Medicaid provides coverage and healthcare services with federal and state funding to 72.2 million people in the Unites States. This coverage is for those with limited income and resources i.e., low-income adults, children, pregnant women, elderly adults, and people with disabilities. Medicaid is administered by the “States” under federal requirements and guidelines. Like the Medicare program, we see fraud, waste, and abuse within the Medicaid program as well.

The Office of Inspector General (OIG) released their annual Medicare Fraud Control Units FY2020 Annual Report  and there are some facts and figures worth mentioning to those professionals in Health Information Management (HIM), Clinical Documentation Improvement (CDI), Revenue Cycle and Compliance. The Social Security Act requires each state to operate a Medicaid Fraud Control Units (MFCU). The primary function of MFCU is to investigate and prosecute Medicaid provider fraud and patient abuse and neglect. There are 53 MFCU and they operate in all 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. The OIG has oversight responsibility for the MFCU and helps them to achieve their goals.

Although the COVID-19 pandemic had an impact on MFCU staff operations and court proceedings, the work of the MFCU did result in 1,017 convictions in 2020. Of those convictions, there were 774 for fraud and 243 for patient abuse of neglect. Some other facts for 202 include:

  • 928 Individuals or entities excluded from federally funded healthcare programs
  • 1 Billion dollars recovered
    • $173 Criminal Recoveries
    • $855 Civil Recoveries

In the area of “fraud” the MFCU reported a variety of healthcare settings in the 2020 report (this is not an all-inclusive list):

Ambulance

Home Health

Lab (Radiology and Physiology)

Pain Management Clinic

Pharmaceutical Manufacturer

Suppliers of Durable Medical Equipment

Nurse Aide (CNA)

Billing Services

Lab (Clinical)

Medical Device Manufacturer

Personal Care Services Agency

Pharmacy (Hospital)

Emergency Medical Technician Paramedic

Unlicensed Mental Health Counselor

The provider types identified by the MFCU for “fraud” include the following (this is not an all-inclusive list):

Audiologist                                                      

Clinical Social Worker                                  

Nurse (LPN, RN)                                            

Optometrist                                                    

Physician Assistant                

Psychologist      

Chiropractors

Dentist

Nurse Practitioner

Pharmacist

Podiatrist                           

Therapist (Non-Mental Health, PT, ST, OT, or RT)

According to the National Association of Medicaid Fraud Control Unit, a MFCU reviews complaints of abuse or neglect in nursing home and board and care facilities.  They may also review complaints of the misappropriation of patients’ private funds in nursing homes. The MFCU is also charged with investigating fraud in the administration of the program and for providing for the collection or referral for collection to the single state agency and overpayments it identifies in carrying on its activities. For more information about the Medicaid program itself visit the following website: Medicaid | Medicaid

Although we may not hear as much in the news about Medicaid fraud or even discuss it within our work environment, it does occur, this OIG report really proves that. Having a broad scope of coding audits and education that includes Medicaid in addition to Medicare and other payers is essential. Working closely with Compliance and Revenue Cycle leadership to ensure the proper checks and balances are in place including written policies and procedures is vital. In addition, discuss Medicaid compliance and fraud issues with ancillary department leaders. Keeping our eyes and ears open for potential healthcare fraud and reporting it to our compliance or internal audit department is our professional responsibility.

Visit the following link to read more details on the OIG report: Medicaid Fraud Control Units Fiscal Year 2020 Annual Report_OEI-09-21-00120 (hhs.gov)

Written by Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

Reimbursement Management Consultants (RMC) can provide assistance with medical coding support, auditing, education, compliance consulting, and HCC/risk adjustment services. RMC is a woman-owned, US-based and operated company which specializes in a variety of medical coding and auditing services. Contact us here.