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Medicaid Fraud
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Top-Rated Medicaid Fraud Attorney in New York City
A letter from a state inspector’s office, a visit from an investigator, or a subpoena for your billing records can turn routine work into a crisis overnight. You might run a medical practice, a pharmacy, a home care agency, or a transportation company. You might simply receive benefits as a patient.
Either way, now someone wants answers about money that was paid out. Whether the inquiry looks like a routine audit or already feels like a criminal investigation, what you say and do in the next few weeks can shape everything that follows.
A NYC Medicaid fraud lawyer at the Law Offices of Robert Tsigler, PLLC brings experience from courtrooms across New York City. Robert Tsigler, Esq. holds an Avvo 10.0 “Superb” rating and a Martindale-Hubbell Client Champion designation. He is also admitted to the U.S. District Courts for the Eastern, Southern, and Western Districts of New York, and to the U.S. Courts of Appeals for the Second and Sixth Circuits.
That federal reach matters because Medicaid fraud allegations in this city can involve state courts in Brooklyn and Manhattan. They can also reach the federal courts that step in once the dollar amounts grow large.
If you learn you’re under review, reach out before you answer an investigator’s questions.
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Types of Medicaid Fraud Our NYC Medicaid Fraud Attorneys Defend Against
Medicaid fraud covers a wide range of conduct, and an accusation does not always match what actually happened. Common accusations include:
Front organizations: businesses or clinics set up mainly to collect Medicaid payments rather than to deliver real care.
Phantom billing: charging Medicaid for visits, tests, or equipment that were never provided.
Prescription drug diversion: illegally selling, trading, or redirecting medications paid for through Medicaid.
Duplicate billing: charging both Medicaid and a private insurer for the same service.
Upcoding and overbilling: billing for a more expensive procedure or a higher level of care than what actually happened.
Kickback arrangements: payments disguised as consulting fees, rent, or referral bonuses tied to Medicaid-covered patients.
Patient recruiting schemes: paying people to enroll in programs or sign up for services they do not need.
Some of these cases start with a former employee’s tip, and others start with a routine data match that flags unusual billing patterns. Either way, the label investigators put on the conduct at the start of a case is not always the charge that holds up after a careful review of the evidence.
How New York Punishes Medicaid Fraud by the Dollar Amount Involved
Medicaid counts as a “health plan” under New York’s health care fraud law, found in Penal Law Article 177. Because of that, billing Medicaid falsely is prosecuted the same way as defrauding any other insurer. Under this law, prosecutors add up every payment wrongfully received from a single health plan over a period of one year.
That rule matters because several smaller claims can combine into a far more serious charge than any one bill would suggest on its own. The degree charged depends on that total amount:
Fifth degree: no minimum dollar threshold, a class A misdemeanor punishable by up to a year in jail.
Fourth degree: more than $3,000 in a year, a class E felony punishable by up to 4 years in prison.
Third degree: more than $10,000 in a year, a class D felony punishable by up to 7 years.
Second degree: more than $50,000 in a year, a class C felony punishable by up to 15 years.
First degree: more than $1,000,000 in a year, a class B felony punishable by up to 25 years.
Even someone with no prior record can face prison at the felony levels. Prosecutors must prove the payments came from the same health plan within that one-year window and that the person knew the information submitted was false. A defense often starts by challenging either of those two points rather than arguing over the underlying services at all. This information reflects New York law as of October 2026.
How OMIG and Investigators Build a Medicaid Fraud Case
Medicaid fraud cases rarely start with a single mistake. Investigators typically build a file over months, matching your billing records against enrollment data, prescription records, and sometimes even patient interviews, looking for patterns rather than one-off errors.
Common red flags include so-called “ghost patients,” where someone is billed for care that was never actually provided to any real person. Another is what some call red-lining. That is where a provider quietly avoids treating higher-cost patients while still collecting payment meant to cover their care.
Because you need specific identifying information to receive Medicaid benefits or bill the program, investigators often start by checking whether that identification lines up with the services billed. A gap between who the records say received care and what the agency can verify can trigger a formal referral.
