OMIG Compliance and Investigations
Our Health Law Group’s primary practice area includes managing government and regulatory investigations related to health care fraud. This generally entails resolving matters before the Office of Medicaid Inspector General (“OMIG”).
What is “The Office of Medicaid Inspector General?”
The Office of Medicaid Inspector General is a New York State Agency charged with investigating Medicaid fraud by “Investigation, detection, audit, and review.” Of all Medicaid providers and patients. In addition to its own investigative units, it also works with the following agencies:
- Federal Office of the Inspector General (OIG);
- New York State Attorney General’s Office Medicaid Fraud Control Unit (MFCU);
- Various Federal and local Law Enforcement agencies.
In 2018, the largest Medicaid and Medicare fraud operation in history was conducted with the OIG and numerous state and local law enforcement agencies. A total of 600 Defendants were charged and an additional 587 medical practitioners were excluded from future participation in Medicare and Medicaid. The total fraud from these practitioners cost taxpayers in excess of $2 Billion in losses to the Medicaid and Medicare systems.
For additional examples of such cases, see the “Press Release” section below.
What Does the OMIG Investigate?
There are two basic government healthcare programs, Medicaid and Medicare.
Medicare was created in 1965 as a program for people 65 years and older and for people with certain disabilities to provide healthcare benefits at a time when they are likely not to be able to provide for those benefits on their own.
Medicaid is a program for low-income families and individuals. The primary difference when it comes to billing is that Medicare is run by the Center for Medicare and Medicaid services (CMS), a Federal agency, while Medicaid is run by CMS and local State governments.
The Office of Medicaid Inspector General enforces Medicaid fraud in New York State along with the Federal Office of the Inspector General.
If someone is charged with Medicaid fraud the repercussions are severe and could include fines, imprisonment, penalties and interest and a bar on future Medicaid billing. In addition, the case, could result in a lengthy, costly and time-consuming prosecution in State or Federal Court. Don’t go it alone.
What Are Common Types of Health Care Fraud?
According to Healthcare Business and Technology, health care fraud makes up the majority of false claims and insurance fraud per year in the United States.
The following is a list of typical types of fraud:
- Unnecessary procedures.
- Referral kickbacks.
- False diagnoses leading to unnecessary tests and procedures.
- Falsified billing especially for procedures and tests never conducted.
- Billing for more expensive procedures instead of the ones actually provided.
- Multistep billing where a single procedure is billed as if multiples procedures had been conducted.
- Billing an unnecessary procedure such as plastic surgery as if it were a necessary procedure.
- Waiving fees including copayments and deductibles.
- Billing patients directly for procedures covered under an insurance plan.
The most common types of Medicaid fraud are “phantom billing”, “false patient billing”, and “upcoding”. In short phantom billing is when a medical professional bills for false or unnecessary procedures. False patient billing is when a Medicaid number is used for other patients. Upcoding is when more expensive billing codes are entered for less expensive procedures.
Who Can Be Prosecuted for Health Care Fraud?
Medicaid and Medicare fraud are illegal and punishable by State and local laws similar to any other type of fraud. In New York State for example under Penal Law § 170.00 a “Person” prosecutable under the law is defined as any entity or individual including the patient if the patient acted as an accessory to the entity or individual. This means anyone participating in healthcare fraud, including a business is violating the law and can be prosecuted.
What Statute Does Health Care Fraud Violate?
New York Penal Law § 177.05 – 177.25 describes the crime of Healthcare Fraud in New York.
Violation of these sections of the law range in severity from a class A misdemeanor up to a class B Felony.
According to the statute, the severity of the crime and potential exposure to jail time and other penalties rises with the amount of total fraud committed.
In general the crime of Healthcare Fraud criminalizes any activity which causes the submission for payment to a healthcare insurance entity of any amount not actually earned by the healthcare provider.
Different states might have differing definitions and crimes.
Is This Medicaid Fraud Similar to Other Types of Fraud?
Medicaid and Medicare fraud together constituted the most frequent recorded type of insurance fraud.
Other frequent types of fraud in order of frequency include:
- Non-Medicaid and Medicare Healthcare Fraud;
- Auto Fraud:
- Drug Diversion;
- Identity Theft;
- General Fraud;
- Workers Comp;
These are all part of the ongoing list of Frauds that are prosecutable crimes and could have enormous impact on any business.
Who is in Charge of prosecuting these violations?
Healthcare Fraud is aggressively investigated by State and local Law Enforcement Agencies and the Attorney General’s Office. In addition, the following agencies play a large role in enforcement:
- Federal Office of the Inspector General;
- The Office of Medicaid Inspector General;
- Centers for Medicare and Medicaid Services;
- State and Local Agencies.
How Are These Investigations Carried Out?
Fraud investigations can involve the following techniques:
- OIG conducts audits on submitted paperwork to determine obvious signs of fraud and abuse;
- Evaluations are conducted on practices and patients to determine if the correct procedures and billing for those procedures were carried out;
- Investigations are launched by law enforcement and the Attorney General’s Office MFCU to determine fraud. These investigations can be started through recommendations by Medicaid OIG or any other agency as well as police investigations into people and practices suspected independently of fraud.
