HRA Bureau of Fraud Investigation FAQ

Bureau of Fraud Investigation

Were you contacted by an investigator at the HRA Bureau of Fraud Investigation?

The HRA Bureau of Fraud Investigation is part of the NYC Human Resources Administration. It investigates individuals and families who have applied for and received Medicaid benefits.

Investigations may result in administrative disqualification hearings, lawsuits to recover money, or referrals to the District Attorney for criminal prosecution. Investigators work out of offices at 375 Pearl Street, 22nd Floor, New York, New York, and at 243 Schermerhorn Street, 5th Floor, Brooklyn, New York.

If you received a letter or visit from the HRA Bureau of Fraud Investigation, you should consult with an experienced Medicaid fraud attorney immediately. Failing to respond to the investigation properly can result in serious criminal charges. Call us today to schedule a consultation.

Call (212) 601-2728

Answers to Frequently Asked Questions (FAQ)

Why am I being investigated by the Bureau of Fraud Investigation?

The Medicaid fraud investigator has information that suggests you are not qualified for benefits. This information may include payroll records, car registrations, property records, and business records. The investigator may have spoken with your employer, your co-workers, and your neighbors to find out where you live and work, what type of car you drive, and how much you earn.

The investigator suspects that you committed fraud when you applied for benefits. The most common types of Medicaid fraud are:

providing false information on your application or recertification
failing to disclose all of your income
failing to disclose income earned by a spouse or other household member
failing to disclose rent from a tenant or roommate
failing to disclose income from a sideline business
mortgage payments, car payments, or other expenses that are higher than your reported income
concealing information about your income or assets
claiming to live in New York City when you actually live someplace else
re-selling medicine or products obtained with Medicaid benefits
altering, forging, or obtaining duplicate prescriptions
receiving treatment or services for which you are not eligible
allowing another person to use your health insurance card
receiving and using more than one Medicaid card

What will happen if I do not respond to the Bureau of Fraud Investigation?

Do not ignore the HRA Bureau of Fraud Investigation. You must take this seriously, and you must respond.

If you ignore the investigator’s letter, they cannot negotiate with you or your lawyer. So, they will just write up a report and send it to the District Attorney for criminal prosecution. The possible criminal charges include Welfare Fraud and Grand Larceny. If convicted, you could be sentenced to up to 15 years in prison.

The vast majority of investigations handled by a lawyer are either settled or dismissed. That is because an experienced Medicaid fraud attorney knows how to respond to the investigators and negotiate with them. But if you do not respond to the investigators, there will be no negotiation. They will just send your case to the District Attorney for criminal charges to be filed.

What will happen if I meet with the investigators on my own?

If you meet with the investigators on your own, the “interview” will turn into an interrogation. Two investigators will demand that you turn over your tax returns and other financial records. If you refuse, then they will assume that you have something to hide. If you comply, then they will make copies of everything and cross-examine you on every detail.

So many people lie to the investigators that they will not trust anything you say. If you fail to convince them of your innocence, they will either demand that you pay back tens of thousands of dollars in benefits or send your case to the District Attorney for criminal prosecution.

You do not have to deal with the investigators alone. In most cases our clients do not talk to the investigators at all. We meet with the investigators on your behalf. We find out what their questions and concerns are before telling them anything. We negotiate with them for you.

Did you receive a letter from the HRA Bureau of Fraud Investigation?
Talk to an experienced healthcare lawyer today.

Call (212) 601-2728

What are my rights during the investigation?

You have the right to bring an attorney with you to any interviews or meetings with the investigator. You also have the right to consult with your lawyer before providing any documents or answering any questions.

You have the right to remain silent. You do not have to answer the investigator's questions. If you are a Medicaid recipient, your benefits cannot be stopped solely because you refused to answer questions. And if you have an attorney, you may not have to meet with the investigator or answer any of their questions.

Do I have the right to see any evidence against me?

Yes. You have the right to see any evidence the investigator may have against you.
Our first step in any Medicaid fraud investigation is to ask the investigator to provide us with certain documents. At the Bureau of Fraud Investigation, we always ask for our client’s application and re-certifications for Medicaid benefits. In most cases, the application and re-certifications were signed three, four, five or more years ago. Our client should not guess about what they put on their applications and recertifications. We need to know exactly what is written on the documents before we say anything to the investigators.

Our second step is to ask the investigator what the problems are. Sometimes the investigator is looking at one issue, while our client was concerned with a different issue. We do not want to start talking about our client’s defenses until we know what the problems are.

Should I answer the investigator's questions?

How you respond to the investigation depends on your particular facts and circumstances. Some questions and requests for documents are appropriate. Others may be improper. Sometimes it makes sense to cooperate with the investigator and negotiate a resolution. Other times you must fight to protect your rights.

You need an experienced Medicaid fraud lawyer on your side to help you make these decisions.

Should I turn over my tax returns and other documents to the investigators?

The Bureau of Fraud Investigation letter will request that you turn over financial documents such as your tax returns, pay stubs, and driver’s license. If you own property or a business, the letter will also for property and business records.

