Attorney for Healthcare Provider Fraud

Healthcare providers in New York City operate in one of the most heavily regulated and closely scrutinized industries in the nation. Physicians, dentists, pharmacists, home health agencies, medical practices, and clinic administrators face constant oversight from state and federal authorities. When billing practices, documentation, or referral arrangements come under investigation, the consequences can be devastating—threatening your license, your livelihood, and your freedom. If you are a healthcare provider facing fraud allegations, retaining experienced legal counsel as early as possible is essential to protecting your interests.

Our firm represents healthcare professionals and organizations throughout New York City against allegations of fraud, abuse, and regulatory violations. We understand the complex intersection of healthcare law, criminal defense, and administrative proceedings, and we are committed to defending the providers who dedicate their careers to caring for patients.

What Is Healthcare Provider Fraud?

Healthcare provider fraud generally refers to the intentional submission of false or misleading information to obtain payment from government or private payors. In New York, these cases frequently involve the Medicaid program, which serves millions of residents and is administered through state and federal oversight. Allegations of fraud can arise from honest billing errors, misunderstandings of complex coding rules, or aggressive interpretations of compliance requirements—not only from intentional misconduct.

Common forms of alleged healthcare provider fraud include:

• Billing for services not rendered — submitting claims for treatments, procedures, or supplies that were never provided.
• Upcoding — billing for a more expensive service than the one actually performed.
• Unbundling — separately billing procedures that should be billed together at a lower combined rate.
• Phantom patients — submitting claims for individuals who were never treated or do not exist.
• Kickbacks and improper referrals — accepting or paying remuneration in exchange for patient referrals or services.
• Medically unnecessary services — providing or billing for treatments that lack medical justification.
• Falsified documentation — altering medical records or creating false records to support claims.

New York Laws Governing Healthcare Fraud

Healthcare providers in New York may face charges under several state statutes, in addition to potential federal exposure. New York has enacted specific laws that target fraud against the healthcare system.

New York Penal Law Article 177 — Health Care Fraud

Article 177 of the New York Penal Law establishes the crime of health care fraud, which occurs when a person, with intent to defraud a health plan, knowingly provides false information or omits material information to receive payment to which they are not entitled. The severity of the charge escalates based on the dollar amount obtained:

• Health Care Fraud in the Fifth Degree — a misdemeanor involving any amount of unauthorized payment.
• Health Care Fraud in the Fourth through First Degrees — felonies that increase in severity as the amount fraudulently obtained rises, with the first degree applying to amounts exceeding one million dollars and carrying the most serious penalties.

New York Social Services Law

The Social Services Law contains provisions allowing the state to pursue civil and administrative penalties against Medicaid providers, including recovery of overpayments, monetary penalties, and exclusion from participation in the Medicaid program. The New York State Office of the Medicaid Inspector General (OMIG) conducts audits and investigations that can lead to significant financial liability and program exclusion even without a criminal conviction.

Related Charges

Healthcare fraud allegations are frequently accompanied by other charges under New York law, including grand larceny, falsifying business records, offering a false instrument for filing, and money laundering. Each of these carries its own penalties and defenses, and a comprehensive defense strategy must account for the full scope of potential exposure.

Who Investigates Healthcare Fraud in New York City?

Multiple agencies have authority to investigate and prosecute healthcare fraud affecting New York City providers. Understanding which agency is involved is critical to mounting an effective defense.

• New York State Attorney General's Medicaid Fraud Control Unit (MFCU) — investigates and prosecutes fraud against the Medicaid program as well as patient abuse and neglect in healthcare facilities.
• Office of the Medicaid Inspector General (OMIG) — conducts administrative audits, pursues overpayment recoveries, and imposes program exclusions.
• Local District Attorneys — the District Attorneys for Manhattan, Brooklyn, Queens, the Bronx, and Staten Island prosecute healthcare fraud occurring within their respective counties.
• New York State Department of Health — oversees licensing and certification matters for healthcare facilities and providers.

Consequences of a Healthcare Fraud Conviction

The stakes in a healthcare fraud case extend far beyond potential criminal penalties. Providers face a cascade of consequences that can permanently affect their careers.

• Criminal penalties — felony convictions can result in years of incarceration, substantial fines, and a permanent criminal record.
• Restitution — courts may order repayment of all amounts deemed fraudulently obtained, often with additional penalties.
• Professional discipline — the New York State Education Department's Office of Professional Discipline or the Board for Professional Medical Conduct may suspend or revoke your professional license.
• Program exclusion — exclusion from Medicaid and other government health programs can end a provider's ability to practice profitably.
• Reputational harm — public allegations can damage relationships with patients, colleagues, and institutions.

Defending Against Healthcare Fraud Allegations

Many healthcare fraud cases hinge on the question of intent. The government must generally prove that the provider acted knowingly and with intent to defraud—not that an honest mistake occurred. Our defense approach focuses on challenging the prosecution's evidence and demonstrating the absence of fraudulent intent.

Effective defenses may include:

• Demonstrating that billing discrepancies resulted from coding errors, software issues, or staff mistakes rather than deliberate fraud.
• Showing that the provider reasonably relied on guidance from billing professionals or payor instructions.
• Challenging the methodology used in audits, including statistical sampling and extrapolation techniques.
• Establishing that services were medically necessary and properly documented.
• Identifying procedural violations in how investigators obtained evidence.

Why Early Legal Representation Matters

Healthcare fraud investigations often begin quietly—through a records request, an audit notice, or a subpoena—long before formal charges are filed. The decisions you make during this early phase can dramatically affect the outcome. Speaking with investigators without counsel, producing documents without review, or attempting to correct records can inadvertently strengthen the government's case.

By retaining experienced counsel early, you gain the ability to respond strategically to investigative requests, negotiate with prosecutors and regulators before charges are brought, and in some cases resolve matters administratively without criminal exposure. We work to protect your rights at every stage and to position your case for the best possible resolution.

Contact a New York City Healthcare Fraud Defense Attorney

If you are a healthcare provider in New York City who has received an audit notice, a subpoena, or notice of an investigation—or if you have been charged with healthcare fraud—do not wait to seek legal guidance. The complexity of these cases and the severity of the potential consequences demand the attention of skilled defense counsel.

Our firm is prepared to evaluate your situation, explain your options, and build a defense tailored to the unique circumstances of your case. Contact us today to schedule a confidential consultation and learn how we can help protect your practice, your license, and your future.

You can contact us by phone at 212-233-1233 or by email at [email protected].