Because of the rise in home health services, Medicaid is at risk for billions of dollars in fraudulent billing. The Centers for Medicaid & Medicare Services (CMS) and the Office of Inspector General (OIG) are working together to combat Medicaid fraud. Medicaid Fraud Control Units (MFCUs) coordinated over 18,000 investigations of fraud and neglect in 2016, leading to $1.8 billion in recoveries.
“Well, while we hear a lot about Medicare fraud, involving the program for the elderly and the disabled, total taxpayer costs are actually higher in Medicaid, than in Medicare, with total yearly expenditures for Medicaid of over $500 billion dollars,” said Richard Stern, OIG Director of Program Oversight for Medicaid Fraud Units in a recent podcast.
The data shows that the returns from criminal investigations by Medicaid Fraud Control Units (MFCUs) can vary. Some states brought in large returns--such as in Florida, where it spent $17.3 million to recover over $101 million. Others, like New York, had numerous criminal investigations but only managed to recover $157,846 in criminal fraud. But the New York MFCU's civil efforts (such as through whistleblower complaints) recovered over $200 million.
These discrepancies highlight the need for more universal protocols for MFCUs to be effective. "Also, the Medicaid Fraud Control Units need the legal authority to investigate and prosecute patient abuse or neglect in home- or community-based settings in addition to institutions,” said Shimon Richmond, Special Agent in Charge in Miami, FL. “The current rules made some sense when Medicaid services were primarily provided in institution in times past, but as those services are increasingly provided in the home and the community, things really have changed.”