Medicaid Fraud

Audits, investigations, or litigation related to Medicaid

More than one medical professional has concluded that the government does not always make it easy to do the right thing.

Whether accurate or not, we cannot blame a person for feeling frustration when faced with an audit, investigation, or litigation related to Medicaid billing practices from feeling that way.

The program is designed to help people who have difficulty affording medical services. The rates for services are not always equal to the rates paid by private insurance or individuals who can afford out of pocket medical expenses. Yet, medical and dental practitioners are held to a high standard and expected to account for every procedure.

While the government should hold professionals accountable for the use of taxpayers’ money, the paperwork and regulations can seem overwhelming at times.

The stated goal of the NC Medicaid Office of Compliance and Program Integrity (OCPI) is to stop fraud, waste, and abuse in Medicaid. What that sometimes means, however, is that well-meaning professionals have to respond to audits and investigations that are time-consuming and expensive. The process sometimes makes people question why they participate in the programs in the first place.

We understand these feelings and have counseled professionals facing investigations, civil litigation, and criminal charges related to allegations of Medicaid fraud. The process is scary. It can damage your reputation as a medical provider, undermine your integrity, and put your economic and personal liberty in danger.

What leads to a Medicaid fraud investigation?

Failing to report private insurance can lead to an investigation into Medicaid fraud by the Office of Compliance & Program Integrity. It is critical to consider all questions on any application carefully and disclose privately funded insurance. More important, be sure to contact counsel if an investigator contacts you during an investigation into a Medicaid application. We are happy to assist.

Using a Medicaid recipient’s Medicaid card could get the user and the recipient in trouble with the state. When the card is used with the recipient’s knowledge, both parties could be investigated and prosecuted civilly and criminally for Medicaid fraud.

Another category of Medicaid fraud involves investigations into the practices of medical and dental providers. These include allegations that a provider’s credentials are inaccurate, that the provider billed for services that were not rendered, or that the provider billed for services that were not medically necessary. Sometimes all these violations are alleged against a single provider.

These investigations can be highly technical, detailed, and time-consuming. Investigators may choose to review the details of medical records to compare to the treatment a person received. They may request supply records to compare against supplies listed on the bills. These investigations often result in a review of volumes of records, multiple interviews with the patients, and a comparison of the records and the interviews. Sometimes potential witnesses are examined under oath.

We have advised many people during investigations, represented witnesses forced to appear before grand juries, and helped clients prepare for imminent charges. We understand the exposure you face and can help you navigate this difficult process.