Rivas Goldstein, LLPNew York Health Care Law Attorney | Medical Licensing, Medicare Fraud2026-07-07T21:18:47Zhttps://www.rivasgoldsteinnyc.com/feed/atom/WordPressOn Behalf of Rivas Goldstein, LLP<![CDATA[Feds announce crackdown on Medicare overpayments: Two things to know]]>https://www.rivasgoldsteinnyc.com/?p=501792026-07-07T21:18:47Z2026-07-07T19:20:58Z Government Accountability Office (GAO) recently announced the federal government overpaid Medicare claims by almost $57 billion in 2025. This marks a significant uptick from reports of fraudulent payments in previous years which were closer to $12 billion.
The announcement comes shortly after Vice President JD Vance took the lead in a fraud task force that focused on pressuring states like New York to root out fraud or lose federal funding. Health care organizations and private practices should be aware of the following takeaways from the announcement.
#1: The government is continuing its crackdown on Medicare overpayments
The GAO has made it clear that it sees Medicare as a “high-risk” program. As such, there is unlikely to be an easing of the continued crackdown on review of Medicare claims in coming years. Groups are wise to conduct internal audits to make sure their practices are in compliance with applicable regulations and make changes as needed to reduce the risk of allegations of fraudulent claims.
#2: Health care organizations and private practices need to have a response plan
Receiving a Medicare overpayment notice is unsettling for any health care business in New York. Still, the notice is not the end of the story. It is a prompt to act quickly, preserve documentation and choose the right response path. Allegations of overpayments can arise from coding issues, medical necessity determinations, duplicate billing, coordination of benefits problems or post-payment audits by a Medicare Administrative Contractor or other review entity. It is helpful to treat the notice as both a financial and compliance event.Although the exact response depends on the organization and notice, general practices that are helpful include:
Review notice for important deadlines
Organize applicable records and correspondence
Notify leadership and compliance personnel and consider engaging experienced counsel early
After applying the response plan, you typically have several routes: repay, request a redetermination or other appeal level, seek a rebuttal to recoupment where available or pursue an extended repayment schedule if cash flow is a concern. The best option depends on the strength of the documentation, the legal theory behind the denial and the business impact of recoupment.The announcement is a reminder of the government's continued focus on fraudulent claims and likely signals an increase in investigative efforts. As such, groups and health care organizations are wise to prepare for potential investigations and review strategies to address a notification of a Medicare overpayment. Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[When executive perks become a federal funding problem]]>https://www.rivasgoldsteinnyc.com/?p=501762026-06-16T18:12:43Z2026-06-10T13:00:04Z that receive federal dollars operate under a heightened level of scrutiny. While compensation, travel and executive transitions are normal parts of running a health system, using federal funds to cover meals, travel or separation payouts improperly can quickly move from an internal compliance issue to a federal concern. A recent investigation highlights how weak controls, inaccurate reporting or a disregard for reimbursement rules can trigger an official investigation.
Though New York state’s attorney general’s office has not provided much information about the reasons behind the investigation, the investigation of a hospital in Nassau County likely focuses on the allegedly improper provision termination payments and improper use of public money towards meals and travel.
Why meals, travel and exit payouts can draw attention
Federal funds frequently come with strings attached, including allowability standards, documentation requirements and restrictions on entertainment, travel class, per diem and “reasonableness” of costs. If a hospital uses federal funds to help cover executive expenses without a solid basis, it can face inquiries from auditors, oversight agencies or law enforcement.
How a routine audit can turn into an investigation
Many federal investigations begin with something ordinary: a hotline complaint, a whistleblower allegation, an adverse audit finding or a repayment dispute. Once questions arise about the use of federal funds, investigators may request policies, board minutes, employment agreements, expense reports and general ledger detail. They may also interview employees who processed payments or approved reimbursements.
