Each year the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) releases its annual Medicaid Fraud Compliance Performance Report. There is much to learn from this compendium of information provided by 50 Medicaid Fraud Control Units (MFCUs), and this article will highlight some of the accomplishments and significant cases.
Why MFCUs Exist
The mission of the MFCUs is to investigate and prosecute under state law Medicaid provider fraud and patient abuse or neglect. With limited exceptions, each state is required to have an MFCU. Cases can be brought from the public or a state or federal agency for investigation and/or criminal prosecution or civil action. Outcomes can include criminal conviction, civil settlements, exclusions, or other program recommendations (including overpayment recoveries).
Since each MFCU is funded jointly by state and federal funding, the OIG has jurisdiction. Each unit receives federal funding equivalent to 75 percent of its total expenditures. In 2016, combined state and federal expenditures for the MFCUs totaled $259 million (of which $194 million represented federal funds).
The OIG is responsible for accessing each MFCU’s performance and compliance with federal requirements, OIG policy, and 12 performance standards. Performance standards can involve staffing, maintaining adequate referrals, and cooperation with federal authorities. The OIG releases its statistical data about MFCU outcomes on its website. Take a look to see how your state performed.
Overall Summary of Findings
In the 2016 fiscal year, Units reported 1,564 convictions, over one-third of which involved personal care services attendants. Fraud cases accounted for 74 percent of the 1,564 convictions. The number of convictions related to drug diversion cases increased from 2015. Units reported 998 civil settlements and judgments, with settlements with pharmaceutical manufacturers making up almost half of Unit settlements. Units also reported almost $1.9 billion in criminal and civil recoveries.
In 2016, Units continued a trend of increasing numbers of convictions, and civil settlements and judgments reached a five-year high. The number of OIG exclusions resulting from Unit conviction referrals decreased slightly in 2016, as compared to the previous two years.
Other Interesting Findings
Summary
The OIG has many hats to wear in its role as enforcement and policy provider for HHS. One of its most interesting reports is its annual Medicaid Fraud Control Unit performance report. The OIG is tasked with oversight as well as investigative and prosecutorial roles of any and all federal healthcare funds (Medicare, Medicaid, CHIP, Tricare, etc.). Given its involvement in oversight of each state MFCU’s performance with the 12 performance standards, the OIG is not only instructive, but provides a picture of state healthcare fraud and abuse convictions, settlements, and enforcement trends. The results of 2016 prove once again that MFCUs play an important role in ferreting out healthcare fraud and abuse, and their combined efforts with the OIG return huge dividends to the U.S. Treasury.
Since Jan. 20, it seems that uncertainty in healthcare has become the new normal. After a contentious hearing, Robert F. Kennedy, Jr. was appointed to
The U.S. Department of Health and Human Services (HHS) has recently made a declaration to cease the public comment period for their proposed regulations. By
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
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.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
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.
Copyright © 2025 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 →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
