Medical Assistance Fraud | Duluth Attorney

Fighting a Medical Assistance Fraud Accusation in St. Louis County with a Dedicated Defense Attorney

Being accused of Medical Assistance fraud can send shockwaves through your life. For healthcare providers, patients, or administrators in Northern Minnesota—from the vibrant city of Duluth to the close-knit communities of Two Harbors or Proctor—this isn’t just a legal challenge; it’s a profound assault on your professional reputation, your livelihood, and your very standing in a community that relies on trusted healthcare services. The fear of public humiliation, the potential loss of your medical license, the threat of crippling fines, and the devastating impact on your family can be overwhelming, leaving you feeling isolated and vulnerable against the immense power of the state.

This is not the end of your life; it is the beginning of a fight, a battle that demands immediate, aggressive, and strategic action. When facing a charge as serious as Medical Assistance fraud, the state will bring its full resources to bear, including specialized fraud units, and you cannot afford to face them alone. This is not the time for passive observation or hoping it will just “blow over”; it is the moment for a relentless counter-offensive. You need an attorney who embodies the spirit of a fighter, who understands the intricate complexities of healthcare regulations and criminal defense, and who is prepared to challenge every facet of the state’s allegations. Your clear path forward, forged by strength, strategy, and an unwavering commitment to your defense, begins now, with a dedicated advocate ready to stand with you in St. Louis County.

The Stakes: What a Conviction Truly Costs

A conviction for Medical Assistance fraud is not a minor financial issue; it is a severe felony that can shatter your future and irrevocably damage your professional and personal life. The fight against this accusation is essential because the consequences extend far beyond any immediate penalties, fundamentally reshaping every aspect of your existence.

Your Permanent Criminal Record

A conviction for Medical Assistance fraud will brand you with a permanent criminal record, an indelible mark that will follow you for the remainder of your life. While the specific statute (609.466) defines it as an “attempt to commit theft of public funds,” this is treated as a felony theft offense. This isn’t something that fades with time or can be easily explained away; it’s a public record accessible to future employers, licensing boards, and anyone conducting a background check. In professional circles and close-knit communities across Northern Minnesota, from Duluth to Bemidji, a conviction for healthcare fraud will irrevocably damage your reputation. It signals to the world that you were found guilty of defrauding public healthcare programs, a label that carries immense social and professional stigma. This record will constantly resurface, severely limiting opportunities and making it incredibly difficult to ever truly move past the accusation, even after your sentence is served.

Loss of Second Amendment Rights

As Medical Assistance fraud is classified as an attempt to commit theft of public funds, it is a felony offense. Consequently, a conviction for this crime carries the permanent loss of your Second Amendment rights. This means you will be legally prohibited from owning, possessing, or carrying firearms, a fundamental right for many law-abiding citizens. For individuals in rural communities like Cloquet or Two Harbors, where hunting, sport shooting, or personal protection are often integral to their lifestyle, this loss can be particularly devastating. It’s not just about a pastime; it’s about a deeply ingrained sense of self-reliance and personal liberty that will be stripped away for life, regardless of how much time passes or how much you change as a person. This prohibition serves as a constant and painful reminder of the conviction’s far-reaching impact.

Barriers to Employment and Housing

The devastating impact of a Medical Assistance fraud conviction extends directly into your ability to secure gainful employment and stable housing. For healthcare providers, a conviction for defrauding public health programs almost certainly means the end of that specific career path. Furthermore, many private sector employers, particularly those requiring positions of trust, financial responsibility, or any type of background check, will view a conviction for healthcare fraud as a severe red flag, potentially leading to immediate disqualification. Similarly, landlords are increasingly scrutinizing applicants, and a felony conviction of this nature will often lead to immediate disqualification from desirable housing options, potentially forcing you into precarious or undesirable living situations. This creates a relentless cycle of hardship, making it incredibly challenging to rebuild your life, support yourself, or provide for your family in any community, including those in St. Louis County.

