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PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

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Presentation on theme: "PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:"— Presentation transcript:

1 PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box Baton Rouge, Louisiana Telephone: (225) Fax: (225) Attorney General Buddy Caldwell

2 investigate and prosecute Medicaid fraud as well as patient abuse and neglect in health care facilities operate in 49 States and in the District of Columbia. Forty-four of the MFCUs are located as part of Offices of State Attorneys General 6 are in other State agencies

3  OIG certifies, and annually recertifies, each MFCU  OIG collects information about MFCU operations and assesses whether they comply with statutes, regulations, and OIG policy  OIG also analyzes MFCU performance based on 12 performance standards and recommends program improvements where appropriate  mfcu/index.asp

4  MFCUs must be "single, identifiable" entities  professional staff are required to work full-time on MFCU duties.  States administer the MFCUs  they are jointly funded on a matching basis with the Federal Government. (The Federal Government pays 90 percent of a Unit's costs for the first 3 years of a Unit's operation and 75 percent for subsequent years; the States pay the remaining portion.)  MFCUs operate on an interdisciplinary model  must employ investigators, auditors, and attorneys.  The MFCUs are required to have statewide authority to prosecute cases or to have formal procedures to refer suspected criminal violations to an office with such authority.  The MFCUs' investigative authority extends to Medicaid-funded facilities and to "board and care" facilities that do not receive Medicaid funding. OIG, or another agency's Inspector General, may in some circumstances permit the Units to investigate fraud in Medicare or other Federal programs.

5  Combined Federal and State grant expenditures totaled $217.3 million  $162.9 were Federal funds  Collectively, all 50 MFCU’s  Employed 1,901 individuals  Conducted 15,531 investigations  11,660 were Medicaid fraud related  3,871 were patient abuse cases  1,359 individuals were indicted or charged criminally  995 criminally charged with fraud  364 criminally charged with abuse  1,337 convictions were reported  982 related to Medicaid fraud  355 related to patient abuse  Civil judgments and settlement totaled 823

6  Collectively, the MFCU’s reported $2.9 billion in recoveries*  Translates into a return on investment of $13.48 per $1 expended by the Federal Government  747 of the 3,131 exclusions reported to HHS-OIG were based on referrals made by MFCU’S * recoveries are defined as monies that defendants are required to pay as a result of a settlement, judgment or pre-filing settlement in criminal and civil cases and may not reflect actual collections

7  Created in 1978  Convicted hundreds of persons for program violations and recovered millions of tax dollars  The unit has twice been recognized as the number one MFCU in the nation by the United States Department of Health and Human Services, Office of the Inspector General.  National Association of Medicaid Fraud Control Units (NAMFCU) 

8  Federal Fiscal Year 2012  Investigations – 349  Indictments/charges – 91  Convicted – 150  Civil settlements/Judgments – 44  Recoveries - $124,095,  Total Medicaid Expenditures  $7,353,759,  52 MFCU employees

9 MEDICAID IS FOR THE NEEDY -- NOT THE GREEDY!

10 Case Examples BFSNR Hospital Overlaps Worker not present False Documentation – DSW and/or Owner Falsified documents in personnel folder CPR card background check Other Reporting Cases

11 Type name and search

12 TO REPORT FRAUD OR ABUSE CONTACT: ATTORNEY GENERAL’S MEDICAID FRAUD CONTROL UNIT Reports may also be made to The Department of Health and Hospitals (DHH), Local Police, or the Sheriff’s Office


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