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 over 1.2 billion in civil and criminal recoveries in Fiscal Year (FY) 2023. The new report analyzes the statistical data on case outcomes—such as convictions, civil settlements and judgments, and recoveries—that the 53 MFCUs submitted for the 10-year period ending with FY 2023.
MFCUs reported 1,143 convictions in FY 2023, which is a decrease from the year before. After remaining steady for several years, the number of MFCU convictions decreased significantly during FY 2020, which coincided with the first year of the COVID-19 public health emergency. Although the convictions in FY 2023 were more than in FY 2020, the number of convictions remained lower than in the years before the pandemic.
According to the report, the proportion of total convictions involving fraud charges has remained steady over the 10-year period, ranging from 71 to 76 percent. In FY 2023, MFCU reported 814 fraud convictions (71 percent of the total convictions) and 329 patient abuse or neglect convictions (29 percent of the total).
In FY 2023, OIG imposed a total of 2,112 exclusions on individuals and entities. MFCU cases were responsible for 850 (40 percent) of those exclusions. In addition to these 850 MFCU-generated exclusions, MFCUs participated in joint cases with the OIG Office of Investigations that also may have resulted in exclusions.
The number of annual drug diversion convictions reported by MFCUs declined in FY 2020 and has remained in a lower range. MFCUs reported 153 convictions related to drug diversion cases in FY 2023, a decrease from the previous 2 years.
Personal care services (PCS) attendants accounted for a large proportion of all fraud convictions during FYs 2014 through 2023 and were by far the most prominent provider type for fraud convictions in 2023. Convictions for patient abuse or neglect involved nurse’s aides or nurses more than for any other provider type in FY 2023.
You can access the full report here. A statistical chart can be viewed here, and an interactive map is available here.
Compliance Perspective
Issue
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. 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. 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.*
