Auditing

The OIG is tasked with auditing the performance of state Medicaid Fraud Control Units (MFCU).  The mission of Medicaid Fraud Control Units (MFCUs or Units) is to investigate and prosecute Medicaid provider fraud and patient abuse or neglect under state law.

Key Points

* OIG also performs onsite reviews of the Units. During these onsite reviews, OIG evaluates Units’ compliance with laws, regulations, and policies, as well as adherence to the performance standards.

* OIG also makes observations about best practices, provides recommendations to the Units, and monitors the implementation of the recommendations.

* OIG provides additional oversight including the collection and dissemination of performance data, training, and technical assistance.

* OIG maintains pertinent information for each MFCU on the OIG web site, including an interactive map with statistical information about each MFCU.


The OIG just released its review of 2015 MFCU performance and the stats are enouraging.

What data was reviewed:

Information in this report was derived from these three sources: (1) annual statistical reports submitted for FY 2015; (2) quarterly statistical reports for FYs  2011 through 2014; and (3) onsite review reports published in FYs 2011 through 2015.

What the OIG Found:

Medicaid Fraud Control Units Fiscal Year 2015 Annual Report (OEI-07-16-00050) https://go.usa.gov/xKCF3

In FY 2015, MCFU Units reported 1,553 convictions, nearly one-third of which involved personal care services attendants or other home care aides. Another 11 percent (166 of 1,553) of convictions were of licensed nurses, physician assistants (PA), or nurse practitioners (NP). These convictions involved abuse or neglect, provision of services without a license, and services not rendered, among other charges.

Screen_Shot_2016-09-20_at_9.23.27_AM.png

Fraud cases accounted for 71 percent of the 1,553 convictions. Units reported 731 civil settlements and judgements, with pharmaceutical manufacturers making up over a third of Unit settlements. Units also reported $744 million in criminal and civil recoveries.

Screen_Shot_2016-09-20_at_9.24.48_AM.png

In FY 2015 . . .

MCFU Units reported the highest number of convictions in the last 5 years, and OIG exclusions resulting from Unit conviction referrals have grown since 2011. Civil settlements and judgments have decreased modestly over the last 5 years, and civil recovery amounts have decreased significantly. Finally, many Units made operational improvements in response to OIG recommendations.

Exclusion Reporting: 2015

OIG exclusions resulting from Unit conviction referrals have grown since 2011

In FYs 2015 and 2014 the number of exclusions resulting from Unit referrals was significantly higher than the number of annual exclusions from Unit referrals in FYs 2011 through 2013, as shown in Chart 4.

Screen_Shot_2016-09-20_at_9.28.28_AM.png

REMEMBER:  The OIG has the authority to exclude convicted individuals and entities from Federally funded health care programs and maintains a list of all currently excluded individuals and entities. Anyone who hires an individual or entity on this list may be subject to civil monetary penalties.

MFCU Cases reported to the OIG: In FY 2015, OIG excluded 4,112 individuals or entities; 1,306 (32 percent) resulted from convictions referred by MFCU Units.

Written by Michael Rosen, ESQ
ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as: Inc Magazine’s Inc 500 Award and Nashville Chamber of Commerce Small Business of the Year
Connect with Michael on Linkedin