Practical steps to reduce exposure
Hospitals can regularly conduct internal audits to help reduce risk. It is also beneficial to have clear rules around executive travel and meals to better ensure compliance. For exit packages, confirm that payouts follow written agreements, are supported by contemporaneous approvals and are evaluated for allowability before funding sources are assigned.Federal dollars are not interchangeable with unrestricted operating funds. Improper charges for executive meals, travel or departure payments can trigger audit scrutiny and potentially lead to a broader federal investigation. Strong governance, disciplined documentation and careful cost allocation can help safeguard the organization from allegations of wrongdoing.Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[Staying within the bounds of nursing licensure]]>https://www.rivasgoldsteinnyc.com/?p=501742026-06-03T22:48:20Z2026-05-28T15:37:40ZThose who have worked to earn their nursing licensure have put in countless hours studying and gaining clinical experience. Once in their chosen field, nurses also gain additional knowledge and skill on the job. In many cases, they may feel comfortable providing services that could be outside the scope of practice. It is important for nurses to understand what they can and cannot do and to tread carefully. A single misstep can trigger an allegation that could threaten everything.
Why scope boundaries matter to the board
State nursing boards investigate conduct for various reasons. Common examples include allegations of unsafe practice, unprofessional behavior or impairment. “Beyond scope” concerns often arise after a patient complaint, employer report, adverse event, chart audit or unusual prescribing pattern. Even well intentioned actions can be viewed as unauthorized practice when they bypass required credentials, protocols, orders or supervision.
Examples that can trigger a nursing board investigation
Common complaints include:
Performing a medical act without authority, such as independently diagnosing, prescribing or altering medication orders without a licensed prescriber order
Administering high risk medications or sedation outside required training, competency or supervision standards
Delegating tasks improperly, such as assigning assessment or medication administration to unlicensed staff
Inadequate assessment or triage, such as failing to escalate a change in condition or delaying provider notification
Documentation issues, such as charting after the fact without proper notation, copying forward inaccurate information, or incomplete medication reconciliation
These situations often involve a true intent to help or balance difficult staffing strain. Regardless, boards will still focus on patient safety and adherence to legal standards.
What to do if you are under investigation
An investigation is serious but you can mitigate the fallout with a structured approach. Early decisions can shape outcomes, especially statements, record handling and employment communications.
Review the notice carefully, note deadlines, request the allegation summary if unclear
Avoid informal explanations to investigators or managers until preparation is complete
Preserve records, keep a timeline, identify witnesses, gather policies, competency files, training logs
Seek experienced licensing counsel, consider malpractice carrier resources when available
Continue safe practice, request supervision or reassignment when a scope question exists
These steps support accuracy, reduce misunderstandings and can help to demonstrate professionalism and insight.Practicing within licensure scope protects patients, supports professional credibility and safeguards the license that supports a nursing career. Those who find themselves under investigation can review the steps outlined above to get an idea of potential actions to protect their future in their chosen profession. An attorney with experience in this niche area of law can provide further guidance and advocate for your interests. Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[Investing in NY health care without getting burned: Avoiding fraud allegations as a non‑physician]]>https://www.rivasgoldsteinnyc.com/?p=501672026-04-23T15:49:24Z2026-04-28T16:11:41Z York’s health care market can look like a sure bet — until an investor discovers that the state draws hard lines around who may own, control or profit from the practice of medicine in the state. Because New York closely polices non-physician involvement in physician practices and other clinical operations, investors must structure transactions with care, paying close attention to licensing, ownership, management arrangements, fee-splitting restrictions and who truly controls clinical decision-making.
Compliance concerns arise when a deal operates in a way that regulators view as disguising improper control or remuneration. Failing to follow these rules can invite scrutiny from state and federal authorities and, in serious cases, trigger allegations of health care fraud. Investors who plan early, document roles clearly and obtain experienced legal guidance can pursue opportunities while reducing the risk of enforcement actions and reputational harm.
What could go wrong?