In New York City, that referral often goes to the state’s Office of the Medicaid Inspector General (OMIG) first. It then moves to the New York Attorney General’s Medicaid Fraud Control Unit (MFCU) once the agency suspects intentional fraud rather than a billing mistake.
Each of those paths treats the same set of facts very differently, and getting ahead of that distinction early can change the entire direction of a case.
What the Attorney General's Medicaid Fraud Control Unit Does
The Medicaid Fraud Control Unit, often called the MFCU, is part of the New York Attorney General’s Criminal Justice Division. The Attorney General’s office describes it as the largest unit in that division. It investigates and prosecutes people and companies accused of improper Medicaid billing. It also handles abuse and neglect cases involving nursing homes and other care facilities.
OMIG and the MFCU do different jobs. OMIG is a state agency that audits Medicaid providers and seeks repayment, and those reviews are usually civil. The MFCU is a law enforcement office. Its prosecutors can bring criminal charges, and the Attorney General can also bring civil cases to recover Medicaid money. When OMIG believes a provider may have committed criminal fraud, state law lets it refer the case to the MFCU.
An MFCU matter often begins with a subpoena, a records request, or a request for an interview. Do not answer questions or hand over records until a lawyer has reviewed the request.
The unit has also been in the news. In June 2026, the U.S. Department of Health and Human Services Office of Inspector General denied the unit’s annual recertification and suspended its federal funding. The Attorney General’s office announced new Medicaid fraud arrests as recently as October 2026.
The 60-Day Deadline That Can Turn a Billing Mistake Into a Fraud Case
New York law requires anyone who identifies a Medicaid overpayment to report it, return it, and explain how it happened within 60 days, under Social Services Law § 363-d. Missing that window does not automatically mean a criminal charge. It can give prosecutors an opening to argue that a provider knew about a problem and chose to keep the money anyway.
Penalties for failing to report, return, and explain an overpayment can run up to $10,000 per item or service. They can rise to up to $30,000 per item if the same kind of penalty was already imposed on that provider within the past 5 years. This rule is where providers can get into trouble without meaning to.
An honest billing error that gets voided and corrected right away is usually treated as a routine compliance issue. The same error, left unaddressed past the 60-day mark, can be reframed as evidence of intent once an auditor or investigator takes a closer look.
Anyone who discovers a potential overpayment should get legal guidance before deciding how, or whether, to respond to the agency.
Social Services Law and the New York False Claims Act in Medicaid Cases
Penal Law Article 177 is not the only state law that reaches Medicaid fraud. New York’s Social Services Law has its own criminal and civil rules, and the state has its own False Claims Act. Prosecutors and agencies can use these laws alongside Article 177.
Social Services Law § 366-b: it is a class A misdemeanor to knowingly make a false statement or hide a material fact to get Medicaid you are not entitled to. The same classification applies to presenting a false claim with intent to defraud, or knowingly submitting false information to be paid more or to get services approved. If the conduct also breaks the Penal Law, the Penal Law penalties apply instead.
Social Services Law § 145-b: this is a civil law. The state or a local social services district can recover three times the amount a figure was falsely overstated, or $5,000, whichever is greater. The Medicaid Inspector General can also seek penalties in certain cases, including up to $15,000 for each day a provider fails to give investigators timely access to records. The per-item penalties described in the 60-day section above come from this same law.
New York False Claims Act: State Finance Law Article 13, sections 187 to 194, lets the state recover a civil penalty plus three times its damages from anyone who knowingly submits a false claim. Knowingly includes reckless disregard and deliberate ignorance, so the state does not have to prove an intent to defraud. A private person can file a suit on the state’s behalf, and the Attorney General can take over the case. Before filing a Medicaid-related action, the Attorney General must consult OMIG.
These laws use different standards and different penalties. One set of billing records can lead to a criminal case, a civil suit, and an OMIG penalty at the same time. A lawyer can look at which law the state is relying on before you respond.
If You Receive Medicaid and Are Accused of Fraud
Medicaid fraud cases do not involve only providers. Patients and families can be accused too. These accusations can involve income, household size, or other facts reported on an application or renewal. The same law that covers providers, Social Services Law § 366-b, also covers patients.
