New York City Medicaid Fraud Lawyer
Federal and state investigators have built entire task forces around Medicaid fraud prosecution in New York, and those task forces are extraordinarily well-funded, well-staffed, and patient. They spend months or years constructing cases before a single arrest is made. By the time a target learns they are under investigation, the government typically has billing records, patient files, undercover operations, cooperating witnesses, and financial forensics already assembled. For anyone who has received a subpoena, a civil investigative demand, a no-knock search, or a quiet call from a compliance officer, that context matters enormously. A New York City Medicaid fraud lawyer who understands how these investigations are built is also the attorney who knows where they can be dismantled.
New York is the single largest Medicaid program in the country by expenditure. That scale makes it a perpetual enforcement priority for both the state Attorney General’s Medicaid Fraud Control Unit and federal prosecutors in the Southern and Eastern Districts of New York. The charges that emerge from these investigations run from misdemeanor billing irregularities to federal healthcare fraud carrying substantial prison exposure. They can be brought against solo practitioners, large provider networks, billing companies, office managers, and individuals who may have been employees with little or no authority over the conduct the government is targeting. The range of who gets charged is broad, and the theory of liability the government uses is often more expansive than clients initially expect.
Because these cases involve both state and federal jurisdiction simultaneously, they require an attorney who is equally comfortable in state Supreme Court and in federal district court, and who understands the interplay between a state administrative proceeding, a parallel civil false claims act case, and a criminal indictment that can all be moving at the same time. The strategic decisions made in the earliest days of an investigation routinely determine how the entire matter resolves years later.
How Jason Goldman Approaches Medicaid Fraud Defense in New York
Jason Goldman began his career as a Brooklyn prosecutor, which means he has seen firsthand how the government builds complex fraud cases and where its evidence strategies are vulnerable. That prosecutorial background is not incidental to Medicaid fraud defense. It is directly relevant. Understanding how investigators prioritize targets, how cooperators are cultivated, how billing data is analyzed, and how charging decisions get made at the prosecutorial level gives a defense attorney structural insight that cannot be replicated from the defense side alone.
Over the course of his career, Mr. Goldman has represented corporate executives in finance, real estate, and hospitality, as well as doctors, lawyers, and other professionals whose livelihoods, licenses, and reputations are inseparable from the outcome of the case. Medicaid fraud investigations fall squarely within that profile. A physician, a nurse practitioner, a pharmacy owner, or a durable medical equipment supplier facing healthcare fraud allegations is not just facing potential incarceration. They are facing license revocation, exclusion from all federal healthcare programs, civil monetary penalties, asset freezes, and the destruction of a professional identity built over decades. Mr. Goldman has described his approach as part trial lawyer, part dealmaker, and part fixer, which reflects the reality that Medicaid fraud cases rarely travel a single path from accusation to resolution.
Mr. Goldman has tried over 25 cases to verdict and maintains robust experience in appellate practice and federal sentencing, both of which matter significantly in healthcare fraud prosecutions where sentencing guidelines can produce outcomes that feel disproportionate to the conduct alleged. He has been recognized as a New York Super Lawyers Rising Star and is a member of the National Association of Criminal Defense Lawyers, the New York State Association of Criminal Defense Lawyers, and the New York City Bar Association’s Criminal Courts Committee. His admissions in both the Southern and Eastern Districts of New York, the two federal districts that prosecute the overwhelming majority of significant Medicaid fraud cases in the city, are directly relevant to clients in this area.
Charges and Theories That Appear in New York Medicaid Fraud Prosecutions
- Billing for services not rendered: One of the most frequently charged theories, this involves submitting claims for patient encounters, procedures, or tests that did not occur, often identified through data analytics comparing a provider’s billing volume against patient census and documentation.
- Upcoding and unbundling: Billing for a more intensive service than was actually provided, or separating procedures that should be billed together to collect higher reimbursement, are common targets of audits conducted by the New York State Office of the Medicaid Inspector General.
- Kickbacks and referral arrangements: The federal Anti-Kickback Statute prohibits payments or inducements for patient referrals involving federal healthcare programs, and New York state law parallels those prohibitions; prosecutions often emerge from arrangements that providers believed were structured legitimately under safe harbors that did not actually apply.
- Prescriptions and orders for medically unnecessary services: Particularly common in home health care, durable medical equipment, and prescription drug billing, these charges require the government to establish what services were actually clinically warranted, which creates real evidentiary battlegrounds involving expert testimony and documentation review.
- False Claims Act civil exposure: Parallel to any criminal prosecution, the federal False Claims Act and New York’s own false claims statute allow the government and private whistleblowers (through qui tam suits) to pursue treble damages and per-claim civil penalties, frequently running into the millions even in cases involving relatively modest billing irregularities.
- Identity theft and stolen beneficiary credentials: Sophisticated fraud schemes sometimes involve billing under patient identities without the beneficiary’s knowledge, which layers identity theft charges on top of fraud allegations and substantially affects how the government frames the culpability of everyone connected to the operation.
