pays your bills. Your business is booming and then one day you get a letter or a call from The Office of Medicaid Management or an Attorney General's Office. They tell you they investigate certain claims made by your office. They ask you for your billing records and your mood suddenly is not the same it was 5 minutes ago. Assuming the investigators have reasons not be impressed with your Medicaid billing practices, you will need a lot of hope and maybe some serious help because serious trouble is probably on the way.
New York's Medicaid program has been funded more than 40 years ago and what it presently is may be defined as a cash cow or a 'honey jar' that attracts all kinds of money-loving bees. New York Medicaid enrolls millions of people and spends over $40 billion a year for everything from medical care to transportation to adult daycare to paying for shoes, diapers, etc. Because may Medicaid programs were so easy to exploit, New York Medicaid fraud became quite rampant and uncontrollable. It became an industry in itself and fortunes were made on Medicaid Fraud.
There are several ways in which Medicaid Fraud can occur. The most popular method of Medicaid fraud with which defense attorneys routinely deal is billing for services that were not provided. In fact, some providers manage to bill millions of dollars in fees for services they have never performed. The next forerunner is double billing (billing Medicaid after private insurance and/or the recipient have already paid for services). Unnecessary procedures and appointments billed to Medicaid are popular, too.
Many providers find themselves in hot water because they have unlicensed personnel perform services that may only be provided by licensed persons as per Medicaid regulations and bill Medicaid as if the professional do the work. Health care providers routinely overcharge Medicaid by inflating time they actually spend on providing their services.
On occasions, providers engage in fees sharing with other provider. This means referring patients to other offices that bill Medicaid and share the reimbursement paid by the Medicaid program.
Among New York Medicaid Providers involved with New York Medicaid Fraud are medical and dental offices, 'ambulette' transportation companies, hospitals, nursing homes, pharmacies, school districts officials, and even retailers.
New York Medicaid Fraud cases may be investigated by the Office of Medicaid Management, the Office of the Attorney General, the local law enforcement, or even federal investigators. Because the problem has gotten out of hands lately, Attorney General Cuomo and the local district attorneys are really cracking down on New York Medicaid Fraud. According to the April 30, 2008 Attorney General Office's report, New York had recover $112,5 millions in Medicaid fraud recoveries in 2007.
The latest in the string of New York Medicaid Fraud indictments is the prosecution of B&H Health Care Services, Inc., (Nursing Personnel Home Care), a Licensed Home Care Service Agency and half a dozen of its shareholders and managers who managed to bill over $30 million in Medicaid fees.
Providers accused of New York Medicaid Fraud face various fraud-related charges as well as civil suites claiming damages. In the case of B&H Health Care Services, for example, the indictment contains charges of Grand Larceny in the First Degree (a Class B felony that carries a mandatory minimum sentence of 1 year and a maximum sentence of 25 years' imprisonment) and charges of Offering a False Instrument for Filing in the First Degree (a Class E felony that carries a maximum sentence of 4 years' imprisonment.) The civil suite filed by the state demands treble damages of $90 million.
If it is a federal investigation, charges and potential consequences, both criminal and financial, could be even more severe.
So, let's go back to the beginning. You get that letter or a phone call. Your next steps are limited to telling the investigators to disappear from your life, telling them all they want to hear, or telling them that your lawyer will contact them for you. Let me end with a banality: if you are accused or investigated for Medicaid Fraud, it is not the time to do it yourself.
Joseph Potashnik is an attorney in New York City and Northern New Jersey where he practices criminal defense and civil litigation. You can visit his websites at www.jpdefense.com (for NYC) and www.jpcriminaldefense.com (for NJ)