Should you turn over these documents? The answer depends on your situation. Sometimes turning over documents is the worst thing you can do because it gives the investigator all the evidence they need to convict you of a felony. Other times it makes sense to turn over documents in order to prove your innocence or to negotiate a deal.

You need expert advice from an experienced Medicaid fraud lawyer before turning over anything to the investigator.

Do I have to talk to the investigators?

Medicaid is not allowed to terminate your benefits just because you refuse to answer a Medicaid fraud investigator’s questions. You have the absolute right to remain silent.

Whether or not you provide information to the investigator will depend on a number of factors. What evidence do they have against you already? Do they intend to refer your case to the District Attorney for criminal prosecution? Are they willing to consider a financial settlement with no criminal charges? Are their questions legitimate? Or are they asking for documents and information that you are not required to provide?

If the investigator intends to refer your case for criminal prosecution, then there is no reason to give them any information. Any information you provide will be used against you. On the other hand, you may want to cooperate with the investigator if it will help settle the investigation without criminal charges.

Our experienced Medicaid fraud lawyers can talk directly to the investigator, protect your rights, get the evidence you need, develop a strategy, decide whether or not to cooperate with the investigation and, in most cases, negotiate a settlement that avoids criminal charges . . . even if you are guilty.

If I hire a lawyer, won’t the investigator think I’m guilty?

Let’s get something straight. The investigator already thinks you are guilty. That is why they want to interview you.

If they just needed some clarification on your eligibility, then you would have received a letter from the "Bureau of Eligibility Verification" that deals with clarifications. You received a letter from the "Bureau of Fraud Investigation" because they think you are guilty of fraud.

By the time an investigator contacts you, they already know how much you earn, how much you pay for your rent or mortgage, whether you own a car or property, who lives with you, and whether anyone who lives with you has an income. Now they want you to admit what they already believe. Anything you say to the investigator can and will be used against you.

Hiring a lawyer is your best protection against possible criminal charges. It also sends a message to the investigator that you are taking the investigation seriously and that you are ready to exercise your rights. That is exactly the message that you want to send.

You do not have to face the investigators alone.
Get an experienced healthcare lawyer on your side.

Call (212) 601-2728

What are the possible penalties and consequences?

Medicaid fraud penalties range from repayment of Medicaid benefits to harsh prison sentences. Some of the possible consequences are:

monetary fines, penalties, and restitution orders
disqualification or exclusion from receiving Medicaid benefits
civil judgments and liens on any real property you own
garnishment of your wages
criminal prosecution and a possible prison sentence
suspension or loss of professional licenses
exclusion from participating in Medicaid as a healthcare provider
depending on your immigration status, you could be deported

Failing to respond properly could result in a judgment against you for tens of thousands of dollars in restitution, felony criminal charges, exclusion or disqualification from participating in the Medicaid program in the future, loss of professional licenses and, if you are not a U.S. citizen, deportation.

Do not try to defend yourself on your own. Get an experienced Medicaid fraud defense lawyer on your side.

Will I go to jail for Medicaid fraud?

When it comes to Medicaid fraud, prison is a possibility. Fortunately, it is not the only possibility.
What will happen in your case depends on your specific facts and circumstances. You must begin with an analysis of the evidence by an experienced Medicaid fraud attorney.

Some cases are defendable. You may be innocent. Even if you are not innocent, the investigators may not have all the facts or the evidence against you may be weak. If the government has a weak case, then your lawyer should make every effort to avoid any criminal charges. The best time to do that is during the investigation stage, before any criminal charges are filed. In many cases, we have convinced investigators to drop their investigations or settle the matter with no criminal charges at all.

In other cases, the evidence is so strong that there is no real defense. However, an experienced defense lawyer can still help you avoid the most serious consequences.

Even if you are guilty, you have a very good chance of avoiding a jail sentence if you have never been arrested before, the amount of money involved is relatively small, and you are able to make restitution (that is, to pay back money). In some cases, we have been able to convince the prosecutor to dismiss all criminal charges even when our client admitted that they were guilty as charged. The outcome always depends on the specific facts of your case.

Who are the investigators?

Medicaid investigators are trained professionals who know how to conduct a thorough investigation. They work together with other investigators who have 10, 20, and even 30 years of experience investigating thousands of Medicaid fraud cases. They are supported by data analysts, financial auditors, and medical experts.

You are being investigated by professionals. Do not try to handle this on your own. Get an experienced Medicaid fraud attorney on your side to protect your rights.

What do the investigators already know about me?

The investigators already have your applications and recertifications for benefits. They have property records, car registrations, payroll and business records. They have been to your home, they may have spoken to current and past employers, and they may have pictures of you and the people who live with you.

The investigators have already found something that appears to be inconsistent with your applications for health insurance benefits. Sometimes there is an innocent explanation for the inconsistency. The challenge you face is that the investigators already think you are guilty.

Will the investigators negotiate a settlement?

Depending on the nature of the problem, the investigator may be willing to negotiate a financial settlement to avoid any court cases or criminal prosecution. An experienced Medicaid fraud attorney can help you by negotiating a settlement that reduces the amount owed, by avoiding penalties and interest and, most importantly, by negotiating an agreement that your case will not be referred for criminal prosecution.

