Medicaid Fraud Investigation Questions

Medicaid fraud investigations usually start because of the following factors: an unusually high number of Medicaid claims, a computer-generated analysis of Medicaid claims and billing codes, an anonymous call to a Medicaid fraud hotline, or a whistleblower who hopes to get a financial reward.

You have the right to bring an attorney or other representative with you to any interviews or meetings with the investigator. You also have the right to consult with your lawyer before providing any documents or answering any questions.

You have the right to remain silent. You do not have to answer the investigator’s questions. If you are a Family Health Plus or Medicaid recipient, your benefits cannot be stopped solely because you refuse to answer.

How you respond to the investigation depends on your particular facts and circumstances. Some questions and requests for documents are appropriate; others may be improper. Sometimes it makes sense to cooperate with the investigator and negotiate a resolution; other times you must fight to protect your rights.

Medicaid fraud penalties range from restitution or repayment of what you received from Medicaid to harsh prison sentences. Some of the possible consequences include:

• monetary fines, penalties, and restitution orders

• disqualification from receiving Medicaid benefits

• civil judgments and liens on any real property you own

• garnishment of your wages

• criminal prosecutions and a possible prison sentence

• suspension or loss of professional licenses

• exclusion from participating in Medicaid as a provider

• depending on your immigration status, you could be deported

Depending on the nature of the investigation, the investigator may be willing to negotiate a financial settlement to avoid any court cases or criminal prosecutions. If you cannot pay
the full amount of the settlement at once, the investigator will ask you to sign an installment note. You will receive a statement every month until the settlement amount is paid in full.

A Medicaid fraud attorney can help you by negotiating a settlement that reduces or eliminates penalties and interest – and, most importantly, by negotiating an agreement that your case will not be referred for criminal prosecution.

Medicaid fraud and abuse may involve either recipients or providers. When a recipient of Family Health Plus or Medicaid benefits is investigated, the investigator may suspect that the recipient did not tell the truth or failed to disclose important information about their income and assets when they applied for benefits. Some common types of Medicaid fraud and abuse involving recipients include:

Medicaid providers include any individual or company that is paid by Medicaid for providing services, treatment, or products to beneficiaries. Examples of Medicaid Providers include:

• doctors

• dentists

• pharmacists

• nurses

• occupational and physical therapists

• hospitals and nursing homes

• home health care agencies

• ambulance, ambulette and other medical transportation companies

• diagnostic testing labs