Medicaid Fraud Attorney in New York City

Medicaid fraud is one of the most aggressively prosecuted white-collar offenses in New York. The Medicaid Fraud Control Unit (MFCU) of the Office of the Attorney General handles the criminal docket on the state side, with the New York District Attorneys taking many recipient cases. On the federal side, US Attorneys in the SDNY and EDNY use 18 U.S.C. § 1347 (healthcare fraud), the federal Anti-Kickback Statute, and the False Claims Act. Our Medicaid fraud attorney defends both recipients and providers in each forum.

How Medicaid Fraud Is Charged in New York

Recipient-side Medicaid fraud is usually charged under Penal Law Article 158 (Welfare Fraud), Article 155 (Grand Larceny), and Article 175 (Offering a False Instrument for Filing). The grade tracks the dollar value:

PL § 158.05 — Class A misdemeanor (any amount)
PL § 158.10 — Class E felony (over $1,000)
PL § 158.15 — Class D felony (over $3,000)
PL § 158.20 — Class C felony (over $50,000)
PL § 158.25 — Class B felony (over $1,000,000)

Provider-side Medicaid fraud frequently produces additional counts of scheme to defraud (PL §§ 190.60 and 190.65), forgery, and money laundering. At the federal level, the count list usually includes healthcare fraud (§ 1347), conspiracy (§ 1349), wire fraud (§ 1343), and kickbacks (42 U.S.C. § 1320a-7b(b)). Sentencing under U.S.S.G. § 2B1.1 turns on loss amount.

Recipient Defense

Most recipient Medicaid fraud cases involve allegations of unreported income, unreported household members (most commonly a spouse or partner), or undisclosed assets. The defenses are:

Calculation. The agency's overpayment math frequently includes months that fall outside the limitations period or fail the eligibility analysis on its own terms.
Intent. Welfare fraud is a specific-intent crime. Honest confusion about recertification, language barriers, caseworker advice, and family complexity are real defenses.
Statements. Investigative-interview statements can be challenged under People v. Huntley and Miranda when the case crosses into law enforcement.
Disposition strategy. Civil overpayment plus repayment, with no IPV and no criminal record, is achievable in many cases.

Provider Defense

Provider cases against doctors, dentists, pharmacies, home-care agencies, DME suppliers, behavioral-health providers, and CDPAP fiscal intermediaries are document-intensive and high-stakes. Common defense themes:

Medical necessity. Auditor disagreement is not fraud. Standards of care control.
Coding disputes. CPT and HCPCS interpretation, modifier use, and bundling disagreements rarely meet the specific-intent standard for criminal liability.
Anti-Kickback safe harbors. Many relationships fit within statutory and regulatory safe harbors that the prosecution misreads.
Statistical sampling. Extrapolated overpayment findings are challenged under CMS and HHS-OIG guidance.
Compliance defense. Reliance on compliance officers, billing companies, and counsel is a defense to specific intent.

Parallel Civil, Licensing, and Exclusion Tracks

Every Medicaid fraud case has more than one front. Civil False Claims Act actions, OIG exclusion proceedings, OPMC and OPD licensing matters, Department of Health corrective actions, and ZPIC and UPIC audits can all run alongside the criminal case. We coordinate the tracks so a move in one does not collapse another.

Joint MFCU, OMIG, and Federal Investigations

Modern Medicaid prosecutions are rarely the work of a single agency. A typical provider matter is opened by an OMIG audit, referred to MFCU once the auditors see a pattern that looks willful, and then expanded by a federal grand jury subpoena out of the SDNY or EDNY if the loss number is large or the billing crosses state lines. HHS-OIG agents and FBI healthcare-fraud squads often work alongside MFCU investigators on the same target.

The result is a single set of facts being looked at by four or five different lawyers with different statutes and different deadlines. A statement made to an OMIG auditor can be used by the MFCU prosecutor at trial. A response to an HHS-OIG subpoena can be picked up by the AUSA before the state case is even charged. We track the agencies in parallel and decide, for each piece of information, where it should land first — or whether it should land at all. See our Medicaid investigation attorney and healthcare fraud lawyer pages.

Federal Statutes in Play

When a Medicaid case goes federal, the indictment is usually built from a familiar set of statutes:

18 U.S.C. § 1347 — Health Care Fraud. Twenty-year maximum, life if death results.
18 U.S.C. § 1035 — False statements in health care matters.
18 U.S.C. § 669 — Theft or embezzlement in connection with health care.
42 U.S.C. § 1320a-7b — Anti-Kickback Statute. Criminal liability for remuneration to induce referrals of Medicaid-payable items or services.
42 U.S.C. § 1395nn — Stark Law. Civil, but it feeds False Claims Act and kickback exposure.
31 U.S.C. §§ 3729–3733 — Federal False Claims Act, with treble damages and per-claim civil penalties.
18 U.S.C. §§ 1343, 1349, 1956, 1957 — wire fraud, conspiracy, money laundering, monetary transactions in criminally derived property.

