New York City Health Care Fraud Lawyer: What Billing Records Show

A service may have occurred but failed a coverage requirement. Prior authorization, meanwhile, does not prove that the billed service occurred. Determine whether the dispute concerns treatment, coding, provider identity, or eligibility before assessing health care fraud.

Keep original claims, remittance advice, denials, resubmissions, and refunds together. Amounts billed, allowed, paid, and allegedly overpaid differ. A correction may help explain an error, but its timing matters. Repayment does not automatically resolve allegations about earlier conduct.

Under Penal Law §177.05, the prosecution must establish intent to defraud a health plan and knowing, willful submission of materially false information or omission of material information to request payment. The completed offense also requires resulting payment to which the recipient was not entitled. The analysis must connect the alleged deception to improper payment.

Federal health care fraud under 18 U.S.C. §1347 reaches knowing and willful execution, or attempted execution, of a fraudulent scheme involving a health care benefit program. An unpaid claim is therefore not automatically outside its scope. Prosecutors must prove the charged crime beyond a reasonable doubt.

The civil False Claims Act reaches actual knowledge, deliberate ignorance, and reckless disregard; it does not require specific intent to defraud. An ordinary mistake alone does not establish that standard. Materiality concerns the falsehood's significance to payment, rather than simply whether a rule was violated.

Common-law fraud generally requires a material misrepresentation, knowledge of falsity, intent to induce reliance, justifiable reliance, and resulting damages. These are not universal requirements for criminal or FCA liability. Likewise, the absence of patient loss does not establish that an insurer or government program suffered none.

Contracts show promised services and payment terms; contemporaneous clinical records help establish what happened. Nonperformance may support breach of contract litigation without independently establishing fraud. A knowingly false statement inducing the agreement requires separate analysis, including whether the fraud claim duplicates the contract claim.

A coding warning matters differently depending on its wording, recipients, and subsequent actions. Review audit findings, software changes, billing instructions, and communications with outside billers. A documented correction differs from an instruction to continue billing after a clear warning. Neither outsourcing nor a job title determines responsibility by itself.

Retain attachments, metadata, and audit trails. Do not overwrite earlier entries to complete a file. Legitimate corrections should follow applicable recordkeeping requirements and remain traceable. Before producing records, review the request's authority, scope, and applicable privileges.

Manhattan and the Bronx fall within the Southern District of New York; Brooklyn, Queens, and Staten Island fall within the Eastern District. Actual federal venue depends on the offense's connection to the district. NYC Criminal Court handles misdemeanors and initial felony proceedings; Supreme Court Criminal Term handles felony cases. The state Attorney General's Medicaid Fraud Control Unit investigates and prosecutes Medicaid provider fraud; its role differs from OMIG's administrative oversight.

A federal FCA civil investigative demand specifies response requirements. A petition to modify or set it aside generally must be filed within 20 days after service or before its return date, whichever comes first, unless an authorized written extension applies.

For proposed-action notices governed by 18 NYCRR §515.6, objections generally must be mailed within 30 days of receipt. Preserve delivery evidence; this deadline does not govern every Medicaid audit.

Penal Law §177.30 provides a limited affirmative defense for certain nonexecutive employees who merely followed authorized employer or supervisor orders without personal benefit. Its conditions require individual review. It does not automatically defeat federal charges.