The US Department of Health and Human Services Office of Inspector General (OIG) released their annual report which shows that Medicaid Fraud Control Units (MFCUs) recovered 1.1 billion in civil and criminal recoveries in Fiscal Year (FY) 2022. MFCUs investigate and prosecute Medicaid provider fraud and patient abuse or neglect. OIG is the federal agency that oversees and annually approves federal funding for MFCUs through a recertification process. The new OIG report analyzed the statistical data on annual case outcomes—such as convictions, civil settlements and judgments, and recoveries—that the 53 MFCUs submitted for FY 2022.
MFCUs reported 1,327 convictions in FY 2022, an increase over the previous 2 years. In FY 2022, MFCU cases resulted in 946 convictions for fraud and 381 convictions for patient abuse or neglect. When MFCUs make referrals to OIG regarding convictions for fraud and patient abuse or neglect in their respective states, OIG has the authority to exclude those convicted individuals and entities from federally funded healthcare programs. In FY 2022, OIG imposed a total of 2,332 exclusions on individuals and entities. MFCU cases were responsible for 1,018 (44 percent) of those exclusions. In addition to these 1,018 MFCU-generated exclusions, MFCUs participated in joint cases with the OIG Office of Investigations that also may have resulted in exclusions.
MFCUs reported 171 convictions related to drug diversion cases in FY 2022, an increase over the previous 2 years. In FY 2022, convictions for patient abuse or neglect involved two provider types more than any others: nurse aides and nurses or physician assistants. Nursing homes and assisted living facilities (ALFs) accounted for 55 of the patient abuse or neglect criminal convictions, and 15 of the settlements and judgments. According to the report there are 1,287 nursing home and ALF open investigations for patient abuse or neglect, and 364 open investigations for facility-based fraud.
You can access the full report here. A statistical chart can be viewed here, and an interactive map is available here.
Compliance Perspective
Issue
Skilled nursing facilities are required to have a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations to reduce the likelihood of fraud, waste, and abuse of government funds.
Discussion Points
- Review your policies and procedures for operating an effective compliance and ethics program. Ensure that your policies are reviewed at least annually and updated when new information becomes available.
- Train all staff on your compliance and ethics policies and procedures upon hire and at least annually. Ensure that they understand that an effective compliance and ethics program is everyone’s responsibility. Document that these trainings occurred and file the signed document in each employee’s education file.
- Periodically perform audits to ensure that all staff are aware of compliance and ethics policies and guidelines and understand their responsibility to report any concerns to their supervisor, the compliance and ethics officer, or via the anonymous hotline. Provide the audit information and any necessary action steps to the compliance and ethics committee and the governing body.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
