Medicaid Fraud Control Units Fiscal Year 2015 Annual Report

WHY WE DID THIS STUDY

The Department of Health and Human Services (HHS) OIG is the designated Federal agency that oversees State Medicaid Fraud Control Units (MFCU or Unit). This MFCU Fiscal Year (FY) 2015 Annual Report highlights statistical achievements from the investigations and prosecutions the 50 MFCUs conducted for FYs 2011 through 2015. The report also identifies improvements made in Unit operations.

HOW WE DID THIS STUDY

We based the information in this report on our analysis of data from three sources: (1) annual statistical reports submitted for FY 2015; (2) quarterly statistical reports for FYs 2011 through 2014; and (3) onsite review reports published in FYs 2011 through 2015.

WHAT WE FOUND

In FY 2015, Units reported 1,553 convictions, nearly one-third of which involved personal care services attendants. Fraud cases accounted for 71 percent of the 1,553 convictions. Units reported 731 civil settlements and judgements, with pharmaceutical manufacturers making up over a third of Unit settlements. Units also reported $744 million in criminal and civil recoveries.

In FY 2015, Units reported the highest number of convictions in the last 5 years, and OIG exclusions resulting from Unit conviction referrals have grown since 2011. Civil settlements and judgments have decreased modestly over the last 5 years, and civil recovery amounts have decreased significantly. Finally, many Units made operational improvements in response to OIG recommendations.

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