Adult Day Care Fraud Lawyer
Protecting Healthcare Providers and Facility Owners Accused of Program Fraud
In recent years, adult day care centers in New York and across the country have come under increasing scrutiny from federal and state agencies for alleged fraud involving Medicaid billing, patient recruitment practices, and program eligibility. These facilities, which offer essential support services to elderly and disabled adults, are now frequently the target of audits, civil enforcement actions, and criminal investigations.
If you or your business is being investigated for adult day care fraud, Sosinsky Law is here to help. As an experienced criminal defense firm in New York City, we represent facility operators, healthcare professionals, billing managers, and business owners facing allegations related to fraudulent billing, kickbacks, upcoding, false claims, and more.
Whether you’ve received a subpoena, a target letter, or were contacted by federal agents, do not wait to seek legal representation. Early and aggressive legal action is critical in these cases. Contact Sosinsky Law to speak with a defense attorney who understands the unique legal challenges in adult day care fraud investigations and prosecutions.
What Is Adult Day Care Fraud?
Adult day care fraud refers to any scheme in which an adult day services facility improperly bills Medicaid, Medicare, or other government programs for services that are not medically necessary, not provided as claimed, or provided to ineligible participants. The fraud may involve:
- Submitting false or inflated claims for services
- Billing for services never rendered or not medically necessary
- Recruiting patients with financial incentives or gifts
- Falsifying patient records or eligibility documentation
- Improperly using billing modifiers or procedure codes
- Kickbacks to marketers or referring physicians
- Failing to maintain proper documentation or staff licensing
These cases often arise under New York’s Medicaid Managed Long Term Care (MLTC) program, which provides funding for adult day health care (ADHC) and social day care services to medically eligible individuals. Allegations of abuse or fraud under MLTC have led to aggressive audits and criminal prosecutions under both state and federal law.
Types of Facilities Targeted in Investigations
Federal and state investigators may focus on any facility participating in adult day care services, including:
- Adult Day Health Care (ADHC) programs
- Social Adult Day Care (SADC) centers
- Licensed home health agencies providing related services
- Third-party marketing firms involved in patient recruitment
- Transportation companies contracted to bring patients to and from care centers
If your facility receives payments from Medicaid, Medicare Advantage plans, or MLTCs, your billing practices and patient rosters may already be under surveillance or data review by agencies like:
- The Office of the Medicaid Inspector General (OMIG)
- The U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG)
- The Federal Bureau of Investigation (FBI)
- The New York State Attorney General’s Medicaid Fraud Control Unit (MFCU)
- Local District Attorneys’ Healthcare Fraud Bureaus
Common Allegations in Adult Day Care Fraud Cases
Sosinsky Law has seen an increase in government enforcement targeting:
- Phantom Billing: Billing for services not actually provided to the participant.
- Eligibility Fraud: Enrolling individuals who are not eligible under Medicaid guidelines.
- Inflated Attendance Logs: Falsifying daily sign-in sheets or electronic tracking data to maximize billing.
- Referral Kickbacks: Paying marketing firms or individuals to refer patients, in violation of the Anti-Kickback Statute or state bribery laws.
- Double Billing: Charging Medicaid and a managed care organization (MCO) for the same services.
- False Diagnoses: Exaggerating or fabricating patient conditions to justify services.
- Unlicensed or Inadequately Staffed Facilities: Violating regulatory requirements while still billing at full rates.
Criminal and Civil Consequences of Adult Day Care Fraud
Federal and state prosecutors treat adult day care fraud as a serious criminal offense that can result in:
- Federal healthcare fraud charges (18 U.S.C. § 1347)
- Wire fraud or mail fraud charges
- Conspiracy to commit healthcare fraud
- False Claims Act violations (civil and/or criminal)
- Anti-Kickback Statute violations
- New York Penal Law charges, such as Grand Larceny, Falsifying Business Records, or Offering a False Instrument for Filing
Penalties may include:
- Up to 10 years in prison per count for healthcare fraud
- Significant monetary fines and restitution
- Exclusion from Medicaid and Medicare participation
- Loss of professional licenses and facility certifications
- Asset forfeiture and facility closure
- Civil treble damages and False Claims Act penalties
Even civil enforcement, such as a Medicaid overpayment demand, can be financially ruinous and may lead to follow-up criminal referrals.
How Sosinsky Law Defends Adult Day Care Fraud Charges
When facing allegations of adult day care fraud, the stakes are incredibly high. At Sosinsky Law, we take an aggressive, strategic approach to defending clients at every stage of the case, from initial audits and investigations to federal indictment and trial.
Our defense strategies often include:
1. Challenging the Government’s Billing Interpretation
We evaluate whether the services provided were medically necessary, properly documented, and appropriately coded. Many adult day care billing issues stem from confusing or inconsistent program guidelines, not criminal intent.
2. Presenting a Good Faith Defense
We show that billing was done in reliance on legal advice, compliance programs, or third-party billing services, undermining any allegation of knowing or willful fraud.
3. Disputing Patient Eligibility Claims
We scrutinize whether the government accurately assessed participant eligibility or relied on flawed audits or unreliable data.
4. Attacking the Credibility of Whistleblowers
Many adult day care investigations are prompted by qui tam lawsuits or disgruntled former employees. We expose biases, inaccuracies, or financial motives in their complaints.
5. Engaging Early for Pre-Charge Resolution
If brought in early, at the subpoena or audit stage, we often negotiate civil settlements, avoid criminal charges, or resolve the matter through administrative remedies rather than litigation.
Early Legal Intervention Is Critical
The moment you receive a letter from a Medicaid contractor, state auditor, or federal agent, your business and liberty are at risk. Too often, providers wait until charges are filed before seeking legal counsel, when earlier action could have prevented escalation.
By engaging Sosinsky Law early in the process, we can:
- Manage communications with investigators
- Ensure compliance with subpoenas and audits
- Control the narrative before agents draw conclusions
- Protect your license and reputation
- Negotiate for administrative or civil resolution
If you’ve been contacted by OMIG, CMS, HHS, MFCU, or a grand jury, contact us immediately.
Contact Our Adult Day Care Fraud Defense Attorney
If you or your facility is under investigation for adult day care fraud in New York City, don’t face it alone. The laws governing Medicaid billing and MLTC participation are complex, and the penalties for even unintentional violations are severe.
At Sosinsky Law, we fight to protect the rights, reputations, and futures of medical professionals, facility operators, and healthcare businesses. From audit response to grand jury defense, our firm brings the experience, strategy, and dedication needed to win.
Call Sosinsky Law today for a confidential consultation with a healthcare fraud defense attorney in New York City.