The state has to show that you acted knowingly. An honest mistake on a form, or confusion about what counts as income, is different from a deliberate lie. An agency may also ask you to pay benefits back, even when no criminal case is filed.
If you get a letter from a local social services office, OMIG, or the Attorney General’s office, talk to a lawyer before you reply. Anything you write can be used later.
When a Medicaid Fraud Case Crosses Into Federal Court
Larger Medicaid fraud allegations in New York City do not always stay in state court. The case can move to the U.S. Attorney’s Office for the Eastern District of New York or the Southern District of New York once the dollar amounts grow. It can also move once the conduct touches other federally funded programs.
Other triggers include a scheme that spans more than one state, claims that involve Medicare as well as Medicaid, and payments for referrals. Federal prosecutors use different laws than the state ones described on this page, including the federal health care fraud statute and the Anti-Kickback Statute. Our NYC healthcare fraud lawyer page explains those federal charges in more detail.
Federal prosecutors often work alongside the U.S. Department of Health and Human Services’ inspector general. Federal cases also open the door to civil claims, which can run alongside or instead of a criminal charge.
A state court case and a federal court case are not interchangeable. They involve different agencies, different courtrooms, and different procedural rules, so the defense approach has to adapt to whichever track the case is actually on.
Robert Tsigler’s federal admissions mean a NYC Medicaid fraud lawyer at the firm can continue representing you whether the matter stays in a New York City courtroom or moves into federal court.
Which NYC Court Handles Your Medicaid Fraud Charge
Felony Medicaid fraud charges in Brooklyn are handled at the Kings County Supreme Court, Criminal Term at 320 Jay Street. Felony charges arising in Manhattan go through the New York County Supreme Court, Criminal Term at 100 Centre Street. The borough where the alleged conduct happened, not where you live or work day to day, usually determines which courthouse ends up with the case.
Robert Tsigler founded the firm after interning at the Kings County District Attorney’s Office, including its Homicide and Green Zone units. That experience gave him exposure to how Brooklyn prosecutors evaluate cases.
The firm’s attorneys also hold 10-attorney roundtable strategy sessions, where multiple lawyers review a complex case together.
That matters in Medicaid fraud cases specifically, since they often combine medical billing records, accounting evidence, and witness statements that benefit from more than one set of eyes.
Frequently Asked Questions
Do I need a lawyer if I just received an OMIG audit letter, not an arrest?
It is often a good idea to talk with one, and the sooner the better. An audit letter usually starts as a civil review. What you say in your written response can be used later if the case turns criminal. So it is worth having a lawyer review your answer before you send anything back.
What is the difference between a civil Medicaid overpayment and a criminal Medicaid fraud charge?
A civil overpayment usually means the agency wants money back because of a billing mistake. A criminal charge requires the government to prove you knew the information you submitted was false. The same facts can sometimes support either path, which is why early legal advice matters.
Can losing a Medicaid fraud case affect my professional license?
Yes. A conviction, or sometimes even a civil settlement, can trigger separate licensing board proceedings for doctors, nurses, pharmacists, and other licensed providers, in addition to any criminal penalty.
Will a Medicaid fraud investigation show up before I’m ever arrested?
Often, yes. Many cases begin with subpoenas, document requests, or interview requests from OMIG or the Medicaid Fraud Control Unit well before any arrest. Getting a lawyer involved at that stage can help you respond before a case escalates.
If I’m charged with Medicaid fraud in Brooklyn, will my case stay in state court?
Not necessarily. A case that starts in Kings County can still be referred to federal prosecutors in the Eastern District of New York. That can happen if the amount involved is large or if it connects to a broader scheme being investigated at the federal level.
What happens if I already repaid the overpayment before being contacted by investigators?
Repayment alone does not end an inquiry, since the report-and-explain requirement under New York’s 60-day rule is separate from simply returning the money. Voiding a claim without properly reporting why the overpayment happened can still leave open questions for investigators.
Does it matter if I was just an employee following instructions, not an owner?
It can. New York’s health care fraud law includes a narrow defense for a bookkeeper, clerk, or other employee who had no active management role and received no personal benefit from the fraud. That defense has specific requirements that a lawyer needs to evaluate against the facts of your case.