Let an expert help you.
Get an experienced healthcare lawyer on your side.

Call (212) 601-2728

Why did the Bureau of Fraud Investigation start an investigation?

Most Medicaid fraud investigations start either (a) because your income is higher than what you reported on your application and recertifications; or (b) your expenses – such as for a home or a car – are higher than your income can support.

Here are the major red flags that cause the Bureau of Fraud Investigation to open an investigation into your eligibility for Medicaid:

Real Estate Ownership: Medicaid is designed for families and individuals who live at or just above the poverty level. Most people who receive Medicaid benefits can barely afford to pay their rent, let alone make a down payment on a home. Investigators have access to a number of public records such as deeds and mortgages that show who owns a property, how much was paid for the property, and how much it costs for monthly mortgage payments and real estate taxes. If they discover your name on any of these documents, they will investigate you.

A New Car: Medicaid fraud investigators can easily check public records to find out whether you own or lease a car, and even how much you pay every month. Car titles and registrations are available in public records. If you financed the car through a bank loan or lease, the bank or financing company filed a public record showing how much the car is worth and how much you are required to pay. If your name appears on any of these records, the investigators will question how you can afford the car.

An Address Outside New York City: New York City provides the most generous Medicaid benefits in the country. But those benefits are available only to people who reside within the five boroughs. The Bureau of Fraud Investigation regularly checks the addresses of Medicaid recipients through a number of different databases. If you have an address outside New York City in any of your records, that can trigger a Medicaid fraud investigation.

School Records: Your children are listed on your Medicaid application and re-certifications. Medicaid investigators use that information to determine where your children are attending school. If your children attend a school that is not in the same area as your home, or if your children attend a private school, that can trigger a Medicaid fraud investigation.

Employment by New York City of State Agencies: You are not eligible for Medicaid benefits if you are able to obtain health insurance from your employer – even if you have to pay part of the premiums and even if your share of the premiums is expensive. Since employees of New York State and City agencies are eligible for health insurance for themselves and their families, Medicaid is constantly matching its list of Medicaid recipients with databases of State and City employees. If you or someone who lives with you works for a New York State or City agency, you will be investigated for Medicaid fraud.

Tenants, Boarders, and Undisclosed Family Members in the Home: A large number of investigations are started because the Bureau of Fraud Investigation discovers that people live at the same address as you, but they are not listed as part of your household on your Medicaid application or re-certifications. The investigators will want to know if they are paying you to live there as tenants or boarders. If they are relatives or friends who live with you, the investigators will want to know whether they have an income and whether they contribute anything towards the household expenses.

Business Filings and Special Licenses: The Bureau of Fraud Investigation will often start an investigation if they discover that you or someone in your household owns a business or has a business-related driver’s license (such as a commercial, taxi, livery, or limo license). This results in a very complicated and potentially dangerous investigation. For example, some deductions, such as for depreciation, are perfectly legitimate for tax purposes, but are not allowed for purposes of determining your eligibility for Medicaid benefits.

Why does Medicaid want me to pay back money if I never used the insurance?

Many people assume that Medicaid did not spend much money on their insurance because they did not see a doctor very often. This is not a correct assumption.

Medicaid pays a premium each month to a private insurance company that provides your health insurance. That is why your Medicaid card usually has the name of a private insurance company on it, such as Healthfirst, HealthPlus, MetroPlus, or UnitedHealthcare. Whether or not you actually used the health insurance, Medicaid paid a premium to that company every month.

The premiums are expensive. They are often thousands of dollars per year. If the investigator refers your case to the District Attorney for criminal prosecution, you will be charged with felonies that could result in a prison sentence. You could also be fined and ordered to pay back all of the benefits you received.

You do not have to face the investigators on your own. Get an experienced Medicaid fraud lawyer on your side.

How can an experienced Medicaid fraud attorney help me?

You have the right to consult with an attorney, to have an attorney present whenever the investigators try to “interview” (that is, interrogate) you, and to have the attorney communicate with the investigators on your behalf. Your attorney can ask questions, get evidence from the investigator, develop your defenses, explain your side of the story, and negotiate with the investigators to avoid criminal charges. In most cases, our clients never have to speak with the investigators at all.

How can I find the best Medicaid fraud defense lawyer?

The process begins with a free and confidential consultation. Our lawyers will personally review your unique situation. We will help you understand the issues, develop a strategy, and decide how best to respond to the investigators. If you decide to retain us, then we will meet personally with the investigators in an effort to negotiate a resolution and avoid criminal charges. In most cases, you will never have to speak with the investigators or answer any questions.

We have helped hundreds of people just like you defend against Medicaid fraud claims. We have convinced investigators to drop their investigations or to settle cases without any criminal charges. In more difficult cases, we have convinced prosecutors to reduce charges and agree to no jail time for our clients. We have also taken cases to trial and convinced the jury that our client did not commit Medicaid fraud.

Learn how to protect your rights.
Call our experienced healthcare lawyers today.

Call (212) 601-2728