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Medicaid Fraud Investigations Continue But With Few Indictments

Medicaid FraudMedicaid Fraud Control Units (MFCUs) are responsible for investigating and prosecuting Medicaid provider fraud and patient abuse and neglect.  As part of its Medicaid plan, each State must establish a MFCU.  These Units are funded by both the Federal and State government with the Federal government reimbursing about 75% of the operating costs. MFCUs receive their referrals for investigation from a wide array of sources: program integrity divisions of the State Medicaid agencies; anonymous tips; whistleblowers; audits; and adult protective service agencies.

Each spring, the U.S. Department of Health and Human Services, Office of Inspector General, publishes an Annual Report summarizing the statistical data from the investigations and prosecutions conducted and reported by the 50 MFCUs nationwide. According to this Annual Report, in 2014, MFCUs reported 1,318 criminal convictions involving Medicaid providers; three-quarters of these convictions were for fraud. Recoveries in the criminal cases were close to $300 million, and 1,337 providers were excluded from Federal health care programs as a result of criminal conviction.

Out of the more than 1,000 criminal convictions:

  • 413 were Home Health Care Aides
  • 129 were Certified Nursing Aides
  • 64 were Physicians or Doctors of Osteopathy
  • 56 were Counselors/Psychologists
  • 33 were Durable Medical Equipment Suppliers

Nationwide, MFCUs investigated 13,192 cases of Medicaid Fraud but only indicted 1, 185 cases- roughly, 10%.  Of the 1,185 indictments, 956 resulted in convictions, almost 100% conviction rate.   From this data, it appears as if the trend in investigating often but indicting infrequently continued from 2013 to 2014 and that the high conviction rate also continued.

What about in Georgia?  Georgia MFCU was even less reluctant to indict than the nationwide trend but enjoyed the same success rate with convictions:  410 fraud investigations; 4 indictments for fraud and only 9 convictions.

If you are a Medicaid Provider, you very well may find yourself being investigated for fraud, but stay calm and call an experienced healthcare attorney. Remember, you have a very, very small chance of actually being indicted.

If you do  receive a subpoena or phone call from the Georgia Medicaid Fraud Unit, Jeyaram & Associates can help. Contact Kimberly Sheridan at ksheridan@Jeylaw.com or 678.325.3872.