Impact on Professional Licenses and Reputation

For those who hold professional licenses in healthcare—such as doctors, nurses, therapists, or clinic administrators—a conviction for Medical Assistance fraud can mean the immediate and permanent revocation of your license. Your entire career, built on years of education, training, and service, could be destroyed in an instant, as such professions demand the highest ethical and legal standards. Beyond professional licenses, the damage to your personal and public reputation in communities like Two Harbors or Proctor is immeasurable. Your name will forever be associated with defrauding a program designed to help vulnerable citizens, leading to widespread distrust, condemnation, and social ostracization. Your standing in the community, once built on integrity and service, will likely crumble, making it difficult to maintain existing relationships, form new ones, or engage in civic activities without constant judgment and suspicion, particularly in places where integrity is paramount, such as Proctor or Bemidji.

The Accusation: Understanding the State’s Case

When facing a charge of Medical Assistance fraud, it is absolutely critical to understand the precise legal definitions and what the state must prove. This isn’t about simple billing errors; it’s about intentional deception to siphon public funds.

What Does the State Allege? Medical Assistance Fraud Explained in Plain English

When the state alleges Medical Assistance fraud, they are accusing you of attempting to steal public funds by presenting a false or fraudulent claim for reimbursement, a cost report, or a rate application related to payments from Minnesota’s Medical Assistance program (known federally as Medicaid). This is a very serious charge because it strikes at the heart of public healthcare funding, a program designed to assist vulnerable individuals.

The core of their case will revolve around proving your intent to defraud and that the document you presented (whether a claim for reimbursement, a cost report, or a rate application) was false in whole or in part. This isn’t about an honest mistake in billing or an accidental oversight. Instead, the prosecution will attempt to demonstrate that you purposefully submitted information you knew to be untrue, with the specific aim of illegally obtaining Medical Assistance funds. This could involve billing for services not rendered, upcoding (billing for a more expensive service than provided), misrepresenting patient eligibility, or falsifying cost reports to inflate reimbursement rates. In essence, they believe you knowingly tried to illicitly profit from a public welfare program in places like Duluth and across St. Louis County.

The Law on the Books: Minnesota Statute 609.466

Minnesota Statute 609.466, specifically addressing “Medical Assistance Fraud,” is a cornerstone of the state’s efforts to protect public healthcare funds and ensure accountability within the Medical Assistance program (Chapter 256B). This statute criminalizes intentional acts of fraud involving claims for reimbursement, cost reports, or rate applications.

609.466 MEDICAL ASSISTANCE FRAUD.

Any person who, with the intent to defraud, presents a claim for reimbursement, a cost report or a rate application, relating to the payment of medical assistance funds pursuant to chapter 256B, to the state agency, which is false in whole or in part, is guilty of an attempt to commit theft of public funds and may be sentenced accordingly.

History: 1976 c 188 s 5

The Prosecution’s Burden: Elements of Medical Assistance Fraud

To secure a conviction for Medical Assistance Fraud under Minnesota Statute 609.466, the prosecution bears the immense burden of proving every single element of the crime beyond a reasonable doubt. If they fail to establish even one of these elements with sufficient evidence, their entire case against you collapses. This rigorous standard of proof is your constitutional safeguard and where a skilled defense attorney focuses their efforts, meticulously dissecting the state’s allegations.

Any Person: The prosecution must prove that you are the person who committed the alleged act. This element establishes that the individual charged falls within the scope of the statute’s applicability. This can apply to healthcare providers, administrators, billing personnel, or even patients, depending on the nature of the fraudulent claim.
With the Intent to Defraud: This is the most critical and often the most challenging mental state element for the prosecution to prove. They must demonstrate that you acted with the intent to defraud. This means you had a conscious purpose to deceive the state agency and illegally obtain medical assistance funds. Mere negligence, honest mistakes, or complex billing errors are typically insufficient to meet this high standard of criminal intent.
Presents a Claim for Reimbursement, a Cost Report, or a Rate Application: The state must prove that you presented one of the specific documents to the state agency. This includes:
- Claim for Reimbursement: A request for payment for services or goods provided.
- Cost Report: A document detailing the costs incurred by a provider, often used for calculating reimbursement rates.
- Rate Application: A request to establish or adjust the payment rate for services. The physical act of submission is a necessary component.
Relating to the Payment of Medical Assistance Funds Pursuant to Chapter 256B, to the State Agency: The prosecution must prove that the presented document was directly related to the payment of medical assistance funds as governed by Minnesota Statute Chapter 256B, and that it was submitted to the state agency responsible for administering these funds. This establishes the governmental program and recipient agency involved.
Which Is False in Whole or in Part: The core of the fraud lies here. The state must prove that the claim, cost report, or rate application was false in whole or in part. This means the information contained within the document was knowingly untrue, either entirely fabricated or contained material misrepresentations that made it fraudulent. Minor, inconsequential inaccuracies typically do not meet this standard of falsity for criminal charges.

