OIG highlights Medicaid anti-fraud accomplishments

The Office of Inspector General on Friday issued its annual report on Medicaid fraud control units (MFCU) for fiscal year 2013.

The report summarizes outcomes of investigations and civil and criminal prosecutions by MFCUs in 49 states and the District of Columbia. The report also includes policy-related observations about Medicaid anti-fraud work and describes the OIG's oversight activities.

Here are the major findings:

MFCUs reported 1,341 criminal convictions--mostly in fraud cases--with criminal recoveries approaching $1 billion. While a range of provider specialists were convicted, home health agencies were the most frequently represented group. Relatedly, the Centers for Medicare & Medicaid Services recently announced new and extended moratoria on home care provider applications in six fraud-prone cities, as FierceHealthPayer reported.    

MFCUs reported 879 civil settlements and judgments last year, with civil recoveries topping $1.5 billion. Most recoveries came from multistate, global settlements. Civil settlements and judgments involved many provider types, with pharmaceutical companies strongly represented.  

Low volumes of fraud referrals to MFCUs from Medicaid managed care organizations (MCO) present an opportunity for improvement, the report noted. Specifically, only 25 MFCUs received referrals from MCOs in 2013, and 21 MFCUs received fewer referrals than expected based on the number of managed care beneficiaries in their states. Unit officials voiced concern that some MCOs may not have incentive to detect and refer fraud, the report stated.  

And provider payment suspension rules stemming from the Affordable Care Act require more coordination between MFCUs and state Medicaid agencies, the OIG observed.    

The report also highlighted the OIG's Medicaid anti-fraud accomplishments: The agency conducted 10 onsite unit audits and published eight reports on them. The agency released regulations permitting data mining by MFCUs and proposed new authority for units to investigate alleged beneficiary abuse and neglect. And the OIG excluded 1,022 Medicaid providers convicted in MFCU cases from participation in federal healthcare programs.

For more:
- read the report (.pdf)