Medicaid Fraud Control Units Fiscal Year 2022 Annual Report   

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The OIG has posted its annual report on Medicaid fraud for FY2022.  The 29-page report highlights:

Here’s the Table of Contents:

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 reviews and inspections (hereinafter referred to as inspections) of Units; providing technical assistance to Units; and monitoring key statistical data about Unit caseloads and outcomes.

Annually, OIG reviews each Unit’s application for recertification; approval of this application is necessary for the Unit to receive Federal reimbursement.10 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.

 OIG further assesses a Unit’s performance by conducting inspections of Units that may identify findings and lead to OIG making recommendations for improvement. During an inspection, OIG also makes observations regarding Unit operations and practices, and may identify beneficial practices that could be useful to other Units. Finally, OIG provides training and technical assistance to Units, as appropriate.

OIG also provides ongoing technical assistance and guidance to Units. These activities may include outreach, 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.

MFCUs play a vital role in holding wrongdoers accountable for Medicaid provider fraud and protecting patients from abuse or neglect. Medicaid, as a Federal-State partnership that provides health insurance for over 80 million individuals, requires skilled and effective oversight from both the Federal and State governments. MFCUs, which report to, or work closely with, the State Attorney General, and which receive funding and oversight from OIG, are uniquely positioned to investigate and prosecute provider fraud and patient abuse or neglect in coordination with Federal and State law enforcement and oversight agencies.

This report outlines the criminal and civil outcomes achieved by MFCUs in FY 2022, including total recoveries of $1.1 billion with an ROI of $3.08 for every $1 spent. Notably in FY 2022, MFCUs continued to achieve increased criminal outcomes after encountering pandemic-related challenges that we described in the FY 2020 and FY 2021 MFCU annual reports.

As in past MFCU annual reports, OIG has identified beneficial practices implemented by the MFCUs, included in Appendix A, which other MFCUs may want to consider for adoption.

OIG annually recognizes the efforts of one MFCU with the Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse. In 2023, the Utah MFCU received this award for achieving strong case outcomes and maintaining outstanding partnerships with OIG’s Office of Investigations and other Federal and State partners, as well as managed care entities.