The Potential Outcome: Penalties for a Medical Assistance Fraud Conviction

A conviction for Medical Assistance Fraud under Minnesota Statute 609.466 carries exceptionally severe penalties, as it is treated as an attempt to commit theft of public funds. The specific sentence will depend on the value of the alleged fraud, but as a felony, it carries profoundly life-altering consequences.

Because Medical Assistance fraud is prosecuted as an “attempt to commit theft of public funds,” the penalties are determined by Minnesota’s general theft statutes (Minnesota Statute 609.52), which are graduated based on the value of the property (in this case, the medical assistance funds) involved. This means you could face:

Theft of over $35,000: Imprisonment for not more than 20 years or payment of a fine of not more than $100,000, or both.
Theft of over $5,000 to $35,000: Imprisonment for not more than 10 years or payment of a fine of not more than $20,000, or both.
Theft of over $1,000 to $5,000: Imprisonment for not more than 5 years or payment of a fine of not more than $10,000, or both.
Theft of $500 to $1,000: Imprisonment for not more than 1 year and 1 day or payment of a fine of not more than $3,000, or both.
Theft of $500 or less: Imprisonment for not more than 90 days or payment of a fine of not more than $1,000, or both.

The combination of lengthy imprisonment and substantial financial penalties underscores the extreme seriousness of this charge. Beyond these direct statutory punishments, a felony conviction for Medical Assistance fraud will irrevocably alter your life, leading to the permanent loss of certain civil rights (such as the right to vote and own firearms), immense difficulty in securing future employment or housing, and an enduring stigma that will follow you in communities like Duluth, Bemidji, and across St. Louis County for the remainder of your life. This charge isn’t just about a legal outcome; it’s about the potential destruction of your career and a lasting stain on your reputation.

The Battle Plan: Building Your Strategic Defense

An accusation of Medical Assistance fraud is a direct assault on your integrity, your career, and your freedom. But an accusation is not a conviction. This is the moment to unleash a powerful, strategic defense, understanding that a criminal charge is the beginning of a fight, not the end of your life.

An Accusation is Not a Conviction: The Fight Starts Now

Let’s be absolutely clear: an accusation of Medical Assistance fraud is not a conviction. When the state levels a charge as profound and damaging as this, especially given your involvement in the healthcare system or a public assistance program, the weight of their allegations can feel suffocating. It’s easy to feel as if your guilt is a foregone conclusion. But the truth is, the state bears the immense and unyielding burden of proving every single element of their case against you beyond a reasonable doubt. In the American justice system, you are presumed innocent, and it is my relentless mission to ensure that presumption is upheld with every fiber of my being. This is not a time for passive acceptance, for hoping the situation will simply fade away, or for succumbing to the pressure. When facing a charge that can destroy your reputation, career, and freedom, you must meet the state’s power with an equally formidable, proactive, and strategic counter-offensive.

Your defense must be meticulously designed to dismantle the prosecution’s case from every conceivable angle. This means rigorously testing every piece of billing data, patient record, financial ledger, and communication they claim to possess, challenging their interpretations of complex healthcare regulations, exposing any flaws in their investigation, and asserting your constitutional rights at every turn. We will demand full discovery, meticulously review all submitted claims, payment records, audit trails, and internal policies, and, if necessary, bring in independent forensic accountants, medical billing and coding professionals, or other financial investigators to uncover the full truth that the state may be overlooking, misinterpreting, or even deliberately ignoring. The state’s case crucially relies on proving your intent to defraud and the falsity of the claim; a robust defense will rip apart those assumptions and present the full, complex picture, forcing them to genuinely prove their claims rather than just present them. This is your fight, and it starts now, with an unwavering commitment to challenge everything.