Is the Attorney General’s Medicaid Fraud Control Unit the same as OMIG?
No, OMIG audits providers and usually seeks repayment, while the Attorney General’s Medicaid Fraud Control Unit can bring criminal charges. OMIG can refer a case to the unit when it suspects intentional fraud.
Can a Medicaid patient be charged with fraud?
Yes. Knowingly making a false statement to get Medicaid you are not entitled to is a crime under Social Services Law § 366-b, but an honest mistake is not enough.
Can a whistleblower file a Medicaid fraud suit under New York law?
Yes. The New York False Claims Act lets a private person sue on the state’s behalf, and the Attorney General can take over the case.
How much does it cost to hire a Medicaid fraud defense lawyer in New York City?
Costs vary with the complexity of the case, whether it is a misdemeanor-level fifth-degree matter or a multi-year federal investigation. The firm offers financing so a serious Medicaid fraud allegation does not have to wait on your ability to pay a lump sum upfront.
Speak With a NYC Medicaid Fraud Lawyer Before You Respond to Any Agency
Whether you received an OMIG letter, a subpoena, or an arrest, you can reach the Law Offices of Robert Tsigler, PLLC 24 hours a day, 7 days a week to start discussing your defense. Contact us today to talk through what you’re facing and what comes next.
Schedule your consultation by calling 718-878-3781
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To start, Medicaid is a health plan that provides a variety of health care services to people. Medicaid fraud is when someone provides false information to have their medical expenses paid through Medicaid. This is done in many ways including retention of over payments, ghost patients, false certification and red-lining. Retention of over payments is when Medicaid gives someone more money than they were supposed to and the person keeps the money. Instead of keeping the money, the person should return the amount that they were over paid within 60 days of receiving the money. Ghost patients are people who are receiving Medicaid funding but do not actually exist. They were instead fraudulently created just to abuse the Medicaid system. False certification is when someone provides fake certificates to receive Medicaid funding. Red-lining is done by a Medicaid company and it is when a company discriminates against a patient because they feel that they can save money by not treating them, The company then keeps the money for itself.
First-degree Medicaid fraud is when someone knowingly and willingly provides false information to get the benefits of a Medicaid health care plan and the total value of the benefits exceeds $1,000,000. First degree Medicaid fraud is a class B felony.
Second-Degree Medicaid fraud is when someone knowingly and willingly provides false information to get the benefits of a Medicaid health care plan and the total value of the benefits is between $50,000 and $999,999. Second-degree Medicaid fraud is a class C felony.
Third-degree Medicaid fraud is when someone knowingly and willingly provides false information to get the benefits of a Medicaid health care plan and the total value of the benefits is between $10,000 and $49,999. Third-degree Medicaid fraud is a class D felony.
Forth-degree Medicaid Fraud is when someone knowingly and willingly provides false information to get the benefits of a Medicaid health care plan and the total value of the benefits is between $3,000 and $9,999. Fourth degree Medicaid fraud is a class E felony.
Fifth-degree Medicaid fraud is when someone knowingly and willingly provides false information to get the benefits of a Medicaid health care plan and the total value of the benefits does no exceed $2,999. Fifth-degree Medicaid fraud is a class A misdemeanor.
If you are ever thought to be committing Medicaid Fraud, you will be put through a thorough background check and asked to provide specific identification to investigators. This will let the investigators know if you have knowingly participated in any form of Medicaid fraud and are receiving any medical benefits that you shouldn’t be. They will know this because, to receive Medicaid, you have to provides certain forms of identification. If there is no record of your identification in the Medicaid system, but they can still prove you have used Medicaid, then you have likely been committing Medicaid fraud.
Throughout this article, I have gone over many different forms of Medicaid fraud and told you exactly what Medicaid fraud is. I have also told you the penalties that come with Medicaid fraud and how Medicaid fraud is proven. Having said that, I would like to thank you for reading this article. If you are facing charges of Medicaid Fraud, then contact Tsigler Law. The people at Tsigler Law are committed to providing their clients with the best services possible and would love to be able to serve you.
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