Office of Inspector General Releases Medicaid Fraud Control Units Annual Report

The Office of Inspector General (OIG) is the designated Federal agency that oversees and annually approves Federal funding for Medicaid Fraud Control Units (MFCU) through a recertification process. The function of MFCUs is to investigate and prosecute Medicaid provider fraud and patient abuse or neglect.

In fiscal year 2020, MFCUs recovered $1.0 billion. The breakdown of recoveries includes:

• • $173 million in criminal recoveries
    • 1017 convictions of fraud and patient abuse or neglect, in which 928 individuals or entities were excluded from federally funded health programs.
  • $855 Million in civil recoveries
    • 786 civil settlements and judgements, in which 74% were global cases and 26% were nonglobal cases (“Global” recoveries derive from civil settlements or judgments involving the U.S. Department of Justice and a group of State MFCUs and are facilitated by the National Association of Medicaid Fraud Control Units).

As in previous years, significantly more convictions for fraud involved personal care services (PCS) attendants and agencies than any other provider type. In fiscal year 2020, fraud convictions involving PCS attendants and agencies accounted for 360 of the total 774 fraud convictions.

Reducing Medicaid fraud is a top priority for the OIG. The agency oversees the MFCU grant program by recertifying units, conducting reviews or inspections of units, providing technical assistance to units, and monitoring key statistical data about unit caseloads and outcomes.

In fiscal year 2020 the OIG administered a survey to all 53 MFCUs regarding the effects of the COVID-19 pandemic on MFCU operations. The survey reported that the pandemic created significant challenges for staff, operations, and court proceedings, which led to lower case outcomes in fiscal year 2020.

The OIG’s complete report can be accessed here.

MFCU statistical data per state for fiscal year 2020 can be accessed here.

Compliance Perspective

Issue

Fraud, waste, and abuse of federal and state funds is always illegal. It is imperative that all staff members are trained and well versed in what constitutes fraud, waste, and abuse of federal and state funds. In addition, all staff members should be trained and knowledgeable on how to report any suspicions of fraud, waste, or abuse of federal and state funds. Fraud, waste, and abuse can result in fines, placement on the OIG List of Excluded Individuals and Entities, and civil penalties which can include prison time. Detailed information on this topic is available in the Med-Net Corporate Compliance and Ethics Manual, Chapter 1 Compliance and Ethics Program and Chapter 2 Financial Integrity.

Discussion Points

• • Review all policies and procedures that pertain to fraud, waste, and abuse of federal and state funds. Update policies and procedures as needed.
  • Train all staff on what may be considered fraud, waste, and abuse of federal and state abuse, and the steps that they should take if they suspect fraud, waste, or abuse of government funds is occurring, including that reporting is a mandatory responsibility.
  • Periodically audit staff understanding to ensure that they are knowledgeable about what is fraud, waste, and abuse of federal and state funds and how they can report suspicions of this activity.