OIG Medicaid Fraud
WHY WE DID THIS STUDY
The Department of Health and Human Services (HHS) OIG is the designated Federal agency that oversees State Medicaid Fraud Control Units (MFCUs or Units or Unit). This MFCU Fiscal Year (FY) 2014 Annual Report highlights statistical achievements from the investigations and prosecutions conducted by the 50 MFCUs nationwide. The report also explores issues that affect Medicaid fraud work and describes oversight activities undertaken by OIG.
HOW WE DID THIS STUDY
We based the information in this report on an analysis of data from six sources: (1) Quarterly Statistical Reports submitted by Units; (2) supplemental data collected specifically for this FY 2014 MFCU Annual Report; (3) OIG exclusion data; (4) information gathered through onsite reviews; (5) the annual reports of individual MFCUs; and (6) recertification questionnaires. All statistical information was current as of January 30, 2015, except where otherwise noted.
WHAT WE FOUND
In FY 2014, MFCUs reported 1,318 criminal convictions involving a variety of provider types, most notably home health care aides. Three-quarters of these criminal convictions were for fraud, consistent with recent years, and recoveries in criminal cases reached nearly $300 million. Additionally, MFCU convictions led to the exclusion of 1,337 providers from Federal health care programs. MFCUs also reported 874 civil settlements and judgments that involved a variety of provider types, most notably pharmaceutical companies. Two-thirds of these civil settlements and judgments were “global” settlements, which represent the bulk of the $1.7 billion recovered from civil cases. (Global cases are civil false claims cases that are brought by the U.S. Department of Justice and involve a group of State MFCUs.)
We found that MFCUs and State Medicaid agencies’ program integrity units reported challenges with referrals involving credible allegations of fraud and the payment suspension process and referrals from managed care entities. We also found that MFCUs and State Medicaid agency program integrity units reported three key elements for successful collaboration: communication, experienced and knowledgeable staff, and joint training. Finally, in its oversight role during FY 2014, OIG conducted 7 onsite reviews of Units, published 12 reports, and submitted 2 legislative proposals.