Sneak Preview: Medicaid Exclusions Due to Fraud Rise in FY 2013

April 8, 2014 | By Jerry Ashworth | Post a Comment

xsass_bookshot(The following was excerpted from an article in the Single Audit Information Service.) In fiscal year 2013, the Department of Health and Human Services, Office of Inspector General, in response to referrals from Medicaid Fraud Control Units, excluded a greater number of health care providers and other entities convicted of fraud and other program-related crimes from receiving Medicaid funds compared to the last three fiscal years.

However, HHS OIG found that Medicaid providers may have been conducting even more fraudulent activity, but it was not disclosed because state managed-care organizations had not investigated the potential fraud and reported it to MFCUs.

In its recent “Medicaid Fraud Control Unit Fiscal Year 2013 Annual Report,” HHS OIG summarized the efforts of MFCUs nationwide, which investigate and prosecute Medicaid provider fraud, and patient abuse and neglect in health care facilities. Forty-nine states and the District of Columbia operate MFCUs, which are jointly funded by HHS and the states. MFCUs provide HHS OIG with statistical and other information about the results of its investigations, prosecutions and convictions.

MFCUs reported 1,341 criminal convictions, mostly for fraud in FY 2013, which is relatively consistent with criminal conviction totals since FY 2010, according to the report. These convictions included the owner of several pharmacies in New York who stole $7.7 million from the state’s Medicaid program by submitting phony bills for drugs that were never dispensed to patients. MFCUs also reported 879 civil settlements and judgments in FY 2013, slightly up from 824 in FY 2012. In response to the MFCU convictions and settlements, OIG excluded 1,022 health care providers and other entities from all federal health care programs in FY 2013, which was up from 746 exclusions in FY 2012 and 721 exclusions in FY 2011.

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