OIG: Annual Medicaid Fraud Control Unit Report

Gloryanne Bryant, RHIA, CDIP, CCS, CCDS OIG Leave a Comment

OIG: Annual Medicaid Fraud Control Unit Report

The Office of Inspector General (OIG) released in mid-March 2022 their annual report and statistics for 53 Medicare Fraud Control Units across the country. Significant investigative work and recoveries were obtained in 2021 totaling $1.7 billion recovered and 1,105 convictions.

The 2021 annual Office of Inspector General (OIG) Medicaid Fraud Control Units (MFCUs) report was released on March 15th, 2022 and shows a volume of activity and recoveries. The goal and purpose of the Medicaid Fraud Control Units is to investigate and prosecute Medicaid provider fraud and patient abuse or neglect. The OIG conducted an analysis of the annual statistical data on case outcomes—such as convictions, civil settlements and judgments, and recoveries, all of which came from 53 MFCUs who submitted for fiscal year 2021. The MFCUs operate in all 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands.

It should be noted that the Social Security Act (SSA) requires each State to effectively operate a MFCU, unless the Secretary of Health and Human Services (HHS) determines that (1) the operation of a Unit would not be cost-effective because minimal Medicaid fraud exists in a particular State; and

(2) the State has other adequate safeguards to protect beneficiaries from abuse or neglect. The MFCUs are funded jointly by the Federal and State Governments.

MFCU Statistical Data for FY 2021 contains information for every State and provided figures on total investigations, indictments conviction, total Civil settlements and judgments, total recoveries, total criminal recoveries, civil recoveries and expenditures. In addition, the number of staff each state has for the MFCU is also listed. The statistical data also shows the six (6) states with the most “investigations” in FY2021 where California, Ohio, Texas, Indiana. However, the six (6) states with the highest “recoveries” ($) were:

State  Total Recoveries
Virginia $444,355,458
Texas $394,766,169
Tennessee $184,558,620
North Carolina $120,331,089
New York  $77,077,498
California  $72,973,624

The OIG Medicaid Fraud Statistics Chart is available at: https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2021-statistical-chart.pdf

The OIG report stated that MFCU criminal recoveries increased substantially from $173 million in FY 2020 to $857 million in FY 2021. The increase in criminal recovery amounts in FY 2021 was primarily the result of cases prosecuted by MFCUs in the States of Virginia and Texas. These MFCUs reported a combined $714 million in criminal recoveries or approximately 83 percent of the total reported criminal recoveries.

In FY 2021, MCFUs civil recoveries decreased from $855 million in FY 2020 to $826 million in FY 2021. There are two types of Civil Cases:

  • A global case involves both the Federal Government and a group of States and is coordinated by the National Association of Medicaid Fraud Control Units.
  • A nonglobal case is conducted by a Unit—individually or with other law enforcement partners—and is not coordinated by the National Association of Medicaid Fraud Control Units.

According to the OIG report the MFCUs overall recovered $5.36 dollars for every dollar spent. Within the 32 page report is individual State best practices performed by the MFCUs. To view the site with the OIG MFCUs report, go to: https://oig.hhs.gov/oei/reports/OEI-09-22-00020.asp

Compliance with healthcare rules, regulations and the protection of the beneficiary is the pivotal center of the MFCUs work. Check your internal and external compliance controls and audit work to ensure that Medicaid encounters are included.

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