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Recent Compliance Updates & Tips

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The OIG issued a report on statistical results from the State Medicaid Fraud Control Units (MFCUs) for 2016. The OIG administers a grant to each of the units, which provides 75% of their funding. The OIG also sets performance standards, reviews each state’s program, provides technical assistance, identifies best practices, and collects and analyzes statistics.

Medicaid is a partnership program jointly funded by the federal government and the states. Medicaid operates under a plan approved by HHS and falls under state law and administration, which can vary from state to state. A state’s MFCU is a self-contained unit that includes investigators, auditors, and prosecutors or other attorneys. Most of the units are in the State Attorney General’s Office and the Attorney General either prosecutes the cases or refers them to other state, county, or federal prosecutors. MFCUs also collaborate closely with their state Medicaid programs, the OIG Office of Investigations, the FBI, the Department of Justice and other U.S. Attorney offices nationwide.

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The MFCUs investigate and prosecute Medicaid provider fraud, as well as patient abuse and neglect in health care facilities. MCFUs are state-based agencies, and there is one in 49 states and the District of Columbia. (There are no MFCUs in Puerto Rico or North Dakota.) The OIG released a report on the statistical results of the MFCUs and provided a podcast overview. Notably, current funding for Medicaid fraud control is higher than the federally funded and administered Medicare program. Medicaid annual expenditures exceed $500 billion dollars. Additionally, the funding for MFCUs is also at a high of $258,698,147. The staffing level of investigators, auditors, and attorneys is 1,965. They investigated 15,505 fraud cases and 3,221 abuse and neglect cases. The results from their investigations included 1,564 convictions and 998 civil settlements. They also achieved a total $1,876,532,842 in monetary recoveries with $368,498,733 from criminal actions, $1,225,709,487 from civil settlements, and $282,324,622 from other actions.

The OIG collaborates with the MFCUs on many cases. In 2016, the OIG Medicaid cases resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases totaled almost $3 billion dollars in expected recoveries. However, the MFCUs often handle their own cases without assistance from other agencies. They are tasked with investigating and prosecuting patient abuse or neglect in nursing homes and hospitals, as well as in assisted living facilities. The OIG believes many of the MFCUs need additional resources and the legal authority to investigate and prosecute fraud in their jurisdictions.


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