How a Medical Assistance Fraud Charge Can Be Challenged in Court

A charge of Medical Assistance fraud, while complex and serious, is not insurmountable. The most critical element the prosecution must prove is your intent to defraud. Every element they must prove presents a potential point of attack for a strategic defense. Identifying and relentlessly pursuing these avenues is critical to casting doubt on the state’s claims and asserting your innocence.

Lack of Intent to Defraud

The cornerstone of this charge is the requirement that you acted “with the intent to defraud.” If this corrupt mental state cannot be proven, the case fails.

Billing Error or Mistake: Medical billing is incredibly complex. A common defense is that the alleged false claim was a billing error or mistake, a genuine oversight, miscoding, data entry error, or misunderstanding of complex regulations, not an intentional act of fraud. This directly challenges the “intent to defraud” element.
Good Faith Belief of Legitimate Claim: If you genuinely had a good faith belief of legitimate claim that the services were rendered, the costs were incurred, or the application was accurate, even if there were errors, then you lacked the criminal intent to defraud. This involves demonstrating your reasonable belief based on the information available to you.
Lack of Knowledge of Falsity: The prosecution must prove you knew the claim was false. If you simply lacked knowledge of falsity—for instance, if you relied on incorrect information provided by a subordinate, a patient, or an automated system—then you did not possess the criminal knowledge required for conviction.
No Personal Gain/Motive: While not a direct legal defense, demonstrating that you had no personal gain/motive to defraud can undermine the prosecution’s argument of intent. If you did not financially benefit, it makes it harder for the state to prove a deliberate scheme to defraud.

Claim Was Not False or Fraudulent

A direct defense is to challenge the state’s assertion that the claim itself was actually false or fraudulent.

Services Were Rendered/Costs Incurred: The prosecution may allege billing for services not rendered. A defense can prove that the services were rendered/costs incurred as billed, perhaps through detailed patient records, staff logs, or legitimate invoices, directly refuting the claim’s falsity.
Disputed Medical Necessity: The state might claim services were unnecessary. A defense can argue disputed medical necessity, where the services were genuinely considered medically necessary by you or another provider, even if later debated by the state. Medical judgment is often subjective and can be challenged.
Technical Compliance vs. Substantive Falsity: The alleged “falsity” might stem from a technical compliance vs. substantive falsity in billing codes or documentation, rather than an actual fraudulent claim for services not provided or costs not incurred. This differentiates administrative errors from criminal fraud.
Overpayment Was Self-Reported/Rectified: If an overpayment occurred and was subsequently overpayment was self-reported/rectified by you or your organization to the state agency, or if steps were taken to return the funds, it can undermine the “intent to defraud” and the “falsity” elements for criminal prosecution.

No “Presenting” of Claim/Beyond Scope of Responsibility

The state must prove you were directly involved in the presentation of the specific claim.

Clerical Role, No Discretion: If your role was purely a clerical role, no discretion (e.g., data entry, administrative processing), with no authority or discretion to verify the claim’s accuracy or truthfulness, then you may not have “presented” the claim with the required intent under the statute.
Claim Presented by Other Party: The alleged false claim may have been claim presented by other party without your knowledge or involvement. You cannot be held criminally liable for a claim presented by someone else if you were unaware of its submission or falsity.
Beyond Scope of Responsibility: The specific claim or report may have been beyond scope of responsibility, falling outside your direct purview or area of responsibility within the organization. This challenges the link between your actions and the fraudulent submission.

Constitutional Violations

Even in complex white-collar cases involving healthcare fraud, your constitutional rights are paramount. Any violation by law enforcement or prosecutors can lead to the suppression of critical evidence or even the dismissal of your case.

Illegal Search and Seizure: Evidence (e.g., patient records, billing data, electronic communications, financial records) obtained through an illegal search and seizure, conducted without a valid warrant or probable cause, is generally inadmissible in court. Challenging the legality of how evidence was collected can severely weaken the prosecution’s case.
Miranda Rights Violations: If you were questioned while in custody regarding alleged fraud without being properly advised of your Miranda rights (right to remain silent, right to an to an attorney), any statements you made could be suppressed. This is crucial if the prosecution relies heavily on your alleged admissions.
Due Process Violations: Any fundamental unfairness in the legal process, such as the deliberate destruction of exculpatory evidence, prosecutorial misconduct (e.g., withholding favorable evidence), or significant delays that prejudice your ability to defend yourself, could constitute a due process violation, potentially leading to dismissal of charges.
Vagueness of Regulations: If the medical assistance regulations or billing guidelines are so vague or ambiguous that they fail to give healthcare providers fair notice of what is prohibited, it could be challenged as a vagueness of regulations violation of due process, undermining the “intent to defraud” element.

