On June 1, 2012, the Federal Register published an important mandate to measure the success of state Medicaid Fraud Control Units.
Performance Standard 8(f) calls for all state Medicaid Fraud Control Units (MCFU) to transmit to the OIG for HHS, “for purposes of program exclusions under section 1128 of the Social Security Act, all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea agreements and sentencing orders.” Id. p. 32648.
The OIG published its annual review of state MCFU conformance or non compliance with this required mandate.
The OIG reviews many components of a state MCFU compliance with 12 performance standards and monitor MCFU compliance with federal grant requirements. This can include review of policies and procedures, documentation of the Unit’s operations, staffing and caseload as well as financial documentation, structured interviews with key stakeholders and review of sample of cases worked by the unit.
The OIG issued its report for FY 2013 of all state MCFU on March 7th, 2014. The report found that in FY 2013, state MCFU’s nationwide reported a total of 1,341 criminal convictions in cases involving Medicaid fraud and patient abuse and neglect. In addition, the criminal recoveries reached nearly $1B. MCFU also obtained 879 civil settlements and judgments in FY 2013 and civil recoveries of over $1.5B.
According to the report, the state MCFU’s are an important source of referrals to the OIG for purposes of exclusions, for over 1,000 Medicaid providers convicted in MCFU cases. The OIG took further action to exclude them from all Federal health care programs, including Medicare.
The OIG noted that for FY 2013, criminal convictions involved a variety of provider types, but most notably were home health companies. For civil cases, most providers were pharmaceutical companies. (pp. 5-7). About ¾ of criminal convictions involved fraud while about ¼ were due to patient abuse and neglect.
MFCU convictions often led to the providers’ exclusions from all Federal health care programs. In FYI 2013, the OIG excluded 1,022 invididuals as a result of MFCU investigations, prosecutions and convictions. The OIG data found that the number of MCFU cases that lead to exclusions by OIG has accounted for a quarter or more of all OIG exclusions in recent years.
Here are certain state’s performance:
Let’s see how certain states are doing with Performance Standard 8 (f): 30 day mandated reporting of sentencing, including charging documents, plea agreements and sentencing orders.
Texas (2013) MCFU submitted 321 of 324 convictions that were required to be sent to the OIG for exclusion. However, for 22% of cases, the Unit did not transmit this information in an timely manner. Specifically, the Unit transmitted conviction information to the OIG more than 90 days after sentencing.
Indiana (2013) failed to timely refer 25 convictions to the OIG for purpose of OIG exclusion.
Connecticut (2013) failed to transmit documentation sufficient to exclude 14 of 19 individuals, and for the remaining 5 individuals, the Unit transmitted no documentation to the OIG at all.
Utah (2013) failed to report 3 of the sentenced individuals to the OIG for program exclusion within the appropriate time. This represented 10% of the total convictions.
Summary: In order to for an effective OIG exclusion monitoring program to be met, state MCFU will have to be better at reporting exclusions to the OIG. Until then, you would be wise to search all available state Medicaid exclusion lists, currently 34, plus the OIG LEIE to get a full, accurate and timely exclusion monitoring.