What To Do if You Received a Letter from the New York State Office of the Medicaid Inspector General (OMIG)

If you received a letter from the New York State Office of the Medicaid Inspector General (OMIG), consult a lawyer immediately. The OMIG is an agency tasked with preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds. For this reason, receiving a letter from the OMIG might mean you are being audited or investigated for Medicaid fraud. This is a concern that should be taken seriously. The letter will contain instructions, which you must follow. Before making a reply to the OMIG, it is important to consult with a lawyer to ensure that your bases are covered.

Types of Fraud the OMIG Investigates

Fraud can be committed either by the medical provider or the recipient.

Examples of medical provider abuse are:

• Billing for Medicaid services that were not provided or billing for the same service multiple times
• Upcoding (billing for a more expensive service or procedure than was actually performed)
• Unbundling (billing for each component of a procedure separately, rather than billing for the procedure as a whole)
• Waiving copays or deductibles for patients
• Providing unnecessary or substandard care
• Claiming Medicaid benefits for ineligible individuals or groups
• Giving out or selling unnecessary prescriptions
• Ordering unnecessary tests
• Giving money or presents to recipients in return for agreeing to get medical care
• Accepting kickbacks for patient referrals

Examples of recipient fraud or abuse are:

• Doctor shopping or visiting emergency rooms to get controlled drugs
• Getting medical help that is not needed
• Receiving gifts or money for getting medical services
• Lending your Medicaid card or using someone else’s card
• Forging a prescription
• Receiving Medicaid when you are ineligible
• Not reporting other health insurance
• Altering bills or receipts

Sometimes, OMIG will send a letter to a Medicaid recipient stating the list of services that the Medicaid recipient received. This is one way of conducting audit. If you received this letter called Explanation of Medical (Medicaid) Benefits, there is no need to reply if all the services you received were correctly listed. Otherwise, if the list is not accurate, you need to reply in the comment box and mail it back in the included postage-free envelope. If you feel, however, that you are being audited or investigated for Medicaid fraud, consult a healthcare lawyer before making a reply.

OMIG Powers

When OMIG obtains evidence of abuse or fraud, the OMIG can do any or all of the following: refer the action to regulator agencies and licensing boards, withhold payment of funds, exclude medical providers from participating in Medicaid, recover the improperly received Medicaid funds, and refer suspected criminal activities to the Attorney General’s Medicaid Fraud Control Unit.

Because OMIG will act when it obtains evidence of abuse or fraud, it is important to ensure that the OMIG does not obtain this evidence, at least from you.

What to do when the OMIG is investigating you for Medicaid fraud or abuse

First, it is important to get a lawyer who can speak for you. Do not directly talk to the OMIG officials because everything you say can be used against you. In this case, you have the right to remain silent.

Second, do not disregard the OMIG letters. Act immediately and get the services of a healthcare lawyer.

Third, any course of action the OMIG will pursue really depends on the strength of their evidence. They may claim that you are facing x number of years in prison, forfeiture of property, and restitution. In reality, you can settle and enter into a plea agreement to get a lower penalty.

If you are found to have engaged in fraudulent activity, you may be subject to fines, repayment of fraudulent payments, and even criminal charges. It is important to take the matter seriously and to seek legal counsel if necessary in order to protect your rights and interests.

A healthcare lawyer will be able to help you in dealing with the OMIG. If you have received a letter from the OMIG and need assistance, we at the Law Offices of Albert Goodwin are here for you. We have offices in New York City, Brooklyn, NY and Queens, NY. You can call us at 212-233-1233 or send us an email at [email protected].