The Medicaid Fraud Control Units (MFCUs) presented their annual report this year as usual, breaking down the exclusions, enforcements, and general lessons learned from their work over the preceding fiscal year (FY). The results of Medicaid-related cases are transparently examined in this yearly report, which also provides insightful information about fraud, waste, and abuse in the healthcare industry overall.
Higher Recovered Funds Rates, Lower Conviction Rates
This year’s report highlights a theme of severe financial penalties despite a decrease in convictions. A total of $1.2 billion was recovered by MFCUs, which increased the previous year’s total recovery by around $100 million and ultimately recovered $3.35 for every $1 spent.
The quantity of civil recoveries hit a four-year high in FY 2023, despite MFCUs reporting a decline in the number of civil judgments and settlements. In light of the overall decline in convictions, exclusions, and settlements, this high recovery rate is very noteworthy. MFCUs recorded 1,143 convictions overall in FY 2023, a significant drop from 1,327 convictions in FY 2022. In FY 2023, the Office of the Inspector General (OIG) issued 850 exclusions based on State MFCU cases. These exclusions accounted for 40% of the OIG’s 2,112 total exclusions for the year.
This year’s data makes it quite evident that those who engage in fraud, waste, or abuse will not get away with it; whether these rates go up or down, they will suffer serious consequences.
Key takeaways from the 2023 Annual Report
Comparing the conviction and exclusion rates for the five years prior to FY 2020, which were consistently higher, with the FY 2023 report maintaining the trend of yearly fluctuations since the pandemic’s start.
The significant rise in convictions and exclusions in FY 2022, according to an OIG comment to ProviderTrust last year, may be related to courts and investigations starting up again on a full-scale basis for the first time since the epidemic began. Even though there were 1,143 convictions in FY 2023 compared to 1,017 in FY 2020, the conviction rate is still lower than it was before the epidemic.
Managed care organizations’ (MCOs’) increased involvement is another significant trend in this year’s study. In addition to the significant increase in fraud referrals from Medicaid enrollee-covering MCOs since FY 2021 (from 2,971 in FY 2021 to 4,068 in FY 2023), MFCUs have been opening more cases each year as a result of these referrals (from 774 in FY 2021 to 893 in FY 2023).
More highlights from the 2023 annual report include:
- 1,143 total convictions, of which 814 were for fraud and 329 for patient abuse or neglect
- Compared to other provider types, Personal Care Services (PCS) attendants accounted for 34% of fraud convictions, with 850 individuals or businesses being banned from federally supported programs.
- 436 verdicts and settlements in civil cases
- $1.2 billion was collected in all, $272 million for criminal cases and $963 million for civil proceedings.
- For every $1 paid, MFCUs recovered $3.35.
Article Link: providertrust.com
