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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.

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?

States with the Most Excluded Parties
States with the Most Excluded Parties

Which states have the most exclusions? Glad you asked! First off, did you know that there are 40 states that have a state Medicaid exclusion list in addition to the two federal exclusion datasources (OIG-LEIE and SAM.gov)? Did you also know that a state Attorney General’s Office and/or Medicaid Agency can impose an exclusion on a person or entity in addition to the OIG? In today’s compliance environment, it’s important to have a comprehensive monitoring program that is placing just as much emphasis at the state level to achieve 100% compliance.

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.

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:

OIG Exclusion vs. Termination
OIG Exclusion vs. Termination

Since childhood, we learn to share and to never say "you can't play with us." Everyone loves to feel part of something or a group, and being excluded from a group or community can be pretty painful. As we get older, it does not get any easier. Now if the term "excluded" is tied to our professional career it takes on a whole new meaning - a very serious legal meaning. OIG Exclusions - In the healthcare industry, exclusions have a long-lasting and ulimately a punitive measure and are imposed by the Office of Inspector General of the HHS or a state Medicaid Exclusion authority that receives federal healthcare dollars. There are many OIG exclusions, also known as OIG sanctions, but the most common way for a healthcare professional to get excluded or sancitoned is due to a license revocation or termination for certain defined disciplinary matters.   In most cases the state licensing board has a mandatory obilgation to exlcude or sanction a provider for a minimum of five years to a period up to indefinite for felony convictions that result from: Substance Abuse Patient Abuse Healthcare Fraud and Abuse However, there are permissive exclusion authority granted for misdemeanor convictions for the same and/or of defaulting on a federal student loan.

Compliance Risk Assessment: Integrating Tools in your Compliance Plan
Compliance Risk Assessment: Integrating Tools in your Compliance Plan

Check out the full compliance risk assessment series here: 1. Integrating basics into your compliance plan2. Integrating tools into your compliance plan3. How reliable data improves your compliance plan4. Preparation and use of action plans This is the second blog in the “Risk Assessment” series. While the first blog addressed basic definitions and considerations in conducting risk assessments for healthcare providers and organizations, this blog addresses different types of tools and methods to use in risk assessments, as well as the pros and cons of using those tools.

Compliance Risk Assessment: Integrating Basics in Your Compliance Plan
Compliance Risk Assessment: Integrating Basics in Your Compliance Plan

Check out the full compliance risk assessment series here: 1. Integrating basics into your compliance plan2. Integrating tools into your compliance plan3. How reliable data improves your compliance plan4. Preparation and use of action plans You probably have heard it said in healthcare compliance seminars or read it in compliance articles that risk assessment is the “8th element” in addition to the 7 fundamental elements of an effective healthcare compliance plan as identified in OIG Compliance Program Guidance (published by the OIG for specific categories of healthcare providers). And I strongly believe that. However, I have noticed there are many questions about compliance risk assessments, such as: What is a compliance risk assessment?   It is an analysis of the level of risk of a specific occurrence transpiring and measuring the effect of such potential circumstance. It is also the analysis on how to mitigate the likelihood and effect of such occurrence.

Medicaid Termination in One State – now what?
Medicaid Termination in One State – now what?

Prior to the passage of the Affordable Care Act, a provider terminated from Medicaid enrollment, or eligibility, in one state could easily slip through the cracks and enroll in another state. Most states did not share or have access to a centralized database of terminated Medicaid providers. Obviously, this is not good for ferreting out fraud and preventing a terminated provider (especially if he/she was terminated for fraud and/or abuse) from hopping state lines and enrolling in another state.  

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