NYC Medicaid Fraud Lawyer

Representing Medical Professionals

Medicaid Fraud

Medicaid Fraud Lawyer Focusing in Defense of Health Care Professionals in New York City

In a profession where reputation is everything, even a frivolous Medicaid fraud accusation can jeopardize your ability to practice. As Medicaid continues to serve multitudes of U.S. citizens in the city of New York, both federal and local officials work to maintain the integrity of this vital medical program.

Fighting Baseless Medicaid Fraud Allegations

With strict oversight from multiple layers of government, there are potentially crippling consequences for those accused of Medicaid fraud—particularly health care professionals such as doctors, dentists and pharmacists who are vulnerable to unwarranted accusations due to the nature of their work. Working with a Medicaid fraud lawyer in New York City will provide the best chance to defend yourself against unfounded allegations of Medicaid fraud.

According to New York law, the definition of Medicaid fraud—also referred to as health care fraud—is the action of falsifying information to benefit from reimbursements for medical care beyond the payment for the services provided. Multiple penal codes are in place to punish health care fraud infractions and to protect the American public from those who seek to defraud the government.

In 2015 alone, improper payments due to Medicaid fraud totaled over $29 billion, so the government is highly motivated to prosecute suspected Medicaid criminals to the fullest extent of the law. But as is the case with any government crackdown, innocent people are often accused of crimes that they simply did not commit. Unfortunately, in medicine, an allegation can be just as damaging as a conviction. If you’ve been informed that you’re the subject of an investigation involving Medicaid or health care fraud, be proactive and contact an NYC criminal defense lawyer who has specific experience in defending doctors and health care professionals in these types of cases.

Statutes Governing Medicaid Fraud in NYC

The state of New York categorizes health care of Medicaid fraud by both the frequency of the offenses and the dollar amount obtained by the fraudulent acts. The following are some of the most frequently referenced definitions and statutes in health care fraud cases:

S 177.00 Health Care Fraud Penal Code Articles

The state of New York considers a health plan to be any publicly or privately funded health insurance, contract, or managed care plan. A health plan provides a service and the provider receives payment, in turn.

S 177.05 Fraud in the Fifth Degree

The lowest punishable form of Medicaid fraud and the only level that’s considered a misdemeanor crime, occurs when a person knowingly or willfully provides false information or omits pertinent information. The person in question may do so for the purpose of requesting payment from a health plan for fraudulent services. Fraud occurs when the person benefits and profits from payments they are not legally entitled to. Fifth degree fraud is charged when the amount allegedly stolen from a health plan over the course of a year is $3,000 or less. is a Class A misdemeanor.

S 177.10 Fraud in the Fourth Degree

Charges of fraud in the fourth degree occur when the accused is suspected of committing one or more counts of fifth-degree fraud against the same health care plan within a year’s time, and the amount of misappropriated funds exceeds $3,000 in total. Fraud in the fourth degree is a Class E felony.

S 177.15 Fraud in the Third Degree

Charges of fraud in the fourth degree occur when the accused is suspected of committing one or more counts of fifth-degree fraud against the same health care plan within a year’s time, and the amount of misappropriated funds exceeds $10,000 in total. A third-degree fraud conviction is punishable as a Class D felony.

S 177.20 Fraud in the Second Degree

Charges of fraud in the fourth degree occur when the accused is suspected of committing one or more counts of fifth-degree fraud against the same health care plan within a year’s time, and the amount of misappropriated funds exceeds $50,000 in total. Second degree health care fraud is punishable as a Class C felony.

S 177.25 Fraud in the First Degree

Charges of fraud in the fourth degree occur when the accused is suspected of committing one or more counts of fifth-degree fraud against the same health care plan within a year’s time, and the amount of misappropriated funds exceeds $1,000,000 in total. First degree fraud is categorized as a Class B felony.

Medicaid Abuse vs Medicaid Fraud

Medicaid abuse is different than Medicaid fraud. Fraud involves misrepresentation to obtain an unauthorized benefit, while Medicaid abuse means that the practice is accused of inflating costs in a way that’s inconsistent with acceptable business practices. The City of New York, along with the Federal government, works hard to detect, report, and prevent both kinds of insurance funding misappropriation.

Law Enforcement and Medicaid Fraud in New York City

In New York City, the primary enforcement agency that deals with Medicaid fraud is the Office of Attorney General Eric T. Schneiderman. Under the Attorney General, the Medicaid Fraud Unit utilizes dozens of investigators, prosecutors, and auditors to handle accusations and Medicaid fraud cases. Federally, the Medicaid and CHIP Payment and Access Commission (MACPAC) provides policies and data analysis for legislature. The Bureau of Fraud Investigation fields complaints on fraud reporting throughout the US.

The government is leading multiple initiatives to prevent increases in Medicaid Fraud, but in their vigorous pursuit to of Medicaid abusers, they sometimes err and falsely accuse an innocent practice or person. Some of the tactics used by the government to lower fraud rates include the following:


The Office of the Medicaid Inspector General (OMIG) will work to prevent fraud, detect illegal practices, and recover Medicaid funds via audits. OMIG coordinates at the federal and local levels to investigate Medicaid fraud cases in healthcare offices. Your practice will need to routinely identify, record, and update any changes to Medicaid costs and billing. A practice’s managers should maintain solid communication to prevent inconsistencies and mitigate the risk of intrusive auditing.

Data Mining

Data Mining is a process designed to filter large amounts of digital data to create a pattern. Organizations like the State Attorney’s Office and the OMIG use data mining to quickly sift through a practice’s files. Data mining allows interested parties to analyze and detect patterns that likely indicate Medicaid fraud.

Your practice should have its data sorted and filed correctly to prevent any gaps or inconsistencies in the pattern from causing issues. When data mining analysts identify concerning data, they could launch an inconvenient investigation that could disrupt your practice and create a public embarrassment.  


The City of New York works to lower fraud rates by educating practitioners of the requirements for their businesses. If a practice is not in compliance with guidelines, consequences can be severe, so knowing the law is beneficial to all parties involved.

Risk Analysis

The City of New York is able to use its resources to identify practices with the highest risk of fraud. The patterns created with data mining are used by analysts to hypothesize about trends that practices may use to circumvent the law. The city is able to screen the available data on a practice, gauge its potential to participate in fraudulent tactics, and take action to prevent this from occurring. And while risk analysis is sometimes successful in detecting Medicaid fraud and abuse, it’s by no means perfect. Just as guilty parties can go undetected, innocent practices may be mistakenly flagged.


The Office of the Attorney General is equipped with ample resources and is capable of thoroughly investigating a practice’s activity. A full-blown Medicaid fraud investigation will likely halt or slow a practice’s business transactions. Medicaid fraud investigations are long, arduous, and costly procedures that will likely interfere with a business’s activity for the duration of the investigation and may cause patients and peers to draw unappealing conclusions.

Enforcement Actions

A practice can face consequences from the city of New York if there is suspicion of Medicaid fraud. The Office of the Inspector General, the Department of Justice, the Federal Bureau of Investigation, and different Medicaid fraud units coordinate enforcement.

More serious cases of Medicaid fraud may lead to the involvement of the FBI and U.S. Attorney general. These various agencies are able to issue subpoenas, execute search warrants, and record sworn statements.

Provider and Enrollee Outreach

When a practice is charged with Medicaid fraud, patients, colleagues, and business partners with may learn of the charges. This can damage trust and business relations with past and future clients and patients. Using media relations and reaching out to clients and providers is one of the best methods to contain and mitigate lasting damage. Public statements are admissible in court, however, so it’s important to consult your Medicaid defense lawyer prior to a press release or any other sort of external communications.

Technical Fraud and Abuse Assistance

The city of New York uses technical assets such as the Centers for Medicare & Medicaid Services to help investigate Medicaid fraud. When Medicaid and fraud abuse cases extend beyond the borders of the city of New York, as they often do, it’s imperative that the agencies of the appropriate jurisdictions communicate and coordinate their efforts. Communications like this are often flawed, however, which can lead to mistakes during the investigation and prosecution of crimes.

New York Licensing Authorities

Beyond criminal charges, doctors, medical professionals, and practices accused of fraud may undergo suspension or revocation of their licensure. New York State Education Department’s Office of the Professions, or OP, acts as the authoritative body handling medical professional misconduct. OP investigates and prosecutes the offenses of nearly all medical professions. When a licensed professional fails to meet the standards of practice, then the OP intervenes. It’s the Board of Regents—a division of the Office of Professions—that has the final say on all medical profession disciplinary matters in the state of New York.

Potential Crimes

Medical professionals are held to high standards, and reasonably so. Consequently, the state has implemented specific laws and guidelines to prevent medical misconduct. The OP may become involved if you’ve been accused of:

  • Criminal Activity
  • Practicing Under the Influence
  • Gross Incompetence
  • Gross Negligence
  • Refusing Services Based on Prejudice
  • Medicaid Fraud

New York Medicaid Fraud Investigation

Governments at the state level also act to ensure that Medicaid fraud is adequately dealt with. States such as New York use three strategies to prevent health care fraud:

Provider Screening

The Centers for Medicare & Medicaid Services have specific guidelines to investigate and prevent Medicaid fraud. Providers are held to certain standards in order to lower the risk of fraudulent organizations taking advantage of clients. When requirements are met, a practice is less likely to suffer from future investigations and audits.  

Prior Authorization

Prior authorization happens when there needs to be permission given for services before rendering them to clients. A practice will need prior authorization from officials in the field to determine the legitimacy of a practice. Outside organizations determine a practice’s legitimacy by gauging the following:

  • Benefit Coverage
  • Medical Necessity
  • Member Eligibility

Post-payment Review and Recovery

During a Medicaid fraud investigation, a practice’s funds are reviewed to spot any inconsistencies or gaps. The appropriate organizations then track the funds to ensure that no fraud is taking place. Those patients affected by the fraud will have their funding tracked and recovered.

Government Medicaid Prevention

Congress passed several health care-related provisions in the Affordable Care Act (ACA) that were designed to combat Medicaid fraud. The ACA works to provide tools to identify, detect, and take legal action against suspicion of health care fraud. To focus on beneficial changes, the ACA does the following:

  • Adds Penalties to Medicaid Fraud Crimes
  • Increases Budgets for Fraud Investigation and Reduction
  • Improves the Fraud Screening Process
  • Enhances Data-Sharing to Identify Fraud

What this means for medical practices is that it’s even more important to exercise diligence in their accounting with regard to Medicaid billing and claims. It also makes it more likely for a practice to face undue government scrutiny due to an erroneous clerical error.

Federal DEA Controlled Substance Licenses

If you work in the medical field and need to handle, distribute, or store certain controlled substances, you’ll require a license, training, and certification. The U.S. Drug Enforcement Administration (DEA) has certain requirements and guidelines in place to keep practitioners from handling scheduled narcotics and other controlled substances. Practitioners and businesses alike are expected to have current licensing or risk legal consequences.

New York Licensing Administrative Proceedings

The Office of Professional Medical Conduct investigates complaints of practitioners in the medical field. Said office overviews those subject to Orders of the State Board for Professional Medical Conduct. The Board of Regents provides additional authoritative input in the field. When you or your practice is accused of fraud charges or other misconduct, then these groups may become involved in the penalty process.

Government Integrity Provisions

The goal of Medicaid integrity is furthered through provisions of the Affordable Care Act. These include the following:

  • Investigation Suspension: If a practice is being credibly investigated, Medicaid payments can be suspended.
  • Medicaid Claims: By scrutinizing claims, it prevents inappropriate payment under Medicaid.
  • National Correct Coding Initiative: This catches medical procedures that shouldn’t be submitted together.
  • Provider Enrollment: The process screens any providers before enrollment.
  • Provider Participation: This process terminates some providers when there are records of previous problems from other programs.
  • Recovery Audit Contractors (RACs): These contractors audit payments to Medicaid providers. RACs handle overpayment cases and investigate cases of underpayment.
  • Home Health: Investigations of home health services show whether or not a health care provider has actually met with a patient.

Difference between Medicaid Fraud and Malpractice

Medical malpractice is different from abuse or fraud. Malpractice involves an injury or failure to treat a condition due to improper, illegal or negligent medical behavior. Malpractice can sometimes accompany medical fraud. An example of this would be a doctor billing for a procedure that the patient doesn’t require in order to defraud the insurance plan. Legal defense against malpractice follows a different protocol than health care fraud in the New York and U.S. legal systems.

Individuals Vulnerable to Medicaid Fraud Charges

Anyone with the ability to provide and profit from medical assistance can be accused of Medicaid fraud and abuse. Based solely on the nature of their work, the following professionals are vulnerable to being falsely accused of Medicaid fraud:

  • Doctors
  • Physician’s Assistants
  • Hospital Administrators
  • Dentists and Orthodontists
  • Pharmacists
  • Nurses
  • Dentists
  • Medical Office Managers
  • Medical Equipment Suppliers
  • Medicare Billing Workers

Victims of Identity Theft

Victims of identity theft are sometimes left having to explain crimes committed in their names. This can be particularly damaging to the reputations of medical professionals who have had their identities stolen. Identity theft in New York City and across the United States is a pervasive issue and it occurs daily. When one considers the crimes that another person is able to commit under the identity of a practitioner with Medicaid access, the ensuing damage is boundless. If you’ve had your identity stolen and you believe that a crime related to Medicaid has occurred in your name, you should consider retaining a medicaid fraud defense lawyer until the matter is resolved.

Being the Victim of Medical Identity Theft

Anyone can be the victim of identity fraud. There are multiple ways for a thief to gain a victim’s information, and afterward, the issue becomes a matter of damage control and preventing further problems. There are several government approved steps to defend against identity theft. If there are any indications that identity fraud is taking place, there appropriate countermeasures:

  • Investigation
  • Understanding FCRA Obligations
  • Data Security Checks

Multiple agencies and organizations work to sort through identity fraud cases. Having professional investigators examine a case is essential to resolving the issues surrounding an occurrence of medical identity theft. Identity thieves committing Medicaid fraud can destroy the victim’s practice, which means that investigators need to proceed carefully when pursuing these very nuanced cases.

Agencies Working to Prevent Identity Theft

In addition to the Federal Government working to prevent identity theft in the healthcare industry, groups such as the Medical Identity Fraud Alliance (MIFA) work to make sure that your identity theft case is investigated. By enlisting the help of official fraud prevention organizations, you can strengthen your defense in court, should you have to defend crimes committed by someone else in your name. You will need an attorney experienced with cases related to identity theft and Medicaid fraud to help sort out the legal aspects of your case and explore all avenues of protection.

Types of Medicaid Fraud putting Medical Professionals at Risk for Identity Theft

Medicaid fraud or health care fraud, as discussed throughout, is the act of deceiving patients, insurance companies, or the government, and taking advantage of them for financial gain. As a health care provider, these are the types of fraud that are being committed in your industry and the ones that you could find yourself falsely accused of committing:

  • Billing For Unperformed Services
  • Overcharging
  • Charging for One Service Separately
  • Charging Twice for the Same Service
  • Dispensing False Drugs
  • False Location Claims
  • Re-selling Products Obtained Through Medicaid Benefits
  • Embezzling
  • Failing to Disclose Information
    • Rent
    • Income
  • Prescription-Related Issues
    • Alterations
    • Forging
    • Duplication
  • Providing Particular Services
    • Unspecified Services
    • Medical Services for Improper Payment
  • Providing False Information on Applications or Recertifications
  • Reporting False Costs
  • Taking or Giving Bribes
  • Ordering Excessive or Inappropriate Tests.

