In the October 6 Federal Register, the HHS OIG published proposed revisions to the agency’s standards for assessing the performance of the state Medicaid Fraud Control Units (MFCUs). The OIG uses such standards when certifying and annually recertifying MFCUs tasked with investigating and prosecuting Medicaid provider fraud and patient abuse and neglect. States administer the MFCUs but they are jointly funded on a matching basis with the federal government reimbursing certified MFCUs 75 percent of their operating costs. The revised performance standards address various operational obligations including:

  • Requiring MFCUs to have an information management system capable of tracking cases from inception through resolution and allow for the reporting of aggregate case information;
  • Establishing formal procedures for referring appropriate cases to state or federal agencies;
  • Ensuring that an MFCU’s case mix includes a “substantial number of patient abuse and neglect cases,” as well as a commensurate number of managed care cases in states that rely substantially on managed care entities for the provision of Medicaid services;
  • Requiring that an MFCU makes available, upon request by federal investigators and prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the Medicaid program; and
  • Ensuring MFCUs investigate, under state authority, any cases with significant civil fraud potential or refer them to OIG or the DOJ.

Additionally, on October 13, the OIG posted an interactive map providing fiscal year 2010 MFCU data. The data includes MFCU staff numbers, investigations, settlements, convictions and recoveries. Of the 1.84 billion Medicaid dollars recovered by MFCUs in 2010, New York recovered $279 million, Texas $180 million, Florida $175 million and Ohio $82 million.

We have represented providers under investigation by MFCUs and can assist providers in handling such cases or in proactively addressing areas frequently targeted by MFCUs.