In a recent example, an investor is facing allegations of health care fraud that could cost millions and, depending on how aggressive the prosecution pursues the case, potential imprisonment. The defendant faces allegations he led a complex fraud scheme that involved billing insurance programs to cover medical costs for car accident victims. The prosecution claims he billed these insurance companies for services that were never provided, excessive or medically unnecessary. Furthermore, they state that defendant, a non-physician, illegally owned the medical corporations that were submitting these bills. In New York, it is illegal for non-physicians to own medical practices. There are some ways that non-physicians can invest in health care, such as through the support of administrative functions like billing or facility management, but physicians must retain full control over the practice of medicine. In this case, the prosecution argues that the defendant was not just an investor in administrative areas of these medical practices but actively impacted health care decisions through the submission of claims for benefits from these private insurers. If the prosecution builds a successful case, the accused faces decades of imprisonment.The case serves as a reminder for interested parties to invest carefully when looking at opportunities in the health care sector in New York. When done wisely, these investments can be both profitable and beneficial for local communities. However, a single misstep can trigger allegations of violations of federal and state regulations. Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[How to protect trade secrets when selling your health care facility]]>https://www.rivasgoldsteinnyc.com/?p=501632026-04-21T21:40:47Z2026-04-09T16:47:02ZSelling your health care facility means opening your doors wide. You show buyers your financial records, your systems and the processes that set your practice apart. But here is the challenge. Not every interested party has good intentions. Some may be competitors looking for an inside look at how you operate.
Hence, protecting your trade secrets while still attracting serious buyers is a delicate balancing act and getting it right can make or break your deal. Fortunately, with the right steps, you can do both and it all starts well before the sale begins.
Know what needs protecting before you sell
Before you can protect your business, you need to know exactly what is worth protecting. Take a thorough look at all the confidential information that gives your facility a competitive edge. This includes proprietary software, unique treatment protocols, strategic patient lists and non-public financial models.Once you identify these assets, create a formal written trade secret protection policy. Mark all sensitive documents as confidential and limit access to only the personnel who truly need it. Taking this step early puts you in control and that control becomes even more important once potential buyers enter the picture.
Use due diligence as your shield
With your assets clearly identified, you can now use due diligence as a powerful layer of protection. Due diligence is the careful review of all key information about your facility before a sale closes. Buyers rely on it to evaluate risk, but you can also use it to control what you share and when. Before you disclose any sensitive information, require all potential buyers, investors and advisors to sign a comprehensive non-disclosure agreement (NDA). An NDA is a legally binding contract that prevents the other party from misusing or disclosing what you reveal. Without one, you have little recourse if your trade secrets end up with a competitor.Beyond the NDA, how you organize and present your information also plays a critical role in protecting your business.
You cannot sell what you cannot protect
Strong protections do more than prevent theft. They also increase your health care facility's value. A secure data room, for example, is a controlled environment where only vetted parties can access sensitive documents. A well-organized data room signals professionalism and can even command a higher sales multiple. The stronger your safeguards, the stronger your negotiating position. Ultimately, the way you protect your assets before and during a sale says a lot about how well you run your business and serious buyers will take notice. The right protections in place today can mean a better deal, a smoother process and greater peace of mind when it matters most.Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[3 issues that trigger a nursing license investigation]]>https://www.rivasgoldsteinnyc.com/?p=501592026-03-28T04:10:48Z2026-03-27T18:08:32ZPatient or coworker complaints
Most investigations start with a complaint filed by a patient, coworker or supervisor. Concerns are often related to patient care, professional conduct or workplace behavior. Once the board receives a complaint, it may open a review to determine whether the allegation warrants a formal investigation.
Medication handling concerns
Medication-related concerns often draw regulatory attention because they directly affect patient safety. Suspected drug diversion, improper administration of controlled substances or irregularities in medication records may trigger a report to the board. Investigators may review medication logs, pharmacy records and patient charts to understand what happened.
Criminal charges or arrests
Regulators evaluate whether certain offenses affect your ability to practice safely. Arrests involving drugs, alcohol, fraud or other serious allegations may prompt the board to review the situation. In some cases, you must report certain criminal charges to your licensing authority.
Protecting your license
Knowing what can trigger an investigation helps you spot problems before they grow into licensing issues. If you receive notice of a complaint or learn that regulators are reviewing your conduct, a health care licensing attorney can help you understand your options and plan your response.
Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[Doctors, AI, and board investigations: Three things to know]]>https://www.rivasgoldsteinnyc.com/?p=501602026-03-13T18:26:33Z2026-03-23T18:25:43Z use of artificial intelligence within medical practice continues to grow. A recent publication by the American Medical Association finds that we have gone from less than half of practicing physicians using AI to more than 80% using it in their daily practice. Many use AI to ease administrative burden and support clinical decisions.
Although beneficial, leaders in healthcare remind practitioners to use these tools to enhance – not replace – professional care. These tools are not able to provide the same level of care as a trained and experienced physician. Relying too heavily on AI raises more than just ethical questions, it could put a medical practitioner's professional license at risk.
Where physicians are using AI today
AI use can apply in many different areas of a physician’s practice. Common uses include:
Clinical documentation support and coding assistance
Diagnostic support tools for imaging and pathology
Risk analysis for readmission
These applications can improve efficiency, consistency and detection.
Core legal risk areas to track
Risk is manageable with governance, training and clear workflows. Legal analysis typically focuses on a small set of recurring issues such as:
Standard of care alignment and documentation of clinical reasoning
Data privacy compliance, security safeguards and vendor access controls
Informed consent considerations for material AI involvement
Medical record integrity, attribution of authorship and audit readiness
Amongst practicing physicians, patient privacy is a top concern. Effective programs treat AI as a clinical tool that requires oversight.
Closing reminder on responsibility
AI can support care. It does not displace professional obligations. The physician remains responsible for diagnosis, treatment decisions and follow-up. Allegations of improper AI use, including unsafe reliance, inadequate supervision or misuse of patient data can trigger professional discipline risk. In serious cases, such allegations can threaten a physician’s professional license.Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[New York doctor gets 14 months imprisonment for healthcare fraud]]>https://www.rivasgoldsteinnyc.com/?p=501502026-02-26T19:41:43Z2026-02-24T06:00:33Z of healthcare fraud can lead to more than just a frustrating paperwork problem – it can lead to imprisonment. In a recent case, the courts reviewed allegations a top-level employee with a diagnostics company was pushing for unnecessary tests in an effort to increase profits. The prosecution gathered evidence and built a successful case, with a District Court Judge recently sentencing the operations manager from New York to 14-month federal prison sentence. The sentence for a conviction for conspiracy to violate the Anti-Kickback Statute included one year of supervised release, $27,225,434 in restitution and $1,102,725 in forfeiture.
The conduct that created criminal exposure
In this case, federal prosecutors alleged the operations manager worked with others at a mobile diagnostics company to offer cash payments or check payments to physicians tied to how many brain scans they ordered. The core allegation involved “rental” or “administrative services” agreements that looked compliant on paper. The government argued the agreements were not, in fact, signs of compliance but instead were shams intended to disguise a pay per test arrangement. This fact pattern is an example of a common issue the government looks for during investigations into allegations of healthcare fraud: a facially legitimate contract used as cover for compensation based on volume of referrals. Once the government gathers evidence to establish an intent to conceal the connection between volume and payment, the prosecution can make an argument that the case should escalate to criminal kickback conspiracy.
Practical compliance lessons for ordering physicians
This case underscores a recurring enforcement theme: papered agreements do not neutralize investigations into whether the arrangement is a cover for fraudulent billing practices. Physicians and high-level employees in medical businesses are wise to focus their practice on medical necessity for the patient, not financial gain. The government is dogged in their investigations of allegations of healthcare fraud of this type and will move forward with prosecution if they believe they have evidence to support their claims. Those who find themselves facing such allegations are wise to take the matter seriously and promptly begin building a defense.Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[Report finds nursing home received millions in Medicare overpayments: 3 lessons]]>https://www.rivasgoldsteinnyc.com/?p=501482026-02-20T20:04:15Z2026-02-18T06:18:55Z government is moving forward with allegations that one of the largest nursing home facilities in New York has received over $30 million in Medicare overpayments. A federal watchdog group uncovered the issue and reviews by the Office of the Inspector General (OIG) thus far appear to support the claims. The agency is pushing for repayment. The case provides an opportunity to discuss how these types of investigations are moving forward in the current climate.