- Conspiracy charges in multi-defendant cases: Prosecutors routinely charge broad conspiracies that sweep in administrators, coders, recruiters, and others who may have played limited roles, using the conspiracy framework to extend liability far beyond the individuals who directly submitted claims.
What to Do When You Learn You Are a Target or Witness in a Medicaid Fraud Investigation
The worst decisions in Medicaid fraud cases are almost always made before an attorney is involved. Providers and their staff who receive unannounced visits from Medicaid investigators or law enforcement frequently believe that cooperating openly and explaining themselves will resolve the matter quickly. In practice, voluntary statements made without counsel present often become the most damaging evidence in the subsequent prosecution. Agents conducting these visits are trained to be disarming, and the encounter is investigative regardless of how it is characterized. The single most consequential action someone can take is to decline to answer substantive questions until an attorney is present, and to make that decision calmly and without hostility.
If a subpoena has been received, whether directed to an individual or to a business for its records, the deadline for compliance and the scope of what must be produced are both legitimate legal questions. A subpoena is not a conviction, and its receipt does not mean the government already has everything it needs. A New York Medicaid fraud defense attorney can challenge the scope of the subpoena, negotiate a reasonable production schedule, assert applicable privileges, and use the subpoena response process to begin understanding what the government is actually targeting and why.
On the state side, the Medicaid Fraud Control Unit operates out of the New York Attorney General’s office and has concurrent authority to investigate and prosecute providers across all five boroughs and throughout New York State. The OMIG (Office of the Medicaid Inspector General) handles civil audits and compliance actions separately. Federal cases are assigned to the United States Attorney’s offices in Manhattan (SDNY) and Brooklyn (EDNY), with the Health Care and Major Crimes units handling the most significant prosecutions. Understanding which agency is leading an investigation and what its typical objectives are helps shape the early defense strategy considerably.
Document preservation is critical and must begin immediately upon any indication of government interest. Destruction or alteration of records after an investigation has begun, even informally, creates obstruction exposure that can be prosecuted independently of and sometimes more aggressively than the underlying fraud allegations. At the same time, gathering and organizing records proactively, with an attorney’s guidance, is one of the most effective things a provider can do to understand their own exposure and prepare a meaningful defense.
Sentencing, Exclusion, and the Consequences That Follow a Conviction
Federal healthcare fraud convictions trigger sentencing under guidelines that use the amount of the fraudulent billing as the primary driver of recommended prison time. Because Medicaid billing volume can be large even for relatively small practices, the loss calculations that prosecutors put forward can generate guideline ranges that bear no intuitive relationship to what a defendant actually profited or intended. Contesting the government’s loss figure at sentencing is one of the most significant advocacy opportunities in these cases, and it requires forensic analysis of billing data, reimbursement records, and documentation of services that were legitimately rendered but imperfectly billed.
Beyond sentencing, a conviction or even a civil settlement in a healthcare fraud matter triggers mandatory exclusion from Medicare, Medicaid, and all federal healthcare programs under the Office of Inspector General’s exclusion authority. For a provider whose practice is built entirely or substantially on Medicaid reimbursement, that exclusion is effectively the end of the practice. It is not a fine or a license suspension with a clear end date. It is a permanent bar from participating in any federally funded healthcare program, and re-enrollment is an extensive and frequently unsuccessful process. This reality means that a defense that succeeds in avoiding exclusion, even if it does not avoid all consequences, can be enormously more valuable than its face value suggests. Similarly, state licensing boards for physicians, pharmacists, nurses, and other healthcare professionals typically act on the same factual record that produces a criminal conviction, making the defense of the underlying case inseparable from the defense of the license.
Questions About Medicaid Fraud Defense in New York
What is the difference between a Medicaid audit and a Medicaid fraud investigation?
An audit conducted by the Office of the Medicaid Inspector General is typically framed as an administrative review of billing accuracy, and it can result in repayment demands and civil penalties without any criminal component. A fraud investigation by the Medicaid Fraud Control Unit or federal prosecutors is a criminal matter from the outset, even if the target is not initially told that. The two can run simultaneously, and findings from a civil audit are sometimes used as the foundation for a subsequent criminal prosecution. Treating either as a purely administrative inconvenience is a mistake.
Can I be charged with Medicaid fraud even if I did not personally submit the billing?
Yes. Prosecutors in New York regularly charge practice owners, office managers, and supervising clinicians for billing fraud committed by staff under their supervision, using aiding and abetting theories and conspiracy charges. The fact that someone else physically submitted the claim does not insulate a supervisory employee or owner if the government can show knowledge of or willful blindness to the conduct.
What is the False Claims Act, and how does it affect my case?
The federal False Claims Act and New York’s analogous statute create civil liability for knowingly submitting false claims to the government. Liability under the FCA includes treble damages (three times the amount of the fraudulent claims) plus substantial per-claim civil penalties. These cases can be brought by the government directly or by private whistleblowers who file suit under seal. The civil FCA case often proceeds on a parallel track with any criminal prosecution, and a guilty plea or adverse verdict in the criminal case is typically used against the defendant in the civil proceeding.
What happens to my medical license if I am charged with Medicaid fraud?
