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Medicaid Fraud Control Unit

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Presentation on theme: "Medicaid Fraud Control Unit"— Presentation transcript:

1 Medicaid Fraud Control Unit

2  Self-Disclosing Providers  RACs  The Medicaid Agency  Whistleblowers  What types of referrals do we expect in the near future?

3  The federal false claims act provides a reduced penalty for providers who self- disclose. The minimum court assessment is reduced from three times to two times the amount of damages the government sustained because of the false claim.  See 31 USC 3729(a)(2)

4  HHS-OIG has adopted formal requirements for providers wishing to take advantage of the option to self- disclose. The requirements appear in a notice published in the Federal Register.  63 FR

5  The Indiana Medicaid Fraud Control Unit does not have formal requirements for self-disclosure, but we do look with favor on providers that self-disclose.

6  Section 6411 of the new federal Affordable Care Act (ACA) requires States and territories to establish Medicaid Recovery Audit Contractor (RAC) programs. Medicaid RACs are tasked with identifying and recovering Medicaid overpayments and identifying underpayments.

7  RACs receive a percentage of their recoveries as compensation.  There is an obvious incentive to closely review high-dollar revenue sources.

8  42 C.F.R. § Suspension of payments in cases of fraud.  (a) Basis for suspension.  (1) The State Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending....  (2) The State Medicaid agency may suspend payments without first notifying the provider of its intention to suspend such payments.

9  42 C.F.R. § Suspension of payments in cases of fraud.  (d) Referrals to the Medicaid fraud control unit.  (1) Whenever a State Medicaid agency investigation leads to the initiation of a payment suspension in whole or part, the State Medicaid Agency must make a fraud referral to [the] Medicaid fraud control unit

10  42 C.F.R. § Suspension of payments in cases of fraud.  (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments... if any of the following are applicable:  (1) [The MFCU has] specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation.

11  42 C.F.R. § Suspension of payments in cases of fraud.  (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments... if any of the following are applicable:  (3) The State determines, based upon the submission of written evidence by the individual or entity that is the subject of the payment suspension, that the suspension should be removed.

12  42 C.F.R. § Suspension of payments in cases of fraud.  (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments... if any of the following are applicable:  (4) Recipient access to items or services would be jeopardized by a payment

13  42 C.F.R. § Suspension of payments in cases of fraud.  (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments... if any of the following are applicable:  (6) The State determines that payment suspension is not in the best interests of the Medicaid program.

14  Relators bringing qui-tam cases continue to be the most valuable sources of information leading to the most substantial MFCU recoveries.

15  The MFCU is a law enforcement agency, not a collections agency.  Collections in Latest State Fiscal Year (July 1, 2010 to June 30, 2011): $36,098,

16  September 16 Washington Post headline:  Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud  Sen. Charles E. Grassley (Iowa), the ranking Republican on the Judiciary Committee, said in a written statement that it takes “two sides to perpetuate this fraud” and that both need to be held accountable.

17  September 16 Washington Post headline:  Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud  “Otherwise, regardless of how big of a civil settlement a drug company makes, the incentive to cheat the taxpayers will still be in place for those willing to take part.”

18  September 16 Washington Post headline:  Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud  Lewis Morris, chief counsel to the HHS inspector general, said doctors need to know there are repercussions.“If you don’t focus on doctors, this is a problem that will never end,” he said.

19  September 16 Washington Post headline:  Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud  He also acknowledged that he has the resources to focus only on the most glaring cases.

20  Since 2005, the MFCU has added 300 whistleblower, qui-tam lawsuits to its caseload.  Those qui-tams are assigned to six DAGs. Indiana-Only Cases Multi-State Cases in Which Indiana DAGs are on the National Investigation or Litigation Team Multi-State Cases in Which Indiana DAGs are Supporting a National Investigation or Litigation Team

21  Medicaid providers must not bill Medicaid (or Medicare) for services (professional or otherwise) provided by an individual who has been excluded by HHS-OIG.  To check on current and prospective employees and contractors, follow the link at

22  Medicaid providers must not bill Medicaid (or Medicare) for professional services provided by an individual who is unlicensed or whose license is suspended.  To check on current and prospective employees and contractors, follow the link at https://mylicense.in.gov/everification/Se arch.aspx

23  Areas that the MFCU feels may have received too little emphasis in recent years, and that may receive increased MFCU review in the near future.

24  The MFCU patient-neglect investigators continue to aggressively review allegations involving the diversion of drugs from patients who are vulnerable and who require the strongest pain medications.  Continuous improvement in the control of stored drugs, inadvertently, continues to increase the temptation to divert drugs after they are dispensed to patients, especially non-communicative patients.

25   Find the MFCU under the “Criminal Justice” link.  


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