Medicaid fraud laws work to protect patients, as the subject of any of these crimes faces potentially irreparable damage to their reputation. Even if a medical professional is the victim of identity theft, the crimes will accrue against them—which is why it’s important that individuals facing these circumstances hire an attorney that concentrates in medical fraud law.

Effects of Laws Broken by an Identity Thief

All crimes committed by an identity thief under a victim’s name are naturally attributable to the victim, amplifying the damage to that individual’s life and reputation. As crimes accumulate, victims could find themselves facing arrest for charges that could ruin their medical careers. If you even suspect that there may have a been misappropriation by another entity on any of your privileged medical information, it’s imperative that you immediately consult an attorney who focuses on health care fraud and identity theft. If identity theft is not handled aggressively, the problem could escalate into a health care fraud investigation.

What Happens During a New York Medicaid Fraud Investigation?

Medicaid fraud investigations involves several different groups throughout the process. After the investigators, the first party that is involved are the prosecutors that you will face in court. Before going to court, your legal team from a New York City-based practice will need to confer with the Office of the Attorney General and the Medicaid Fraud Control Unit. New York City has multiple groups handling both Medicaid prosecution and defense, so knowing what to do in an investigation is vital for your legal protection. Knowing the law, understanding the charges against you, and knowing what resources you have available to you will work in your favor if you are arrested or questioned.

Regardless of whether you’re certain about your innocence or not, you should never agree to answer questions without your attorney present. When you are questioned, there are certain guidelines officers must follow. There’s a distinct difference between appropriate and improper questioning, and this distinction will be enforced by your lawyer. During questioning, there may also be a chance for negotiation, which your attorney can handle in order to receive the best result. It’s important to remember that individuals who’ve been accused of Medicaid fraud have rights and they are entitled to due process.

DEA Administrative Registration Hearings

The DEA is required by law to allow the accused a public administrative hearing over the status of their DEA registration to handle controlled substances. Pending the outcome of that hearing, the agency will be able to push for denial on any application for license registration or change the status of any existing registration to suspended or revoked. The reasoning for the DEA’s actions are stated and the hearing will dictate the status of a controlled substance license as well as the consequences for the practitioner.

What to Do If Falsely Accused of Health Care Fraud in NYC

If you’re arrested on false charges, it’s important that you take immediate action to prevent the situation from becoming much worse. You have the right to remain silent, and until you’ve spoken with your attorney, it’s to your benefit to exercise it. Police and health care fraud investigators are trained to use interviews as a way of gathering evidence to support their case. A misstatement or a phrase taken out context can make your lawyer’s job much more difficult.

On a different note, if you are a Medicaid beneficiary yourself, the investigation should not interfere with the benefits you receive. Make certain that you disclose this fact with you Medicaid fraud attorney.

Past New York City Medicaid Fraud Cases

If you think you are the first to be falsely accused of Medicaid fraud, you aren’t. One example involved a doctor’s receptionist who was caught forging prescriptions, which led to an investigation of the doctor as well. There are even cases where non-practitioners pretend to be medical professionals—such as a man who pleaded guilty to posing as a dentist in a Queens practice.

Situations such as these and others will require you to implement an aggressive legal defense to avoid a Medicaid fraud conviction. A New York State investigation revealed widespread Medicaid fraud, which has led to supervisory hypervigilance. With so many cases pertaining to fraud and forgery, it is more important than ever to make sure your legal defense represents and advocates on behalf of the legitimacy of your practice.

Why Hiring a Health Care Fraud Lawyer is Imperative

Health care fraud entails several legal layers you must interpret and understand in order to craft a solid defense against accusations. The legalities are complex; a single mistake could lead to disastrous results for your case—which is why it’s recommended that you hire an attorney practiced in this unique niche. Because of the granular nature of Medicaid laws, fraud and abuse cases require knowledge and experience to analyze the probable cause against you and develop a solid legal defense.

