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State Medicaid Agencies Still Challenged with Determining When to Implement Payment Suspensions
State Medicaid Agencies Still Challenged with Determining When to Implement Payment Suspensions

Using payment suspensions, when appropriate, is important to protect Medicaid funds: payment suspensions based on credible allegations of fraud can swiftly stop the flow of Medicaid dollars to providers defrauding Medicaid. A payment suspension can remain in place throughout a law enforcement investigation and potential prosecution of a healthcare fraud case.

New Mexico Takes Aim at Medicaid Fraud and Abuse
New Mexico Takes Aim at Medicaid Fraud and Abuse

New Mexico’s Attorney General Hector Balderas takes Medicaid fraud very seriously, and late last week announced several new initiatives to weed out Medicaid fraud in his state. For the first time in New Mexico’s history, the Attorney General has requested and received a waiver from the federal government to allow the Office of the Attorney General to proactively search through data to identify patterns of fraud.

Medicaid Fraud Control Unit (MFCU) Reporting Accuracy: Then and Now
Medicaid Fraud Control Unit (MFCU) Reporting Accuracy: Then and Now

The Office of Inspector General (OIG) is not the only source for exclusions. Did you know that the state Medicaid agency and/or State Attorney General, if applicable, in each state must report its actions to the Federal OIG promptly after the agency takes a final action? (Social Security Act 1902(a)(41) and 42 CFR 1002.3(b)(3). In this article, we'll take a look at how well reporting has taken place given the latest OIG research data, and compare Q1 2017 results from our latest CHIRP report.

C-Suite and General Counsel Held Liable for Medicaid Fraud
C-Suite and General Counsel Held Liable for Medicaid Fraud

Larger healthcare companies typically employ an entire and robust legal department in-house to handle legal work and provide good counsel to management and senior executives. Some of these companies will hire outside counsel to supplement areas of expertise that may be lacking by an internal department. But what happens when that advice or legal counsel is considered to be fraudulent? Who is liable? Who takes the fall and can be subject to the long arm of the law?

State Medicaid Fraud Control Units Must Inform OIG Within 30 Days
State Medicaid Fraud Control Units Must Inform OIG Within 30 Days

State Medicaid Fraud Control Units (MFCU) are responsible for investigating Medicaid fraud. This is part of the responsibility assigned to them from CMS as a part of receiving federal health care dollars to reimburse those services and items covered by Medicaid.According to the OIG site, "Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as patient abuse or neglect in healthcare facilities and board and care facilities. MFCUs operate in 49 states and the District of Columbia. The MFCUs, usually a part of the State Attorney General's office, employ teams of investigators, attorneys, and auditors; are constituted as single, identifiable entities; and must be separate and distinct from the State Medicaid agency. OIG, in exercising oversight for the MFCUs, annually re-certifies each MFCU, assesses each MFCU's performance and compliance with Federal requirements, and administers a Federal grant award to fund a portion of each MFCU's operational costs."Performance Standard 8(f) states that a Unit should transmit to the federal OIG reports of all convictions for the purpose of exclusion from Federal health care programs, within 30 days of sentencing. On June 1, 2012, the Federal Register published an important mandate to measure the success of state Medicaid Fraud Control Units. 

Yes Virginia, There is an MFCU Delay in Reporting to the OIG
Yes Virginia, There is an MFCU Delay in Reporting to the OIG

MCFU Not Reporting The Virginia Medicaid Fraud Control Unit (MFCU) recovered $34 for each $1 spent on fighting healthcare fraud. However, with those stellar results, the MFCU did not report half of all convictions to OIG within required timeframes. The Unit did not report 42 of its 79 convictions to OIG within 30 days of sentencing, as required by Federal regulations.

When Home Health is Unnecessary Care- and Fraud
When Home Health is Unnecessary Care- and Fraud

A federal judge sentenced the CEO of an Illinois Home Health company to six (6) years in prison following a jury verdict convicting on grounds of fraudulently billing Medicare for millions of dollars of unnecessary services.  The Assistant U.S. Attorney that prosecuted the case commented that "Home-health fraud has become a significant problem nationally and particularly in the Chicago area."  

Delays in Reporting OIG Exclusions: Florida can’t Blame the Hurricane
Delays in Reporting OIG Exclusions: Florida can’t Blame the Hurricane

Performance Standard 8(f) states that a Unit should transmit to the federal OIG "reports of all convictions for the purpose of exclusion from Federal health care programs, within 30 days of sentencing."  The Unit reported their staff erred in failing to follow guidelines and to report convictions and adverse actions within the required time frames.   Further, the OIG found that of the 193 convictions obtained by the Unit half did not report within required time frame (30 days of sentencing) and 10 did report prior to the onsite review.   Of the convictions they did report:

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