Kusserow on Compliance: OIG reports Medicaid Fraud Control Units results for 2016

The HHS Office of Inspector General (OIG) is the designated Federal agency that oversees state Medicaid Fraud Control Units (MFCUs). It issued a report on their statistical results for 2016. MFCUs are charged with investigating and prosecuting patient abuse or neglect in nursing homes and hospitals, as well as in assisted living facilities. Seventy-five percent of MFCU funding comes from the federal government. The OIG administers the grant to each of the units, sets performance standards, reviews each state’s program, provides technical assistance identify best practices, and collects and analyzes statistics. There are MFCUs in 49 states and the District of Columbia with funding of $258,698,147. With a staffing of 1,965 investigators, auditors, and attorneys, they investigated 15,505 fraud cases and another 3,221 abuse and neglect cases. This resulted in 1,564 criminal 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 in civil settlements, and $282,324,622 from other actions.  MFCUs most often work their own cases without assistance from other agencies. The OIG works a lot of cases with the MFCUs and in 2016, these cases resulted in 312 indictments, 348 criminal actions, and 222 civil actions. These Medicaid cases–some of which also involved Medicare–resulted in almost $3 billion dollars in expected recoveries.

The results of individual units can be found in the OIG report, along with a more detailed statistical breakdown of data. For comparison in results, the OIG issued a detailed report for 2015, noting that the MFCUs achieved 1,553 convictions, 731 civil settlements and judgments, and $744 million in criminal and civil recoveries. In this report, the OIG provided a detailed breakdown of the types of cases and trending data.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2017 Strategic Management Services, LLC. Published with permission.