What triggers Medicaid Fraud or Medicare Fraud Investigations?
In our experience, there are three factors that are most likely to trigger a criminal investigation of Medicaid or Medicare fraud. The first or foremost factor is an unusually high level of billing activity by a service provider. An unusually high billing pattern, when compared with other providers, will automatically raise a red flag. In a recent case, a New Jersey physician was investigated and prosecuted after he billed Medicaid to the tune of $13 million a year, the next highest biller in the state only reaching a $6 million mark. The second common factor is fraud reported to the authorities by third parties or discovered by investigators during an unrelated probe. The third factor is discovery of fraud during a routine audit. What to do when you are investigated for Medicaid or Medicare Fraud? Most providers are not aware that they are targets of a criminal investigation. However, if you believe that you are under investigation, whether because you have been approached by agents o
