OIG: Releases Medicaid Fraud Control Unit (MFCU) Review: Increased Recoveries and Prosecutions Abound

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.

Rosen 052517 image1

Other Interesting Findings

  • Fraud cases accounted for 74 percent of all convictions
  • Almost 50 percent of fraud cases involved unlicensed providers
  • Personal care services amounted to the greatest number of the unlicensed providers
  • The number of drug diversion convictions increased by 4 percent
  • Almost 50 percent of civil settlements/judgments involved pharmaceutical manufacturers
  • $1.9 billion in total recoveries were made 
  • MFCUs spent $259 million to investigate and prosecute
  • MFCUs’ ROI was $7:$1 
  • 2016 OIG exclusions from MFCU conviction referrals decreased slightly
  • In FY 2016, MFCU referrals accounted for 35 percent of OIG exclusions

Rosen 052517 image2

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.  

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

Michael Rosen, Esq.

Michael Rosen brings more than 20 years of experience in founding and leading service-oriented businesses. He co-founded Background America, Inc., which was acquired by Kroll Inc. He was promoted to president of the Background Screening Division, which employed 1,000 people in seven countries. He is now the co-founder of ProviderTrust, Inc. a national healthcare compliance service that helps facilities stay in compliance. He has received numerous accolades, including the Inc. Magazine 500 Award, Nashville Chamber of Commerce Small Business of the Year award, and the Music City Future 50 Award.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Secondary Diagnosis Coding: A Deep Dive into Guidelines and Best Practices

Explore comprehensive guidelines and best practices for secondary diagnosis coding in our illuminating webcast. Delve into the intricacies of accurately assigning secondary diagnosis codes to ensure precise medical documentation. Learn how to navigate complex scenarios and adhere to coding regulations while enhancing coding proficiency. Our expert-led webcast covers essential insights, including documentation requirements, sequencing strategies, and industry updates. Elevate your coding skills and stay current with the latest coding advancements so you can determine the correct DRG assignment to optimize reimbursement, support medical decision-making, and maintain compliance.

Print Friendly, PDF & Email
September 20, 2023
Principal Diagnosis Coding: Mastering Selection and Sequencing

Principal Diagnosis Coding: Mastering Selection and Sequencing

Enhance your inpatient coding precision and revenue with Principal Diagnosis Coding: Mastering Selection and Sequencing. Join our expert-led webcast to conquer the challenges of principal diagnosis selection and sequencing. We’ll decode the intricacies of ICD-10-CM guidelines, equipping you with a clear grasp of the rules and the official UHDDS principal diagnosis definition. Uncover the crucial role of coding conventions, master the sequencing of related conditions, and confidently tackle cases with equally valid principal diagnoses.

Print Friendly, PDF & Email
September 14, 2023
2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

2024 IPPS Summit: Final Rule Update with Expert Insights and Analysis

Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY24 Inpatient Prospective Payment System (IPPS) Final Rule, including new ICD-10-CM/PCS codes, plus insights, analysis and answers to questions from the country’s most respected subject matter experts.

Print Friendly, PDF & Email
2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

2024 IPPS Summit Day 3: MS-DRG Shifts and NTAPs

This third session in our 2024 IPPS Summit will feature a review of FY24 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by senior healthcare consultant Laurie Johnson, with bonus insights and analysis from two acclaimed subject matter experts

Print Friendly, PDF & Email
August 17, 2023

Trending News