1. Billing Discrepancies Must Be Compared with Actual Patient Care
An inaccurate claim does not necessarily mean care was never provided or fraud occurred. Compare the submitted claim with contemporaneous clinical records and the payment requirements in effect when the service occurred.
Compare Billing Data with Clinical Documentation
Match each claim's service date, provider, codes, units, modifiers, and payment to contemporaneous treatment records.
| Billing Issue | Records to Examine | Question to Resolve |
|---|---|---|
| Service delivery | Clinical notes, appointment logs, orders | Was the service provided? |
| Coding accuracy | CPT/HCPCS codes, modifiers, visit notes | Does the code describe the care? |
| Medical necessity | Assessments, diagnoses, coverage criteria | Does the record support payment? |
| Payment accuracy | Remittances, adjustments, refunds | What did the payer pay or recover? |
Service delivery
- Records to ExamineClinical notes, appointment logs, orders
- Question to ResolveWas the service provided?
Coding accuracy
- Records to ExamineCPT/HCPCS codes, modifiers, visit notes
- Question to ResolveDoes the code describe the care?
Medical necessity
- Records to ExamineAssessments, diagnoses, coverage criteria
- Question to ResolveDoes the record support payment?
Payment accuracy
- Records to ExamineRemittances, adjustments, refunds
- Question to ResolveWhat did the payer pay or recover?
This separates unperformed care from coding, documentation, and coverage disputes.
Apply the Rules in Effect on the Service Date
Apply the payer's rules effective on each service date. A missing modifier may affect payment without proving deception or intent. For federal program issues, see Medicare billing fraud.
Trace How Discrepancies Developed
Record histories, coder queries, billing instructions, and audits may show how errors arose and when staff learned of them. Internal audits are not automatically privileged. Their purpose and circulation may matter.
2. Criminal Fraud and Civil False Claims Require Different Proof
A billing irregularity can justify an audit without proving a crime. Criminal and civil laws apply different knowledge standards and require proof of the specific conduct alleged.
Federal and State Criminal Laws Address Intentional Fraud
Under 18 U.S.C. § 1347, prosecutors must prove knowing and willful execution or attempted execution of a scheme to defraud a healthcare benefit program or obtain its funds through false representations. Private plans may be covered. New York Penal Law § 177.05 separately addresses an intent to defraud a health plan through knowing and willful material misrepresentations or omissions resulting in unauthorized payment. An unsupported claim alone proves neither offense.
Civil False Claims Use a Different Knowledge Standard
The federal False Claims Act, 31 U.S.C. § 3729, addresses specified false claims involving government funds. Knowledge includes actual knowledge, deliberate ignorance, and reckless disregard; specific intent to defraud is not required. The false claim must satisfy the materiality requirement. New York State Finance Law § 189 covers certain state-law claims. See the False Claims Act overview for broader remedies.
3. Repayment Demands and Professional Sanctions Follow Separate Procedures
Billing disputes may lead to repayment, program sanctions, license discipline, or criminal charges. These proceedings can overlap, but a finding in one does not automatically establish liability in another.
Medicaid Recovery Requires Claim-Level Review
The Office of the Medicaid Inspector General (OMIG) may recover improper Medicaid payments. Compare each disallowance with the applicable rule and records. For extrapolated findings, examine sampling and calculations. Repayment is distinct from conviction. See Medicaid fraud defense.
Medical License Discipline Has Its Own Standards
The Office of Professional Medical Conduct (OPMC) investigates physicians, physician assistants, and specialist assistants. Education Law § 6530 identifies fraudulent practice as misconduct; Public Health Law § 230 governs proceedings. Other professions have separate oversight. Discipline may occur without a conviction; see medical license defense.
Program Exclusion Affects Participation Rights
OMIG sanctions under 18 NYCRR Part 515 may restrict Medicaid participation. Federal exclusions under 42 U.S.C. § 1320a-7 follow separate rules. Check the grounds, notice, review procedure, and whether exclusion is proposed or final.
4. Nassau and Suffolk Cases Follow Applicable Court and Agency Procedures
Long Island providers may hear from federal investigators, state agencies, or payers. Location affects venue, but the issuing authority and governing law determine the required response.
Federal and State Investigations Have Different Venues
Nassau and Suffolk lie within the Eastern District of New York, with a courthouse in Central Islip. Federal investigators may include the U.S. Attorney's Office, FBI, and HHS-OIG. State Medicaid matters may involve the Attorney General's Medicaid Fraud Control Unit; state charges proceed under state rules.
OMIG Audit Objections Have Specific Deadlines
For specified OMIG reviews, written objections generally are due within 30 days of receiving a Draft Audit Report. Hearing requests generally are due within 60 days of the Final Audit Report's date. Other inquiries may have different deadlines; check the notice and filing rules.
Medicaid Overpayment Disclosure Is Separate
Under Social Services Law § 363-d(6), identified Medicaid overpayments generally must be reported and returned within 60 days after identification or by the applicable cost-report deadline, whichever is later. Reasonable diligence must establish and quantify the overpayment. Acknowledged OMIG self-disclosure may toll the deadline, but an existing audit or investigation can affect eligibility.
5. The Initial Response Should Preserve Records and Clarify Obligations
An investigative request should prompt a review of its issuing authority, scope, and response deadline. Preserve existing evidence before deciding how to answer allegations or produce investigative materials.
Preserve Originals and Record Histories
Preserve charts, claims, audit trails, remittances, messages, and compliance reports. Distinguish later corrections from original entries; do not backdate or delete records. Assess confidentiality, privilege, work product, and disclosure duties before producing findings.
Identify the Questions That Control the Response
The first review should answer four questions:
- Which service, code, or medical-necessity rule is disputed?
- What contemporaneous records support or contradict the claim?
- Is this an audit, repayment proceeding, licensing inquiry, civil action, or criminal investigation?
- What filing deadlines, preservation duties, and disclosure rules apply?
The answers identify the appropriate response and applicable deadline.
26 Oct, 2026
