Medicaid Fraud Control Unit Investigations

With Medicaid Fraud Control Units (MFCUs) reporting $1.9 billion in recoveries, over 1,500 criminal convictions, and almost 1000 civil cases resulting in a recovery, in fiscal year 2016, it is more important than ever to hire counsel that is experienced and knowledgeable in both criminal and civil healthcare fraud related matters. No longer is it suitable to retain counsel with a practice confined to civil or administrative matters. Experienced counsel with a team building approach to representation, like Rosenblat Law, is the only reasonable means to combat the governments’ aggressive prosecution of healthcare fraud.

The MFCU report stated that cases resolved to the governments’ benefit were at a 5-year high, with the majority of criminal cases relating to personal services, followed by nursing care. With 74% of the criminal convictions involved fraud allegations.

MFCUs were created in 1977 as part of the Medicare-Medicaid Anti-Fraud and Abuse Amendments. MFCUs are only authorized to investigate provider fraud, not fraud perpetrated by beneficiaries.

Medicaid and Medicare fraud, prosecutions typically revolve around a number of fraudulent schemes. These often include one of the following:

  • Billing for services not provided can include false claims submitted for tests not performed, services not provided, or even claims submitted for beneficiaries after their death.
  • Double billing when providers submit multiple claims for the same procedure, or when different providers submit false claims for the same service which only one provider performed.
  • Billing for visits that never occurred is another common scheme that is closely related to doubling billing, except in this case no services were provided.
  • Kickback violations, which render tainted claims non-reimbursable, often relate to one provider requiring another provider to provide compensation or certain services. These claims can relate to a nursing home requiring another provider, such as a pharmacy to pay the nursing home for the pharmacy business, or a physician and x-ray clinic entering into a referral arrangement where the clinic provides a kickback for the patients referred.
  • Submitting claims for more than 24 hours for timed services is a common scheme that is alleged related to psychological and other timed services.
  • Un-credentialed or falsely credentialed providers who submit claims. These providers are usually not authorized to submit claims or receive payment.
  • Prescription drug fraud often occurs when claims from more expensive brand name drugs are submitted to Medicaid, but less costly generic drugs are provided to the Medicaid beneficiary. Pharmacies may also short-fill prescriptions by submitting claims for more drugs than were actually provided to the beneficiary.
  • Billing for services or tests that are medically unnecessary is also a common allegation of fraud.
  • Upcoding procedures or equipment occurs when a provider submits a claim under a more expensive procedure code, or submits a claim for more expensive equipment than was provided.
  • Cost Report Fraud is often related to personal expenses being included in nursing home cost reports by nursing home operators or owners.

To discuss representation if you have been contracted by the MFCU, a government agency or contractor, or obtain legal advice related to any healthcare fraud matter, contact Rosenblat Law.

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