Another kind of Medicaid applicants who are not eligible are those who don’t know about it: when a person is institutionalized, sometimes already experiencing the adverse cognitive and memory effects of age-related dementia, Social Workers at hospitals and nursing homes sometimes apply for Medicaid for the institutionalized individuals. These Social Workers are not always thorough in finding out the financial status of the individual, and their sole concern is that their hospital or nursing home gets paid by Medicaid. The Social Workers usually bear no responsibility for the mistakes they make on the Medicaid applications.
Finally, the last category of Medicaid investigations are mistakes by the government organizations investigating suspected fraud because certain government workers are not aware of the rules, have incomplete information about an applicant, or do not understand the specific rules applicable during the time period being investigated (the rules periodically change and the income and resource levels are routinely adjusted).
Depending on what government entity is investigating the alleged Medicaid fraud, the Medicaid recipient may be facing potential civil or even criminal liability if the investigation is not addressed in a timely manner. Termination of Medicaid benefits may only be the start then, followed by large bills for payments made during a period of ineligibility or worse. Pennsylvania Department of Human Services (Bureau of Program Integrity) is responsible for investigations of alleged Medicaid fraud, and Pennsylvania Office of Attorney General, Medicaid Fraud Control Section, or another appropriate law enforcement agency, is responsible for criminal Medicaid investigations. These are the primary Medicaid investigators in Pennsylvania, but there are other state and federal government organizations and contractors that may investigate Medicaid fraud. Health Management Systems, Inc. (HMS) is Pennsylvania’s Medicaid Recovery Audit Contractor (RAC), which reviews claims of items and services submitted by providers or other individuals for the purpose of identifying and recouping overpayments. In either case, a Medicaid audit or investigation is a very serious matter, and the Department of Human Service may seek double damages and/or penalties for overpayments it believes to be improper. Therefore, providers and individuals under a Medicaid investigation or inquiry should immediately seek qualified representation, or risk missing the response deadlines in correspondence notifying of the investigation. You should be aware that even the Bureau of Program Integrity, which conducts a civil investigation, may refer your matter to a criminal prosecutor.
When an individual with Medicaid benefits receives a letter concerning the investigation, it is frequently because the investigators became aware of income, property (real estate, cars, businesses, property overseas) or money in the bank that affect your Medicaid eligibility. The letter may schedule an appointment for you to come in, a telephone conference, and it may request documents and information from you. It is essential that you speak with a knowledgeable attorney about your particular situation before responding. Otherwise, your rights and remedies may be irrevocably lost.
Attorney Leonid Mikityanskiy familiarizes himself with the facts of his clients’ matter and advocates on their behalf, as well as negotiates settlements in Medicaid investigations and audits in Bucks County and Northeast Philadelphia, PA. A settlement usually means that no criminal charges or further civil charges are pursued. The Law Offices of Leo Mikityanskiy will help you with:
- Mistakes on Medicaid applications;
- Misrepresentations on Medicaid applications (intentional and unintentional);
- Failure to report changes in status (income, assets, marital status, adult household members);
- Mistakes of third parties (Social Workers, insurance brokers);
- Mistakes and incorrect presumptions of investigating agencies, including misunderstanding of the rules, income/assets and the supporting documentation;
- Medical provider Medicaid fraud (medical services; medications; Medicaid abuse by doctors, dentists, clinics, pharmacies, laboratories, imaging companies, medical equipment and supplies companies, ambulance companies, home health care companies, and other medical providers; overbilling, billing for unnecessary services and medications, billing for services not provided, and medication substitutions; illegal kickbacks for medical referrals); and
- Calculating the correct amount of Medicaid claim for the period in question.
The Law Offices of Leo Mikityanskiy aggressively represents clients in Medicaid audits, investigations, and fraud allegations in Bucks County and Northeast Philadelphia, Pennsylvania. Please contact attorney Leonid Mikityanskiy at our Feasterville, PA office at (215) 357-1400.
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