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.

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

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