What Happens During a Medicaid Fraud Investigation?

By Shauna Itri

What is Medicaid Fraud?

Medicaid is a health insurance program for low-income individuals that is jointly funded by the State and Federal government. Medicaid covers children, the elderly, blind and/or disabled and other people who are eligible to receive federally assisted income maintenance payments. On occasion, individuals, doctors, medical professionals, hospitals and/or companies are charged with committing Medicaid fraud by knowingly misrepresenting the truth to obtain unauthorized benefits.

Medicaid Fraud and the False Claims Act

While Medicaid fraud can be pursued by the government sua sponte, many times a Medicaid fraud investigation is initiated by the filing of a False Claims Act case. If an individual or group of individuals has evidence of Medicaid fraud, they can seek to file a lawsuit under the Federal or State False Claims Acts. The False Claims Act allows for individuals with such evidence and knowledge to file cases with the government. If the government recovers money from such a case, the individual may be entitled to an award or a percentage of the recovery

Commencing a Medicaid Fraud Investigation

If the individual or group of individuals has a meritorious case and an attorney files a False Claims Act case on their behalf, an investigation into the case commences. The Medicaid fraud investigation is initiated by the filing of a case and the serving of the complaint and all material evidence on the government. After the government is served, the government reaches out to the plaintiff-whistleblower’s attorney to schedule an interview. During that interview, the government assess the credibility of the whistleblower and gathers information to assist in its investigation.

Medicaid Fraud Investigation

After the interview is complete, the government conducts an investigation while the False Claims Act case is under seal. During the investigation, the prosecutor assigned to the case will likely reach out to the government agency involved to obtain the agency’s thoughts/opinion on the case, gather and review the government’s own claims data to assess the size of the case, and decide on a plan to investigate the facts.

In order to investigate the facts, the government might issue a “civil investigatory demand” or “CID” to the alleged defendants to obtain documents, while simultaneously seek and interview former employees. If the government wishes, it might reach out to the alleged defendant to interview or depose current company employees or present the allegations in the complaint to the defendant (without disclosing the whistleblower’s identity or the fact that a case has been filed) and ask the defendant to respond.

Concluding a Medicaid Fraud Investigation

At the conclusion of the government’s investigation of a Medicaid False Claims Act case, the government will make a decision as to whether or not it will intervene or pursue the case or decline the case. At that time, the case comes out from under seal and, if the case goes forward, the alleged defendant is served with the complaint. If the case is declined and the whistleblower does not seek to litigate the case, the case is voluntarily dismissed by the government and whistleblower.

If you have discovered evidence of fraud committed against the government, you may be entitled to a substantial reward and the legal protections afforded to whistleblowers under state and federal laws. The attorneys at Berger Montague are nationally recognized for their work in Whistleblower/Qui Tam actions. For more information or to schedule your confidential consultation, contact us online or call us at 888-647-9292.

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By | 2018-03-25T12:20:11+00:00 December 13th, 2017|Medicaid Fraud|