Avoiding Criminal Charges in Medicaid Fraud Investigations

A Medicaid fraud investigation has potentially devastating consequences, especially if it leads to criminal charges.  How you respond to investigators and prosecutors can mean the difference between an inconvenience and a career-ending prison sentence.

The first thing you need to understand is that Medicaid fraud investigators and prosecutors are not on your side.  They contacted you because they already have evidence suggesting that Medicaid fraud has occurred.  They believe that you either have information helpful to their investigation, or that you were directly involved.  Their primary objective now is to determine whether you knowingly and intentionally participated in the fraud.

Common Types of Medicaid Fraud

Medicaid fraud comes in many different forms.  The most common types of Medicaid fraud that lead to criminal charges are:

• False or fraudulent billing
• Billing for more expensive services than actually provided (up-coding)
• Billing for services that were never provided
• Billing separately for procedures that should be billed as a bundle
• Prescribing narcotics without documented medical necessity
• Selling prescriptions paid for by Medicaid
• Failing to report all your income on applications for Medicaid benefits

Criminal Intent vs. Honest Mistakes

Why do some Medicaid fraud investigations result in serious criminal charges while others are resolved with a monetary settlement?  The answer is usually proof of intent.  In order to prove a criminal case of Medicaid fraud, a prosecutor must prove that you intended to defraud the government.

There are many ways to prove an intent to defraud Medicaid.  A pattern of false statements or claims will often be used to show that they were intentional and not the result of a mistake.  Inconsistent statements can also be used to show intent.  For example, if you make statements to investigators that are inconsistent with written records, statements by others, or your own prior statements, a prosecutor will use that inconsistency to argue that you are not telling the truth.

This is why it is critical to understand all the facts and review all the records before you decide whether or not to speak with investigators.

How an Experienced Medicaid Fraud Lawyer Can Help

You should always engage an experienced Medicaid fraud defense lawyer before you speak with fraud investigators.  Your lawyer can speak with investigators and discuss their concerns before you have to decide whether to speak with them.  He can also review all of your records to identify any problem areas and help you prepare your defense.

Once you and your lawyer understand the issues and the evidence, you can develop a strategy for responding to investigators or prosecutors.  It sometimes makes sense to exercise your right to remain silent.  Other times, your lawyer may recommend cooperating, but only under a proffer agreement that prohibits prosecutors from using your statements in court as long as you tell the truth.

Your lawyer will also conduct a legal analysis.  Does the prosecutor have enough evidence to bring charges against you?  Are there gaps in the evidence that will prevent the prosecutor from proving his case?  Is there an opportunity to avoid criminal charges by negotiating a financial settlement?

These questions cannot be answered in a vacuum.  You and your lawyer must do your own investigation, gather all the facts, and develop a strategy before speaking with investigators or prosecutors.

To schedule a consultation with an experienced Medicaid fraud defense attorney, call John Howley, Esq. at (212) 601-2728.

You can also click here to download our free e-Book, “How to Survive a Medicaid Fraud Investigation.”