Audit, overpayment, or criminal case
Medicaid fraud defense begins with figuring out which kind of matter you are facing, because each runs on its own track. In New York, audits, recovery of overpayments, and exclusion from the program are generally handled by the Office of the Medicaid Inspector General, while criminal investigations are usually pursued by the Medicaid Fraud Control Unit in the Attorney General's office, and federal agencies can be involved as well. A billing error, even a repeated one, is not the same thing as fraud. In criminal cases the dividing line is generally whether false claims were made knowingly, not whether the paperwork was imperfect. Civil cases under false claims laws, sometimes started by a whistleblower, can run alongside either track.
Records and conduct after first contact
Keep copies of what was requested and what you produced, and do not alter, backdate, or 'complete' records after the fact. Late changes to documentation can turn a defensible billing dispute into an obstruction problem. Gather billing policies, the coding guidance you relied on, training records, and any earlier audit correspondence. Employees may be contacted directly by investigators and are entitled to speak with counsel; how that is handled with staff deserves careful thought, since anything that looks like pressure on a witness creates new trouble. Repaying an identified overpayment can be required within a set period, and self-disclosure has its own channels, so those decisions should be made with counsel promptly rather than put off.
Early defense decisions
In the first meetings we work out whether you are viewed as a witness, a subject, or a target, and what the government appears to be focused on. We also look at the collateral exposure that often matters as much as the case itself, including exclusion from Medicaid and Medicare, professional licensing, and payment suspensions that can strain a practice before anything is proven. From there we decide whether to engage with auditors or investigators, how to answer records demands, and whether an independent billing review would help your defense. Those decisions are made with you and revisited as more becomes known.
