The Medicaid Fraud Investigation process begins with the triggering event. The triggering event can be one of a few items:
Triggering Event for HRA Investigation
- It can be a call into one of the medicaid fraud hotlines reporting the fraud.
- It can be a bank match
- It can be property records
- It can be school records of your children
- It can be New York State Tax Returns
- It can be Federal Tax Returns
Once the investigation has commenced, the fraud investigators will actively seek out evidence. They will send out requests to anyone who has relevant information.
Authorization to Release Information from HRA Investigators
The request will be from the Human Resources Administration and state that it is an Authorization to Release Information to HRA, Bureau of Fraud Investigation.
Further, the letter will state the following:
The Human Resources Administration, Bureau of Fraud Investigation is investigating an alleged case of fraud, involving the above named client. In order to complete this investigation, it is necessary for us to obtain certified copy of the following documents you have on file. Please provide clients employment information (period of employment, position, rate of pay and home address.) This request is made in accordance with Section 132 and 134a of the New York State Social Service Law.
The Department of Social Services of the City of New York is hereby requesting a waiver of the filing fee pursuant to Section 394-a-3.0 of the Administrative Code of the City of New York and Section 8018(b)(3) of the Civil Practice Law & Rules.
The investigators will conduct field visits and take photos of your house, your cars, your place of business.
Only once the investigation is complete, will the target letter be sent out asking you to furnish all of the documentation to the investigator. Now, you will receive the target letter by first class mail. This letter will request various documents to analyze whether you are eligible for medicaid benefits.
This is usually the pitfall for the medicaid fraud investigations. The claimant receives the target letter and believes that it’s not a big deal and they will go in and explain the situation. Unfortunately this is not the reality. The investigators are there for one reason only – to expose fraud. They are not your friends and not there to work out the situation with you. Routinely cases investigated by the HRA are referred out for criminal and civil prosecution.
Analysis and Review of the CDR
A Medicaid Fraud lawyer is going to want to review the CDR’s for the medicaid benefit recipient. The CDR is the form that will list out all of the payments by the Provider (the amount and the service period) for the claim period. The CDR is an indispensable document because it details the claims. The premiums are paid out monthly whether you use the insurance of not. If there are co-pays or additional payments, then the claim amount will increase.
Meeting with the HRA Investigator
Depending on the facts and circumstances of your specific case we may go in for an interview with one of the Human Resources Administration Medicaid Investigators. We may go in to review documents, to discuss settlement options and/or present mitigating evidence as to why this investigation should be dropped and/or dismissed.
To speak with a HRA Investigation lawyer, please call us at (212) 300-5196