Defense in Action: Scenarios in Northern Minnesota

Applying legal defenses to real-world scenarios helps illuminate their effectiveness. These examples demonstrate how a strategic defense can be mounted against a Medical Assistance Fraud charge in communities across Northern Minnesota.

Duluth Scenario: Complex Billing System Error

A large healthcare clinic in Duluth uses a sophisticated electronic medical records and billing system. A coding update to the system inadvertently causes a specific common procedure to be billed at a higher rate than allowed for Medical Assistance patients. The clinic’s billing manager, genuinely unaware of the system error, signs off on the submissions. An audit later reveals the consistent overbilling, leading to fraud charges against the manager.

In this scenario, the defense would focus heavily on lack of intent to defraud, specifically arguing billing error or mistake and reliance on subordinates/systems. The attorney would present evidence from IT professionals detailing the system error, show the manager’s training and history of compliance, and demonstrate that the manager had no personal knowledge or intent to defraud. Expert testimony from a medical billing and coding professional could explain the complexity of such systems and how genuine errors can occur, undermining the prosecution’s claim of criminal intent.

Bemidji Scenario: Disputed Medical Necessity for Therapy Services

A physical therapist in Bemidji provides extensive therapy sessions to a Medical Assistance patient with chronic pain. The therapist genuinely believes the intensity and frequency of the sessions are medically necessary for the patient’s long-term recovery and bills accordingly. However, a state agency reviewer, using different criteria, later deems some of the sessions “not medically necessary” and alleges fraud based on billing for unwarranted services.

Here, the defense would center on the argument that the claim was not false or fraudulent, specifically citing disputed medical necessity. The attorney would present the patient’s detailed medical records, the therapist’s treatment notes, and potentially testimony from other medical professionals supporting the therapist’s judgment regarding the necessity of the services provided. The defense would argue that the therapist acted within their professional medical judgment and that a difference of opinion on medical necessity does not equate to criminal fraud or the intent to defraud.

Cloquet Scenario: Claim Presented by a Former Employee Without Knowledge

A small, independently owned home healthcare agency in Cloquet experiences high staff turnover. After a long-term billing clerk leaves, an audit discovers that several claims for reimbursement were submitted under the previous clerk’s login credentials, billing for services not rendered after the clerk had already departed. The agency owner is charged with Medical Assistance fraud, despite being unaware of these specific fraudulent submissions.

This defense would rely on no “presenting” of claim/beyond scope of responsibility, specifically arguing that the claim presented by other party. The attorney would show the date the clerk left, the system’s audit logs indicating the former clerk’s login, and the owner’s lack of access or knowledge of these specific submissions after the clerk’s departure. The defense would contend that the owner did not “present” these false claims with the intent to defraud, as they were the actions of a former employee operating outside the owner’s awareness or control.

Proctor Scenario: Overpayment Promptly Self-Reported and Rectified

A nursing home in Proctor discovers a discrepancy in its cost report that inadvertently led to an overpayment from the Medical Assistance program. The facility’s administrator, upon discovering the error during an internal review, immediately notifies the state agency, initiates a process to return the overpaid funds, and implements new internal controls to prevent future occurrences. Despite this, the state proceeds with a fraud investigation and charges.

The defense here would focus intensely on lack of intent to defraud, specifically arguing that the overpayment was self-reported/rectified. The attorney would present clear documentation of the internal review, the immediate notification to the state, and the efforts made to return the funds. This proactive and transparent behavior directly contradicts any claim of “intent to defraud.” The defense would argue that the facility, through its administrator, acted responsibly and in good faith to correct an error, demonstrating a clear absence of criminal intent.

The Advocate: Why a Dedicated Duluth Defense Attorney is Essential

When facing an accusation of Medical Assistance fraud, you are not simply dealing with a financial dispute; you are confronting a criminal charge that questions your integrity, your professional license, and could jeopardize your entire career in healthcare. This is a moment that demands immediate, assertive, and uncompromising advocacy.