- Data Analytics are a sophisticated way to flag potential fraudulent activity by using statistics and other tools to identify when an otherwise properly filed claim might be an indication of fraud.
- OIG also funds grants to MFCU’s around the Country to help them combat Healthcare Fraud. into The Special Agent Supervisor approves or denies the finding of fraud, after independent review.;
- Once approved the file is returned to the Special Agent for Fact-finding;
- In conjunction with the Chief Counsel. Then obtains evidence, conducts interviews of witnesses, surveillance, obtains and executes search warrants, subpoenas bank records, and reviews financial information to build the case and determine the extent of criminal activity
Defending Yourself Against OMIG Investigations?
When a healthcare fraud claim is brought against you or your business, the repercussions can be devastating. It could result in fines, fees, penalties and even loss of eligibility for future Medicare or Medicaid billing participation.
Our industry-leading attorneys, paralegals and expert support staff are second to none and have the expertise needed to resolve your healthcare fraud issue with the best possible result.
Without the competent representation of an attorney your practice, license and freedom are at grave risk. An attorney provide the protection you need, preserve your rights and provide you with the highest chance of a positive outcome.
The most productive defense usually involves demonstrating that the alleged fraud was due to a mistake or was otherwise unintentional.
In a criminal investigation there is a higher standard of proof than a civil investigation and therefore an attorney can hold the government to the standard of proof required by law.
Frequently the difference between winning and losing the case is having the right attorney provide guidance and advice on how to reply to subpoenas and requests for evidence by the Medicaid Office of the Inspector General.
Saying or doing the wrong thing during an investigation can easily be the difference between being found liable and being acquitted of any wrongdoing.
Only an experienced healthcare fraud Attorney will have the insight, knowledge, experience and ability to properly guide you if you are subject to an investigation for healthcare fraud.
Cases Reported in the News
Charge: Health Care Fraud
Allegations: Fraudulently billing Medicaid and Medicare
In January 2019,Rober H. Carrado and Interline Empoyee Assistance Program were convicted of violating New Yrk State Healthcare laws. They conducted an extensive kickback scheme involving improper referral payments and other healthcare fraud. Kristina Carrado was also convicted in this scheme. This was part of the MFCU’s “three-quarter house” operation to prevent healthcare fraud which has already resulted in several healthcare providers being brought to justice.
Terms of Sentence were not available.
Charge: Grand Larceny in the Second Degree
Allegations: Health care fraud
Dr. Edwardo M. Yambo, a Medical Doctor and Principle Owner of Edwardo Yambo P.C., a healthcare provider and Practice in Lake Grove New York, was charged with Grand Larceny for fraudulently billing Medicaid for a number of years. Dr. Yambo is seventy years old. Information on his conviction and sentence were not available
Principle Charge: Falsely Billing Medicaid
Allegations: Taxi Company falsely submitted bills to Medicaid for fraudulent taxi rides.
Sadat Khan, Kashif Pervez, Marcus Mathis, Chester Haugabook, and William Medina, all of Niagra Falls, New York, were arrested and charged with filling over $50,000.00 in fraudulent transport bills. The arrest was a result of a sting operation dubbed “Operation Ghost Ride,” which determined that the Defendants and the Company they worked for, Wego Taxi Tours, were billing Medicaid for rides to doctors offices and healthcare providers that had never actually been taken. Terms of sentence were unavailable.
Principle Charge: Medicaid Fraud
Allegations: Falsely Billing Medicaid for transportation services.
Wossen Ambaye, of Buffalo, New York, President of 716 transportation Inc. was sentenced on for stealing $1.2 million from a Medicaid program. Eerie County Supreme Court Judge John Michalsky sentenced him to three years conditional discharge, 150 hours of community service, a fine of $10,000 and restitution of $900,497.00
Principle Charge: Medicaid Fraud
Allegations: Falsely Billing Medicaid for prescriptions.
Arkady Goldin owner of Value Pharmacy Inc. of Queens New York, was convicted on June 8, 2018, of Medicaid Fraud. The case was investigated by a joint task force led by Attorney General Barbara Underwood and State Comptroller Thomas DiNapoli called the Joint Task force on Public Integrity. Mr. Goldin admitted to defrauding the New York State Medicaid program out of $1.5 Million by submitting false claims for prescription drugs.
What to do if you are under an OMIG Investigation
If you are the subject of a Healthcare Fraud investigation don’t go it alone, you need professional help right away.
Healthcare Fraud can lead to fines, penalties, interest, back taxes, jail time, and the loss of Professional Licenses and the right to bill Medicaid or Medicare in the future. You need an experienced Healthcare Fraud Attorney working for you.
Our experienced and attorneys will get the job done the right way. They will negotiate on your behalf with the authorities, establish the best possible defense, and resolve any civil and criminal charges filed against you with the best possible outcome in mind.
No matter what kind of investigation you are faced with, call us. We have defended numerous clients in court and before the Medicaid Office of the Inspector General. We have helped many people, just like you, resolve their Healthcare Fraud matters successfully and with peace of mind.