State Criminal Exposure Beyond Article 158

The Medicaid-specific welfare fraud statutes in Article 158 are not the only state charges a Medicaid case generates. Prosecutors routinely stack additional counts:

PL Article 155 — Grand Larceny. Medicaid funds are property, and the dollar thresholds in PL §§ 155.30, 155.35, 155.40, and 155.42 map onto loss amounts the same way the Article 158 grades do.
PL Article 175 — Falsifying Business Records (PL §§ 175.05 / 175.10) and Offering a False Instrument for Filing (PL §§ 175.30 / 175.35), one count per claim or chart in many indictments.
PL Article 176 — Insurance Fraud, when private secondary payors are also billed.
Social Services Law § 145-b — false statements to obtain public assistance, including Medicaid; civil penalties up to three times the amount falsely received.
State Finance Law §§ 187–194 — the New York False Claims Act, the state qui tam vehicle with treble damages and per-claim penalties.

Sentencing Exposure

On the state side, sentence length tracks the felony grade and the defendant's criminal history under PL Article 70. A first-felony Class C conviction (over $50,000) carries a presumptive prison range; a first-felony Class B (over $1,000,000) is almost always a state-prison case absent significant mitigation. Restitution under CPL § 420.10 is ordered in essentially every Medicaid case and is not dischargeable in bankruptcy.

On the federal side, the calculation runs through U.S.S.G. § 2B1.1, with the loss table doing most of the work. Sophisticated-means enhancements, abuse-of-trust enhancements for licensed professionals, role adjustments, and number-of-victims enhancements add quickly. Loss is calculated as intended loss, not just actual loss — a critical point that drives much of the defense effort at sentencing.

Restitution, Disgorgement, and Civil Multiples

A Medicaid fraud conviction or settlement almost always carries financial exposure beyond any criminal fine:

Criminal restitution to Medicaid, joint and several with co-defendants.
Civil False Claims Act recovery at treble damages plus a per-claim penalty under federal and state FCAs.
OMIG administrative overpayment recovered under 18 NYCRR Part 518, often calculated through statistical extrapolation from a sample.
Civil monetary penalties imposed by HHS-OIG under 42 U.S.C. § 1320a-7a.
Asset forfeiture under 18 U.S.C. § 982 in federal cases and CPLR Article 13-A in state cases.

Structuring restitution and civil resolution together is one of the central tasks of the defense. A poorly sequenced payment can foreclose later relief or generate a tax problem larger than the underlying fraud.

OIG Exclusion and License Discipline

A conviction for a program-related offense triggers mandatory exclusion from all federal health care programs under 42 U.S.C. § 1320a-7(a) for at least five years. For most providers, exclusion is a career event — a hospital, nursing home, or pharmacy cannot employ or contract with an excluded individual without losing its own ability to bill Medicare and Medicaid. New York operates a parallel exclusion list under 18 NYCRR Part 515.

Licensing discipline runs on its own track. Physicians face the Office of Professional Medical Conduct (OPMC) under Public Health Law Article 131-A. Other licensed professionals — dentists, pharmacists, nurses, social workers, psychologists — face the Office of Professional Discipline (OPD) within the Department of Education. A Medicaid fraud conviction is generally treated as a basis for revocation or surrender. We coordinate the criminal resolution with the licensing case so that the criminal plea does not foreclose a negotiated licensing outcome. See professional license defense.

Cooperation, Proffers, and Corporate Resolutions

Some Medicaid cases — particularly multi-defendant provider cases — are best resolved through cooperation. The decision to proffer is irreversible and has to be made with a clear-eyed view of what the client knows, what the government already knows, and what the realistic floor and ceiling on the sentence are. We do not send clients into a proffer without a written queen-for-a-day letter and a written outline of the topics. For corporate providers, NPAs, DPAs, and corporate integrity agreements with HHS-OIG are often available as an alternative to indictment, preserving the entity's ability to keep billing.

Sealing and Post-Conviction Relief

CPL § 160.59 sealing is available for many older Medicaid convictions after ten years and is worth pursuing for licensing, employment, and immigration reasons. CPL §§ 440.10 and 440.20 motions may reach the conviction or the sentence where there was newly discovered evidence, prosecutorial misconduct, or ineffective assistance.

Collateral Consequences

Loss of Medicaid eligibility
Federal program exclusion under 42 U.S.C. § 1320a-7
Restitution and civil multiples under the False Claims Act
License revocation or surrender
Immigration consequences (welfare fraud is a CIMT)
Loss of professional employment and federal contracting eligibility
Loss of federal student loans, grants, and certain housing benefits
Civil judgment that is not dischargeable in bankruptcy

For the audit and investigation stage of these cases, see our Medicaid investigation attorney page. For an overview of what to do the day a letter arrives, see received a Medicaid investigation letter. For the broader healthcare fraud practice, see healthcare fraud lawyer and our general criminal defense lawyer page.

If you are facing Medicaid fraud charges, an MFCU subpoena, or a target letter, call us at 212-233-1233 or email [email protected].