Countering the Resources of the State

The state of Minnesota, through its Attorney General’s Office, the Department of Human Services, specialized Medicaid Fraud Control Units, and various law enforcement agencies, possesses a formidable and seemingly limitless arsenal of resources to investigate and prosecute Medical Assistance fraud cases. They have vast investigative powers, access to all patient records, billing data, financial accounts, sophisticated data analysis tools, and highly skilled prosecutors who specialize in healthcare fraud. Their objective is to secure a conviction, and they will deploy every tool at their disposal to achieve it. As an individual, particularly a healthcare professional or administrator, you cannot possibly match this overwhelming power alone. A dedicated defense attorney is your essential equalizer, your unyielding shield against this formidable adversary. This attorney possesses the knowledge and strategic acumen to meticulously dissect every piece of financial and medical evidence the state presents, to identify and exploit weaknesses in their audit or investigation process, and to relentlessly challenge every assertion they make about your knowledge and intent. They will scrutinize billing codes, patient files, internal policies, and communications, engaging with forensic accountants and medical billing professionals if necessary, and relentlessly push back against the state’s narrative, ensuring that your rights are vigorously protected and that the state is truly forced to prove its case beyond a reasonable doubt in St. Louis County.

Strategic Command of the St. Louis County Courts

Navigating the intricate and often intimidating legal landscape of the St. Louis County court system, particularly with a charge like Medical Assistance fraud which involves complex healthcare regulations and financial intricacies, requires more than just a basic understanding of criminal law. It demands a profound, intimate knowledge of the local rules, the specific procedural nuances, and the unwritten customs that can significantly influence the trajectory and outcome of your case. Each judge, each prosecutor, and even the administrative staff in Duluth, Two Harbors, or Cloquet, operates within a unique framework that only an attorney with extensive local experience truly commands. This means knowing precisely which motions to file, when to challenge the interpretation of medical necessity standards or the accuracy of an auditor’s statistical sampling, and how to effectively present your defense in a way that resonates with local judges and juries. A dedicated defense attorney understands the intricacies of the local legal community, anticipates the prosecution’s strategies, and leverages every procedural advantage available to you, ensuring that your case is presented with the strongest possible strategic foundation within the specific context of Northern Minnesota’s judicial system.

Fighting for Your Story, Not Just the Billing Data

When an accusation of Medical Assistance fraud is leveled against you, the billing data, patient encounter logs, and audit findings often become the dominant narrative. These documents, however, are mere snapshots, frequently incomplete and inherently biased, failing to capture the full truth of your situation, the complexities of healthcare delivery, or the nuances of your intentions. Investigating bodies and law enforcement are focused on identifying patterns of discrepancies and establishing a case for criminal misconduct, not on understanding your complete clinical judgments, administrative challenges, or the pressures you faced in providing care. A dedicated defense attorney recognizes that your professional future, your license, and your freedom hinge on your story being heard, understood, and believed, not simply dismissed as a convenient perpetrator of fraud. They will tirelessly investigate every aspect of the alleged claims, interview relevant staff, patients, and other medical professionals, uncover evidence that corroborates your version of events, and work to construct a comprehensive, compelling narrative that goes far beyond the narrow, often misleading, scope of a fraud audit or investigative report. This is about humanizing you to the court and to a potential jury, ensuring that your life, your motivations, and your character are not reduced to a few lines in a prosecutor’s file.

An Unwavering Commitment to a Winning Result

Facing an accusation of Medical Assistance fraud is a deeply stressful, professionally devastating, and isolating experience. What you need most in this moment is an unwavering commitment from your legal advocate – a commitment not just to provide a defense, but to relentlessly fight for a winning result. This means exploring every possible avenue for dismissal, pursuing an acquittal, or securing the most favorable outcome possible given the unique and often complex facts of your case. It goes far beyond simply appearing for court dates; it involves countless hours of meticulous preparation, aggressive negotiation with prosecutors who will be under intense pressure to secure a conviction in public healthcare fraud cases, and a profound willingness to take your case to trial if that is what it takes to protect your freedom and your future. An attorney dedicated to your cause understands that your world has been violently disrupted, and they will pour their expertise, their strategic acumen, and their relentless energy into ensuring that this accusation does not become the defining event of your life in Northern Minnesota, but rather a battle you bravely fought and ultimately overcame.

