The agency still recovered more than $1 billion from healthcare providers.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) just published its annual survey of how well or poor Medicaid Fraud Control Units (MFCUs) across the country performed in 2020, during the ongoing COVID-19 pandemic.
Each state has its own MFCU to prosecute criminal and civil fraud. I promise that you do not want a MFCU to be calling or subpoena-ing you unexpectedly. The MFCUs reported that the pandemic created significant challenges for staff, operations, and court proceedings, which led to worse case outcomes in the 2020 fiscal year. But during that time, the MFCUs still recovered over $1 billion from healthcare providers, marking a 48 percent drop.
As MFCUs initially moved to a telework environment, some staff reported experiencing challenges conducting work because of limitations with computer equipment and network infrastructure. To help protect staff and members of the public from the pandemic, MFCUs reported curtailing some in-person field work, such as interviews of witnesses and suspects. These activities were further limited because of an initial lack of personal protective equipment that was needed in order to conduct similar activities in nursing homes and other facilities. Basically, COVID made for a bad recovery year by the MFCUs. Courts were closed for a while as well, slowing the prosecutorial process.
The report further demonstrated how lucrative the MFCU agencies are, despite the pandemic. For every dollar spent on the administration of a MFCU, it rakes in $3.36. In 2020, the MFCUs excluded 928 individuals or entities from participation in federal healthcare programs. There were 786 civil settlements and judgments; the vast majority of judgments involved pharmaceutical manufacturers. Convictions decreased drastically, going from 1,564 in 2019 to 1,017 in 2020. Interestingly, looking at the types of providers convicted or penalized, the vast majority were personal care service attendants and agencies, which were affected at a rate five times higher than that of the next most common provider type – nurses (LPNs, RNs, NPs, and PAs).
The Maine MFCU received the Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse for its high number of case outcomes across a mix of case types.
OIG also established desired performance indicators for 2021. OIG expects the MFCUs to maintain an indictment rate of 19 percent and a conviction rate of 89.1 percent.
The OIG report foreshadows 2021 MFCU actions:
While Medicare is strictly a federal program, Medicaid is funded with federal and state tax dollars. Therefore, each state’s regulations germane to Medicaid can vary. Medicaid fraud can be prosecuted as a federal or a state crime.
Programming Note: Listen to Knicole Emanuel’s live RAC report every Monday during Monitor Mondays, 10 a.m. Eastern.
The Eleventh Circuit Court of Appeals has ruled that a lower court made a significant misstep by excluding crucial evidence in a case involving a
Recently, the U.S. Department of Justice (DOJ) issued a press release announcing a massive nationwide healthcare fraud bust, creating the types of headlines designed to
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