Medicaid Fraud Punishments

Medicaid fraud is a considerable issue in New York City, and the courts have answered the problem by increasing penalties against individuals convicted of Medicaid crimes. In most cases, Medicaid fraud is a felony and punishments are harsh. Medicaid fraud charges may lead to one or more of the following:


Fines for Medicaid fraud charges come with court conviction and generally are a reflection of the amount of funds fraudulently taken. The degree of charges determines the amount of fines, including recovered funds. Fines can be tens of thousands of dollars.

Restitution Orders

The court can order reimbursement of the moneys taken from victims. Restitution can stack on top of fines and reflect the money owed, which may amount to millions.

Medicaid Benefit Disqualification or Exclusion

Fraud charges may disqualify or exclude a practice from future Medicaid benefits and programs. Felony conviction leads to mandatory exclusion of no less than five years. Prosecutors are able to suspend and withhold provider payments to exert pressure on the accused.

Civil Judgements

A civil lawsuit by wronged clients may be resolved if the court issues a civil judgement. The civil judgement is the final decision of the court regarding the dispute between the practitioner and clients. A court will be able to order restitution or further payments in order to have the plaintiff’s losses addressed. A civil judgment can be nearly as damaging to one’s reputation as a criminal charge.


A federal tax lien usually results from the tax evasion that inherently accompanies Medicaid fraud. The lien is the government’s legal claim against a practice that has neglected or failed to pay its taxes. The government can protect its interest in property via a lien. The assets affected include can real estate, personal property, credit, and other financial assets.

Wage Garnishment

Reimbursement for Medicaid fraud may require the regulation of paychecks and forced deductions on paychecks. Wage garnishment can be the result of court orders for restitution, fines, or damage awards.

License Loss or Suspension

Medicaid fraud may lead to the loss or suspension of a medical license entirely. Even if the accused was only in the employ of the practitioner, there may still be consequences to that practice’s medical license.


Felony level Medicaid fraud is capable of leading to deportation. Depending on the level of degree, entry back into the United States may be barred entirely.

Jail Time

Even though it’s a misdemeanor, even fifth degree Medicaid fraud may still result in jail time. A practitioner may face up to year in jail or three years’ probation as a result from a Class A conviction. Higher levels of Medicaid fraud are punishable by prison instead of jail.

Prison Time

First, second, third, and fourth degree fraud are all felony-level charges, punishable by prison terms ranging from one to twenty-five years. Probation is unavailable after second degree of Medicaid fraud.

Conviction Consequences on Licenses

The Board of Regents is able to issue harsh penalties for medical misconduct based on the charges. A censure may be issued which will damage both public standing and reputation in the medical field. Depending on the type of misconduct taking place, the fines issued could reach up to $10,000. In a worst-case scenario, the Board of Regents are able to suspend or even revoke a license entirely.

DEA Conviction Consequences

The DEA implements harsh penalties for controlled substance related crimes. You could be facing imprisonment, heavy fines, and medical license revocation. Penalties issued by the DEA may also be added to those issued by state or federal court and authorized by law. A hearing may take place to determine the suspension or revocation of a DEA controlled substance license.

Defense and Recovery from False Accusations

In order to further defend against false accusations of Medicaid fraud, there are different ways to plan ahead of time and preemptively create a defense against worst-case scenarios. A compliance plan can help you make sure that your practice is up to government standards and can help prove identity theft took place in extenuating circumstances. The faster you bring your attorney in and construct a defense strategy, the more favorable the trajectory of your health care fraud defense may be.

Hire a Health Care Fraud Law Firm that Serves Clients in New York City and the Surrounding Areas

Medicaid fraud accusations are a danger to both your medical career, your practice, and your freedom. We work in New York City and the surrounding areas to defend you against false Medicaid fraud charges. Our law firm has the qualifications and case experience in this unique niche to develop your defense. We aggressively advocate on your behalf in court. Call now for a free consultation on your Medicaid fraud case.

Contact The Law Office Of Ali Najmi today!


“Ali Najmi did excellent work reducing my case to a minimum, helping me avoid jail time as well as giving me the opportunity to have another chance to live a law abiding life. I had quite a heavy case and Ali succeeded in defending me.”

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