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The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently issued its analysis of Medicaid Fraud Control Unit (MFCU) statistical results in an Annual Report for 2016. The OIG is the designated federal oversight agency for MFCUs and is instrumental in establishing these units. The OIG administers a federal grant to each of the units which provides 75 percent of their funding. The states provide the remaining MFCU funding. The OIG also sets performance standards, reviews each state’s program, provides technical assistance, identifies best practices, and collects and analyzes related statistics. Under state law, the MFCUs’ mission is to investigate and prosecute provider fraud and patient abuse or neglect. Currently, MFCUs operate in 49 states and the District of Columbia.
The OIG examined statistical data and recertification materials from the 50 MFCUs to conduct the required analysis. The report includes a detailed breakdown of the types of fraud cases and trending data. Statistical results by state are also presented alongside comparisons from the previous year. In FY2015, the OIG reported that the MFCUs made 1,553 convictions, 731 civil settlements and judgments, and $744 million in criminal and civil recoveries.
The OIG reported the following findings:
- In FY 2016, the MFCUs reported 1,564 convictions. Seventy-four percent of the convictions involved fraud and twenty-six percent involved patient abuse or neglect.
- Nearly 1,000 civil settlements and judgments were reported in 2016. Settlements and judgments with pharmaceutical manufacturers constituted almost half of the settlements.
- MFCUs reported approximately $1.9 billion in criminal and civil recoveries.
- The largest category of convictions involved personal care services, constituting 35% of the convictions. Nursing care services involving licensed practical nurses, registered nurses, physician assistants, or nurse practitioners (NP), comprised the second highest category, accounting for 11% of convictions. Convictions of nurse-aides represented the third largest category involving 10% of total convictions.
- The 2016 OIG Medicaid cases, involving the partnership of OIG and the MFCUS, resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases, some of which also involved Medicare, resulted in approximately $3 billion in expected recoveries.
The OIG Report is available at: