The US Department of Health and Human Services Office of Inspector General (OIG) released its annual report showing that Medicaid Fraud Control Units (MFCUs) recovered $1.4 billion in civil and criminal recoveries during Fiscal Year (FY) 2024. This report analyzes case outcomes, such as convictions, civil settlements, judgments, and recoveries, from the 53 MFCUs over the 10-year period ending FY 2024.
MFCUs reported 1,151 convictions in FY 2024, reflecting a slight increase from the previous year. Additionally, the total amount of criminal recoveries for FY 2024 was the highest over the 10-year period, with an increase from $272 million in FY 2023 to $961 million in FY 2024. This increase was largely due to multiple cases prosecuted by the California MFCU, which accounted for $513 million (53 percent) of the total criminal recoveries.
The number of fraud referrals received from Medicaid Managed Care Organizations (MCOs) and the number of MCO fraud cases opened by MFCUs also increased in FY 2024. The proportion of referrals resulting in opened fraud cases rose slightly to 23 percent (1,078 of 4,650) in FY 2024, compared to 22 percent (893 of 4,068) in FY 2023. MFCUs reported receiving 14,780 referrals for suspected fraud in FY 2024.
In FY 2024, the OIG imposed a total of 3,233 exclusions on individuals and entities. MFCU cases were responsible for 1,042 (32 percent) of these exclusions.
The proportion of fraud convictions and patient abuse or neglect convictions has remained consistent over the past 10 years, ranging from 71 to 76 percent. In FY 2024, MFCUs reported 817 fraud convictions and 334 patient abuse or neglect convictions.
Fraud convictions involving personal care service (PCS) attendants were significantly higher than any other provider type in FY 2024. PCS attendants assist Medicaid enrollees with activities of daily living, such as bathing, dressing, and personal hygiene, in their homes or community settings.
Nurse aides and nurses were the top two provider types for patient abuse or neglect convictions in FY 2024. This marks the third consecutive year in which they have accounted for the largest number of convictions in this category.
You can access the full report here. A statistical chart can be viewed here, case outcomes here, open cases here, and beneficial practices here.
Compliance Perspective
Issue
MFCUs investigate Medicaid provider fraud and patient abuse or neglect. The OIG oversees and approves federal funding for MFCUs through an annual recertification process. When MFCUs report convictions for fraud or patient abuse/neglect, the OIG has the authority to exclude the convicted individuals and entities from participating in federally funded healthcare programs. Skilled nursing facilities are required to maintain a compliance and ethics program that effectively prevents and detects violations to minimize fraud, waste, and abuse of government funds.
Discussion Points
- Ensure that your compliance and ethics program is regularly reviewed. Policies should be assessed at least annually and updated promptly when new information, regulations, or risks emerge.
- Provide training to all staff members on your compliance and ethics policies upon hire and at least annually thereafter. Reinforce the importance of an effective compliance and ethics program being the responsibility of everyone in the organization, not just designated staff.
- Periodically audit your compliance and ethics program to ensure staff adherence to policies and guidelines. Ensure employees are aware of their responsibility to report concerns to their supervisor, the compliance officer, or through the anonymous hotline. Share audit results and any corrective actions with the compliance committee and governing body for follow-up and accountability.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