#1: AI is allowing for large audits
Not surprisingly, federal watchdog groups and government agencies are making use of artificial intelligence (AI) software to help review large amounts of data to flag any potential violations. Although this can be efficient, anyone that has used AI knows there are nuances. It often fails to take other factors into account–factors that could explain what may look like an overpayment but was, in fact, within the bounds of the law.
#2: Agencies will review medical records
Facilities are understaffed, demands are high, and a need to move on to the next patient who needs care can cause physicians and other medical staff to take shortcuts when filling out paperwork. It is important to keep thorough, clear and organized medical records. In this case, inspectors for the OIG state they are reviewing medical records provided by the facility and have not found evidence to support the claims.
#3: Defenses are available
Even when investigators build an argument like the one noted above, defenses are available. In this case, the nursing home argues that they did not intentionally defraud the government but instead misapplied coding guidelines and that there were errors with the audit. The biggest error, according to representatives for the nursing home, involved a failure of the auditors to take into account waivers during the COVID-19 pandemic. Facilities and medical practices can use this case as a reminder to conduct regular internal audits to check for compliance with Medicare billing rules. Know that agencies and watchdogs are checking for mistakes and will aggressively pursue any signs of overpayment. Those who receive notification of an impending audit are wise to take the matter seriously and begin preparations to appeal the agency’s determination.Attorney John Rivas is responsible for this communication.]]>On Behalf of Rivas Goldstein, LLP<![CDATA[Recent case questions medical necessity: 3 important lessons]]>https://www.rivasgoldsteinnyc.com/?p=501472026-02-20T20:08:17Z2026-02-10T06:00:09Z of fraudulent billing can negatively impact the physician who faces the accusations and their medical practice. It is important for both parties to take steps to protect their interests. It is helpful to learn from other cases to better prepare for the investigation and any resulting legal action. In a recent example, the Justice Department accused a neurosurgeon of billing Medicare for medically unnecessary spine surgeries. Three things every medical practitioner should learn from this case are discussed below.
#1: What triggers this type of case?
These investigations often start with data analytics identifying outliers or a whistleblower complaint. Depending on the information gathered in these early stages, the investigation can expand into a broader probe involving the Office of Inspector General, the Department of Justice and state licensing authorities.In this example, a former patient initiated the case by filing a whistleblower lawsuit. Upon review, the government decided to join in and pursue further legal action.
#2: What are common defense strategies?
When a case hinges on medical necessity, one of the most important pieces of evidence to help build defense is medical records. Gather and organize documentation to show support for provided care. Expert testimony is also beneficial as it can show that other professionals would have provided the same care in a similar situation. It can be helpful for the practice itself to gather documentation to support their reason for hiring the physician and evidence that establishes the physician as competent and, if applicable, an expert in their field.
#3: How can physicians and medical practices protect business operations?
It is important to take the allegations seriously and cooperate with the investigation, though best to do so with the guidance of legal counsel with experience in this niche area of law. Private practices and hospital organizations are wise to recognize that these investigations are rarely quick. This matter took more than six years to resolve. During this period, business operations must continue so that physicians can provide care to patients in need. The best approach while under investigation will depend on the particulars of the case. In many situations, a physician can continue to practice while the investigation moves forward. In the case noted above, although the surgeon was initially allowed to continue to provide care the Department of Health ultimately stepped in and restricted him from continuing. Physicians and practices are wise to have plans in place to adapt as needed as the investigation and case move forward.Physicians and medical groups that find themselves the subject of a healthcare fraud investigation should take action to protect their interests. Gather documentation and begin building a defense while navigating a business strategy that allows for continued operations. Legal counsel can advocate for your interests and help to mitigate the impact on your practice.Attorney John Rivas is responsible for this communication.]]>