In New York, the Office of Professional Medical Conduct and relevant licensing boards actively monitor healthcare fraud prosecutions and frequently open their own proceedings. An indictment alone can trigger an immediate suspension in some circumstances. A conviction or a guilty plea to a healthcare-related fraud offense will almost always result in disciplinary action, up to and including license revocation. Because licensing proceedings and criminal cases run on different evidentiary standards and timelines, coordinating the defense across both forums requires deliberate strategy from the outset.
Is it possible to resolve a Medicaid fraud investigation before charges are filed?
In some cases, yes. Pre-indictment negotiation with prosecutors and investigators, conducted carefully and through counsel, can result in a civil resolution that avoids criminal prosecution entirely, a deferred prosecution agreement, or a narrowed set of charges that preserves more of the client’s future than a full indictment would. Whether pre-indictment resolution is available and advisable depends heavily on the strength of the government’s evidence, the specific conduct alleged, and the posture of the particular prosecutor’s office handling the matter. This is one of the primary reasons why retaining counsel at the earliest possible stage, before charges are filed, often produces materially better outcomes.
How does New York’s Medicaid fraud enforcement compare to other states?
New York’s Medicaid Fraud Control Unit is consistently among the most active and well-funded in the country, in part because New York operates the largest state Medicaid program by dollar volume. The MFCU here has a long track record of pursuing complex, multi-defendant cases involving provider networks, pharmacy schemes, and home health care fraud. Federal prosecutors in both the Southern and Eastern Districts of New York have dedicated healthcare fraud units with significant institutional experience and resources. The combined enforcement environment in New York is among the most aggressive in the United States.
What is mandatory exclusion, and can it be challenged?
Mandatory exclusion from federal healthcare programs is automatic upon conviction for certain healthcare fraud offenses, and it is administered by the Department of Health and Human Services Office of Inspector General. It bars the excluded individual from participating, directly or indirectly, in Medicare, Medicaid, and other federal programs. It can sometimes be challenged or its length modified through formal waiver proceedings, but success rates are low and the process is lengthy. Avoiding the conviction, or structuring a resolution that avoids conviction for a mandatory exclusion offense, is almost always preferable to attempting to reverse exclusion after the fact.
What if a patient or former employee filed the complaint against me?
Both patients and current or former employees can trigger Medicaid fraud investigations, and the False Claims Act specifically incentivizes employees to report suspected fraud by entitling whistleblowers to a share of any civil recovery. Knowing who initiated the investigation and what their specific allegations are is critical to understanding the scope of the government’s case. Witness relationships, cooperator motivations, and the credibility of the initial complainant are all legitimate areas of defense investigation.
Can asset freezes be challenged if the government seizes money from my practice accounts?
Federal prosecutors in healthcare fraud cases frequently seek pretrial restraining orders and asset seizures under theories that restrained funds represent proceeds of fraud. These orders can be challenged through hearings at which the government must demonstrate probable cause for the restraint. Successfully challenging an asset freeze can restore operational cash flow to a practice and, more importantly, can provide the defense with access to resources needed to fund an adequate defense. These challenges require moving quickly after the restraint is imposed.
If my billing was handled by a third-party company, am I still responsible for errors?
Providers frequently argue that billing errors were the fault of their billing service rather than their own conduct. While this argument is relevant to intent, it does not automatically eliminate liability. Prosecutors take the position that providers retain ultimate responsibility for claims submitted under their provider numbers, and they look for evidence that the provider was on notice of billing irregularities or instructed the billing company to engage in problematic practices. The quality of documentation showing appropriate oversight of the billing company, and the specifics of what the provider actually knew, are the key factual questions.
Medicaid Fraud Defense Representation Across New York City and the Surrounding Region
The Law Offices of Jason Goldman represents clients throughout New York City’s five boroughs, including providers and professionals in Manhattan, Brooklyn, the Bronx, Queens, and Staten Island. Within Manhattan, the firm serves clients from practices located in Midtown, the Upper East Side, the Upper West Side, Washington Heights, East Harlem, the Financial District, and the neighborhoods throughout Lower Manhattan and the outer boroughs where Medicaid-enrolled providers are concentrated. The firm also extends its representation to clients in Nassau County, Suffolk County, Westchester County, and Rockland County, where federal and state healthcare fraud investigations frequently target suburban provider networks and home health agencies serving the broader metropolitan area. For matters that originate in New York but involve conduct or defendants across multiple jurisdictions, Mr. Goldman is admitted pro hac vice throughout the country and has handled cases extending well beyond the geographic boundaries of New York State.
New York City Medicaid Fraud Attorney: Speak With Jason Goldman
Government healthcare fraud investigations move on the government’s timeline, not yours, and the decisions made before formal charges are filed often carry more weight than anything argued at trial. If you have received a subpoena, a notice of audit, a visit from investigators, or any signal that a Medicaid fraud inquiry may be underway, speaking with a New York City Medicaid fraud attorney as early as possible is not a precaution. It is the strategic decision that shapes everything that follows. Contact The Law Offices of Jason Goldman to schedule a confidential consultation and discuss where matters stand and what the full range of options looks like from here.
