Medicaid Fraud Control Units fiscal year 2019 annual report

Medicaid Fraud Control Units fiscal year 2019 annual report

Collection:
Health Policy and Services Research
Contributor(s):
United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
Publication:
Washington, D.C. : U.S. Department of Health and Human Services, Office of Inspector General, March 2020
Language(s):
English
Format:
Text
Subject(s):
Fraud -- prevention & control
Government Regulation
Law Enforcement -- methods
Medicare -- legislation & jurisprudence
United States
United States. Department of Health and Human Services
Genre(s):
Technical Report
Abstract:
Oversight of the MFCU Program. Reducing Medicaid fraud is a top priority for OIG, and its role in overseeing MFCUs helps achieve that priority. OIG oversees the MFCU grant program by recertifying Units, conducting onsite reviews of Units, providing technical assistance to Units, and monitoring key statistical data about Unit caseloads and outcomes. Further, OIG has identified enhancing Medicaid program integrity—including efforts to maximize the effectiveness of MFCUs—as an OIG Priority Outcome. (See Appendix A for details.) Annually, OIG reviews each Unit’s application for recertification; approval of this application is necessary for the Unit to receive Federal reimbursement.9 To recertify a Unit, OIG performs a desk review to assess the Unit’s compliance with the Federal requirements for MFCUs contained in statute, regulations, and OIG policy transmittals. OIG also examines the Unit’s adherence to 12 performance standards, such as those regarding staffing, maintaining adequate referrals, and cooperating with Federal authorities.10 OIG further assesses a Unit’s performance by conducting onsite Unit reviews that may identify findings and make recommendations for improvement. During an onsite review, OIG also makes observations regarding Unit operations and practices, and may identify beneficial practices that may be useful to other Units. Finally, OIG provides training and technical assistance, as appropriate, to Units while onsite. OIG also provides ongoing technical assistance and guidance to Units. These activities may include responding to questions from the Units, providing training to Units, and issuing policy transmittals to all Units. OIG also collects and presents statistical data reported by each MFCU annually, such as the numbers of open cases, indictments, and convictions and amounts of recoveries. These data can be accessed on the OIG website in two formats: a statistical chart and an interactive map. Methodology. We based the information in this report on the FY 2019 Annual Statistical Reports that 52 MFCUs submitted to OIG, the recertification materials that the MFCUs submitted to OIG, and OIG exclusions data. We aggregated case outcomes across all Units for FY 2019 and for each of the preceding 4 years—FYs 2015 through 2018. These outcomes include convictions; civil settlements and judgments; and recoveries. For convictions and recoveries, we calculated an average across the 5-year period of FYs 2015 through 2019. We also calculated the return on investment (ROI) for MFCUs.11 We identified the provider types with the highest numbers of criminal and civil outcomes in FY 2019 and the numbers of exclusions that OIG imposed in FY 2019 on individuals and entities as a result of conviction referrals from MFCUs. We also analyzed MFCU drug diversion cases using data for FYs 2015 through 2019. In addition, we highlight the beneficial practices described in each Unit’s more recent onsite review reports, as described in Appendix B.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (30 pages))
Illustrations:
Illustrations
NLM Unique ID:
9918281677506676 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/9918281677506676