Your first notice of the investigation is usually a letter from the NYC Human Resources Administration asking you to bring your tax returns and other documents to an “interview” at 151 West Broadway in lower Manhattan.
By the time you receive this letter, the Medicaid fraud investigator has already conducted an investigation. They know where you live, who you live with, where you work, and whether you own a home or a car.
They also have all your applications and re-certifications for Medicaid. If the information they have gathered in their investigation is different than what you put on your application and re-certification forms, then you could have a very serious problem.
You should get advice from an experienced Medicaid fraud attorney. Your lawyer can help you present your case and negotiate a resolution in an effort to avoid criminal charges.
The most common types of Medicaid eligibility fraud include:
Your Income: Your eligibility for Medicaid, Family Health Plus, and Child Health Plus is based on your monthly income. If your income exceeds the eligibility levels for these programs, then you are not eligible to receive benefits.
Understating your income, or failing to disclose income from a spouse or rental property, is a type of Medicaid fraud. It can result in a lawsuit against you for restitution – that is, the City can sue you to pay back all the benefits you received. Misrepresenting your income can also result in criminal charges being filed against you.
The Bureau of Fraud Investigation has a number of ways they can discover what your actual income is. Sometimes they ask your employer for payroll records without telling you. other times they infer what your income must be based on your expenses. For example, if you wrote that your income was only $1,000 per month, but public records show that you are paying a $2,500 per month mortgage, then they will infer that your income must be more than what you said it was.
Your Residence: Eligibility for Medicaid and Family Health Plus is based on where you live. If you are receiving these benefits through the New York City Human Resources Administration, then you must be a New York City resident.
People sometimes move out of New York City and fail to change their address for their Medicaid and Family Health Plus benefits. This creates a problem.
Even if your income is still below the eligibility levels for Medicaid where you live, you do not qualify for benefits from New York City. You may be asked to pay back thousands of dollars and, in some cases, tens of thousands of dollars. And if you lied about where you lived on your application or re-certification forms, you could face criminal charges.
Home and Asset Ownership: If you applied for Medicaid or Family Health Plus before 2010, then you were required to disclose if you owned or home or had other assets such as bank or investment accounts. Failing to disclose your assets, or understating their value, can constitute Medicaid eligibility fraud.
After 2010, your eligibility was determined only by looking at your monthly income. But the investigators still may want to know if you own a home. As mentioned above, your ability to pay a mortgage may raise questions about what your actual income is.
Employer Health Insurance: Your eligibility for Medicaid and Family Health Plus is also affected by your ability to obtain health insurance from your employer.
The application and re-certification forms for Medicaid and Family Health Plus ask whether you are able to obtain health insurance through your employer or your spouse’s employer. Providing a false answer to that question may constitute Medicaid eligibility fraud, even if you never actually received medical benefits from an employer.
Here’s the bottom line: Medicaid fraud is a serious offense. You could face lawsuits to recover money from you and even criminal charges. A letter from an investigator, therefore, should be taken seriously and should not be ignored.
To arrange a free and confidential consultation with an experienced Medicaid fraud attorney, call John Howley, Esq. at (212) 601-2728.
John Howley, Esq.
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