1. Identify What the Notice Challenges
A repayment notice may question documentation, coding, or coverage. A subpoena may seek records without identifying disputed claims. Record the issuer, payer, service period, legal authority, requested materials, and response date before preparing an answer.
Connect Findings to Individual Claims
List each claim’s service date, clinician, code, modifiers, units, and payment beside the stated objection. Fabricated treatment and an unsupported billing level require different evidence. For broader requests, identify the patient population and date range while reviewing scope, confidentiality, and available objections.
Identify the Proceeding
The Office of the Medicaid Inspector General (OMIG) audits Medicaid payments and pursues administrative remedies. The Attorney General’s Medicaid Fraud Control Unit investigates and prosecutes provider fraud. Federal inquiries may involve a U.S. Attorney’s Office, FBI, or HHS-OIG. Repayment, civil liability, administrative sanctions, and criminal charges require separate analysis, even when they concern the same claims.
2. Compare the Claim with the Care Provided
Connect each disputed charge to contemporaneous records and the payment rules effective during the service period. Include contradictory evidence and missing information. A statement that the patient received care may leave the actual coding or coverage question unanswered.
Match the Issue to Supporting Records
| Disputed Issue | Records to Compare | Question |
|---|---|---|
| Service not provided | Encounter notes, procedure logs | What documents performance? |
| Unsupported code or units | Clinical notes, coding rules | What level or quantity does the record support? |
| Medical necessity | Orders, assessments, coverage criteria | Was the service clinically indicated and payable? |
| Duplicate payment | Remittances, voids, adjustments | Did the payer reverse or recover the additional payment? |
Distinguish Care from Payment Eligibility
Treatment can occur without satisfying documentation or coverage requirements. A missing note may support disallowance without proving fabricated care; proof of an encounter does not establish that every unit was payable. These distinctions define the evidence needed in Medicaid fraud defense.
3. Trace Knowledge through the Audit History
Read internal audit findings alongside warnings, training materials, billing instructions, and corrections. Establish who identified the discrepancy, when they raised it, and how others responded. A later correction does not settle whether the original submission created liability.
Separate Criminal and Civil Standards
Federal law, 18 U.S.C. §1347, addresses knowing and willful execution or attempted execution of a healthcare fraud scheme. Prosecutors need not prove knowledge of the statute itself. The state offense under Penal Law §177.05 requires intent to defraud through knowing and willful material misinformation or omissions resulting in unauthorized payment.
The federal False Claims Act uses a different civil knowledge standard: actual knowledge, deliberate ignorance, or reckless disregard. Specific intent to defraud is unnecessary. State false-claims liability separately concerns qualifying claims involving state or local government funds.
Preserve Originals and Assess Privilege
Keep charts, submission histories, vendor records, and amendments distinguishable. Record who changed an entry, when, and why. Routine business records do not become privileged through counsel’s review. In government and internal investigations, assess legal advice, work product, and patient confidentiality before production.
4. Prepare Objections within the Applicable Deadline
An objection should identify the finding, explain the disagreement, and connect supporting records to the applicable payment rule. Administrative objections do not replace responses to investigative demands, and an appeal does not necessarily suspend collection.
Preserve Omig Objections Early
Written objections generally are due within 30 days of receiving the Draft Audit Report. Receipt is presumed five days after the report date unless contrary evidence exists. Include specific objections and supporting documents; later hearing issues and evidence can be restricted.
For extrapolated findings, review both the sampled claims and the projected recovery calculation. A written hearing request generally is due within 60 days of the Final Audit Report’s date. Follow its filing instructions and retain delivery evidence.
Track Medicare Appeal and Recoupment Dates Separately
For an appealable Medicare Fee-for-Service initial determination, redetermination generally is due within 120 days after receipt, presumed five calendar days after the notice date unless contrary evidence exists. Submit it to the issuing Medicare Administrative Contractor.
For overpayments subject to recoupment limitations, filing by day 30 from the demand-letter date can prevent recoupment from starting on day 41. Interest may continue accruing. These periods do not govern every payer dispute or investigative request.
5. Confirm the Forum and Remaining Obligations
Manhattan and the Bronx fall within the Southern District of New York; Brooklyn, Queens, and Staten Island fall within the Eastern District. Actual venue depends on the alleged conduct and governing rules. Confirm the court, filing route, and appearance requirements from the case documents.
Does City Law Apply Automatically?
No. A city address alone does not establish application of the NYC False Claims Act. Examine whether the alleged conduct involves qualifying claims against the City.
Can Repayment Analysis Wait?
An investigation does not automatically suspend reporting and return obligations. For identified Medicaid overpayments, Social Services Law §363-d generally requires reporting and return within 60 days after identification or by the applicable cost-report deadline, whichever is later. Identification and any available tolling require separate review.
Prepare for a Focused Case Review
Bring the notice, disputed-claim list, supporting records, audit chronology, and deadline log. Ask which findings the evidence answers, which gaps remain, and whether the organization and individual employees need separate advice.
28 Oct, 2026
