A state program with federal money
Medicaid is run by each state with federal funding, so enforcement often starts at the state level. In New York, the Office of the Medicaid Inspector General audits providers and can recover overpayments or exclude providers from the program, while the Attorney General's Medicaid Fraud Control Unit investigates and prosecutes provider fraud and patient abuse. Federal agencies and prosecutors can join, particularly in larger cases. Other states have their own versions; in California, for example, Medi-Cal audits run through the Department of Health Care Services, and the state Attorney General has its own fraud unit. Allegations commonly involve billing for hours or services that were not provided, timesheets that do not match visits, or kickbacks for referrals.
Recipients face a different process
People who receive Medicaid can also be accused, usually of misreporting income or household changes when applying or renewing. Those cases are often handled first by the local social services agency, which may seek repayment or end coverage, and some are referred to prosecutors. A notice about eligibility or an overpayment usually comes with a limited time to request a fair hearing, so do not set it aside. Gather the applications and renewals you submitted, pay records and bank statements for the period, and any letters you sent the agency. Talk with a lawyer before giving a statement to an investigator.
For providers and aides
Providers should treat an audit or document request as the start of a process with deadlines, keep records exactly as they are, and avoid adding notes after the fact. Aides and other staff contacted by investigators should know that the agency's lawyers represent the agency, and that they may need advice of their own. In a first meeting we work out which office is involved, whether the matter is an audit, an exclusion threat, or a criminal investigation, and how those tracks affect each other. We also look at licensing and immigration consequences where they apply. Those answers determine how we reply to the agency and whether we approach prosecutors.