Your Questions Answered

What is Medical Assistance fraud in Minnesota?

Medical Assistance fraud occurs when a person, with the intent to defraud, presents a false claim for reimbursement, cost report, or rate application relating to the payment of medical assistance funds (Medicaid) to the state agency. It’s considered an attempt to commit theft of public funds.

Is Medical Assistance fraud a felony?

Yes, Medical Assistance fraud under Minnesota Statute 609.466 is treated as an attempt to commit theft of public funds, which is a felony offense. The specific penalties depend on the value of the alleged fraud, ranging from a year and a day up to 20 years in prison.

What kind of “claims” are covered under this statute?

The statute covers claims for reimbursement (e.g., for services rendered), cost reports (used to calculate provider rates), and rate applications (requests to set payment rates). It broadly covers documents submitted for payment from the Medical Assistance program.

What does “intent to defraud” mean in this context?

“Intent to defraud” means you had a conscious purpose to deceive the state agency and illegally obtain medical assistance funds. It’s not about accidental errors or mistakes; it requires proving a deliberate plan to commit fraud.

Can I be charged if I made an honest mistake in my billing?

No, if you made an honest mistake, clerical error, or miscoding without the intent to defraud, you should not be convicted of Medical Assistance fraud. The “intent to defraud” element requires proving you knew the claim was false and submitted it purposefully to deceive.

What are the potential penalties for a conviction?

Penalties vary based on the amount of fraud: up to 20 years in prison and $100,000 fine for over $35,000 fraud, down to 90 days and $1,000 fine for $500 or less. As a felony, it also brings loss of civil rights, including gun ownership, and severe career impacts.

Will I lose my professional healthcare license if convicted?

Yes, a conviction for Medical Assistance fraud will almost certainly lead to the suspension or permanent revocation of your professional healthcare license (e.g., medical license, nursing license, therapist license). Licensing boards view this as a severe breach of professional ethics.

How quickly should I contact an attorney if I’m under investigation?

You should contact an attorney immediately upon learning of an investigation or accusation. Do not speak with state investigators, auditors, or law enforcement without legal counsel present. Early intervention is critical to protecting your rights and shaping the defense.

What is “upcoding” and how does it relate to fraud?

Upcoding is a common form of medical assistance fraud where a provider bills for a more complex or expensive service than was actually provided or was medically necessary. It makes a claim “false in part” by inflating the cost for reimbursement.

Can patients also be charged with Medical Assistance fraud?

Yes, while often targeting providers, the statute applies to “any person” who with intent to defraud presents a false claim. This could include patients who knowingly misrepresent their eligibility or services received to obtain benefits they are not entitled to.

What kind of evidence does the prosecution typically use?

The prosecution will use billing records, patient medical charts, electronic health records, audit reports, statistical analysis, financial records, communications (emails, texts), and witness testimony (including from whistleblowers or former employees).

Are there civil penalties in addition to criminal charges for Medical Assistance fraud?

Yes, in addition to criminal charges, you can also face substantial civil penalties under the Minnesota False Claims Act, which can include treble damages (three times the amount of the fraud) and significant per-claim fines. These civil actions have a lower burden of proof.

What if I self-reported an overpayment to the state?

If you genuinely discovered an overpayment or error and promptly self-reported it to the state agency, took steps to rectify it, and returned any funds, this can be a strong defense. It directly contradicts the “intent to defraud” element, showing you acted in good faith.

Does this statute apply to Medicare (federal) funds?

No, Minnesota Statute 609.466 specifically relates to “medical assistance funds pursuant to chapter 256B,” which governs the state’s Medical Assistance (Medicaid) program. Fraud involving federal Medicare funds would fall under federal healthcare fraud statutes.

Can an attorney help me understand complex billing regulations?

Yes, a crucial part of your attorney’s defense will be to analyze the specific medical billing, coding, and reimbursement regulations applicable to your case. Often, alleged “falsehoods” arise from ambiguous or complex regulations, and your attorney can clarify these.