Medicaid Fraud Control Units Performed Poorly During the Pandemic

The agency still recovered more than $1 billion from healthcare providers.

The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) just published its annual survey of how well or poor Medicaid Fraud Control Units (MFCUs) across the country performed in 2020, during the ongoing COVID-19 pandemic.

Each state has its own MFCU to prosecute criminal and civil fraud. I promise that you do not want a MFCU to be calling or subpoena-ing you unexpectedly. The MFCUs reported that the pandemic created significant challenges for staff, operations, and court proceedings, which led to worse case outcomes in the 2020 fiscal year. But during that time, the MFCUs still recovered over $1 billion from healthcare providers, marking a 48 percent drop.

As MFCUs initially moved to a telework environment, some staff reported experiencing challenges conducting work because of limitations with computer equipment and network infrastructure. To help protect staff and members of the public from the pandemic, MFCUs reported curtailing some in-person field work, such as interviews of witnesses and suspects. These activities were further limited because of an initial lack of personal protective equipment that was needed in order to conduct similar activities in nursing homes and other facilities. Basically, COVID made for a bad recovery year by the MFCUs. Courts were closed for a while as well, slowing the prosecutorial process.

The report further demonstrated how lucrative the MFCU agencies are, despite the pandemic. For every dollar spent on the administration of a MFCU, it rakes in $3.36. In 2020, the MFCUs excluded 928 individuals or entities from participation in federal healthcare programs. There were 786 civil settlements and judgments; the vast majority of judgments involved pharmaceutical manufacturers. Convictions decreased drastically, going from 1,564 in 2019 to 1,017 in 2020. Interestingly, looking at the types of providers convicted or penalized, the vast majority were personal care service attendants and agencies, which were affected at a rate five times higher than that of the next most common provider type – nurses (LPNs, RNs, NPs, and PAs).

The Maine MFCU received the Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse for its high number of case outcomes across a mix of case types.

OIG also established desired performance indicators for 2021. OIG expects the MFCUs to maintain an indictment rate of 19 percent and a conviction rate of 89.1 percent.

The OIG report foreshadows 2021 MFCU actions:

• Hospice: expect audits. No funds were recovered in 2020.
• Fraud convictions increased for cardiologists and emergency medicine. Expect these areas to be more highly scrutinized, especially given all the COVID exceptions and rule amendments last year.
• Expect a MFCU rally. The pandemic may not be over, but with increased vaccines, and after a down year, MFCUs will be bulls in the upcoming year.

While Medicare is strictly a federal program, Medicaid is funded with federal and state tax dollars. Therefore, each state’s regulations germane to Medicaid can vary. Medicaid fraud can be prosecuted as a federal or a state crime.

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