Medicaid Fraud Control Units Fiscal Year 2016 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 (MFCUs or Units). This MFCU Fiscal Year (FY) 2016 Annual Report highlights statistical achievements from the investigations and prosecutions the 50 MFCUs conducted for FYs 2012 through 2016. The report also identifies beneficial practices noted in OIG onsite review reports.

HOW WE DID THIS STUDY

We based the information in this report on our analysis of FYs 2012 through 2016 statistical data submitted by the 50 MFCUs, as well as materials MFCUs submitted to OIG for recertification.

WHAT WE FOUND

In FY 2016, Units reported 1,564 convictions, over one-third of which involved personal care services attendants. Fraud cases accounted for 74 percent of the 1,564 convictions. The number of convictions related to drug diversion cases increased from FY 2015. Units reported 998 civil settlements and judgments, with settlements with pharmaceutical manufacturers making up almost half of Unit settlements. Units also reported almost $1.9 billion in criminal and civil recoveries.

In FY 2016, Units continued a trend of increasing numbers of convictions, and civil settlements and judgments reached a 5-year high. The number of OIG exclusions resulting from Unit conviction referrals decreased slightly in FY 2016, as compared to the previous two FYs.

---