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NAAGazette

MFCUs Fight Fraud and Abuse: Representing the Leaders in Health Care Fraud Enforcement

Barbara L. Zelner, Counsel, National Association of Medicaid Fraud Control Units (NAMFCU)

Barbara Zelner, Counsel, National Association of Medicaid Fraud Control Units (NAMFCU)

According to a recent USA Today article, the Medicaid program has increased by more than 10% in the first six months of this year, the largest increase since 2001. More than a record $300 billion dollars will be spent on this program in 2007. Such a dramatic growth is an increasing cause for concern for both state and federal officials. The existence of fraud in the Medicaid program is detrimental to taxpayers, the program’s financial stability and the quality of care provided to beneficiaries.

State Medicaid Fraud Control Units (MFCUs) lead the fight against fraud and abuse in the Medicaid program and offer state Attorneys General a leadership role in strengthening state health care fraud enforcement efforts. Forty-three of the 50 federally certified units are housed in the office of the state Attorney General. For the other seven states (Connecticut, the District of Columbia, Georgia, Illinois, Iowa, Tennessee and West Virginia), the MFCU operates from a separate state agency, but even in those jurisdictions, the MFCU works with staff in the Attorney General’s office. This year, Idaho became the 49th state to establish a MFCU.

The MFCUs are first and foremost state-based criminal law enforcement agencies that are funded 75% by the federal government and are responsible for investigating and prosecuting providers that defraud the Medicaid program. In addition, the MFCUs can investigate complaints of abuse or neglect against residents in long-term care and board and care facilities. When Congress created the MFCUs in 1977, it did so not only because of substantial evidence of fraud in the Medicaid program, but also because of horrendous evidence of nursing home abuse and victimization. The MFCUs are the only law enforcement agencies in the country that are specifically charged with investigating and prosecuting abuse and neglect of residents in nursing homes, other Medicaid funded health care institutions and board and care facilities.

Over the past ten years, the MFCUs have substantially increased their aggregate number of convictions and financial recoveries. For example, in Federal Fiscal Year (FFY) 1996, the MFCUs collectively obtained 871 convictions and recovered $147.6 million dollars in court ordered restitution, fines, civil settlements and penalties. In FFY 2006, the MFCUs obtained 1,226 convictions and recovered more than $1.1 billion dollars.

The National Association of Medicaid Fraud Control Units (NAMFCU) was founded in 1978 to provide a forum for the MFCUs for the mutual exchange of information, to foster interstate cooperation, and to improve the quality of Medicaid fraud and resident abuse investigations and prosecutions through training programs. The 50 MFCUs comprise the Association and are staffed by almost 2,000 attorneys, auditors, investigators and support staff. The majority of these employees work for their state Attorney General.

NAMFCU has developed high quality professional training that provides new MFCU employees with essential investigative and prosecutorial techniques and skills to conduct Medicaid fraud and resident abuse investigations. NAMFCU also provides state-of-the-art training on the latest fraud schemes. Such specialized Medicaid fraud training is not available elsewhere.

Since 1998, NAMFCU has conducted 27 Introduction to Medicaid Fraud training programs for approximately 1,200 MFCU employees. This introductory program is deemed mandatory training in many state Attorneys General offices. Additionally, NAMFCU has provided introductory training to individual states such as Illinois, Georgia, Texas and Florida in conjunction with significant Unit expansions in those states.

In addition to introductory training, NAMFCU offers MFCUs a Practical Skills training program that focuses on fraud scenarios in different specialty areas. The training is conducted in breakout-group format with substantial interaction between instructors and students. The training targets more experienced MFCU employees. NAMFCU held this training in Virginia this year and is planning for two programs in 2008, to be held in Florida and Colorado.

NAMFCU also holds an annual Directors Symposium in Washington, D.C. This program provides MFCU Directors with in-service training on MFCU grant requirements and provides a forum for learning about best practices in managing an MFCU. National trends in Medicaid fraud and resident abuse cases are also discussed.

Each year NAMFCU also co-sponsors two healthcare fraud programs with the American Bar Association. These seminars bring together state and federal prosecutors along with the defense and relator (“whistleblower”) bar to share information about national trends and cases.

In addition to its training programs, NAMFCU is available to provide support to MFCU staff by providing technical assistance. At a state’s request, NAMFCU will form a team of experienced MFCU staff to visit the state and review the requesting Unit’s structure, cases and its relationships with state/federal agencies. Several states have taken advantage of this opportunity, which is provided at no cost to the Attorney General’s office or state agency.

For many years, NAMFCU has provided the links necessary for individual MFCUs and their respective state Attorney General offices to coordinate Medicaid fraud multi-state cases and investigations. The Association’s Global Case Committee (GCC) meets quarterly to discuss existing and potential cases, policies, procedures and strategies that affect a particular case, but may also affect other cases as well. This Committee also develops specialized training about global cases and investigations for MFCU data analysts, attorneys, investigators and auditors. To date, NAMFCU coordinated multi-state settlements have returned $2.3 billion dollars to the states. Currently, NAMFCU has 22 multi-state teams assigned to cases.

Two years ago, NAMFCU created a Qui Tam Subcommittee of the GCC to provide a forum for the increasing number of states that have adopted qui tam statutes modeled after the federal False Claims Act. The Subcommittee assigns intake teams to each newly filed under seal. The Subcommittee provides a vehicle for Attorneys General through their MFCUs to play a prominent role in multi-state cases. At the successful conclusion of each case, a model press release is sent to each participating state. Many Attorneys General use the NAMFCU model press release to publicize the successful work of its MFCU.

Providing the public with information about the Medicaid fraud program is another important purpose of NAMFCU. To further that goal, NAMFCU maintains a website, http://www.NAMFCU.net/, which contains information about the history of MFCUs, past press releases, copies of the Association’s Medicaid Fraud Report newsletter, as well as links to individual state Attorney General offices, the National Association of Attorneys General, and other organizations and federal agencies.

All MFCUs work closely with the United States Attorney and HHS-OIG offices in their respective states, along with other federal law enforcement agencies. There are active state-federal health care fraud task forces and working groups in many states and the MFCUs are active participants on these task forces and working groups.

In many states, MFCU staff provide statewide leadership in training local law enforcement to recognize, investigate, and prosecute resident abuse cases. MFCUs also sponsor training programs, while other MFCUs educate health care professionals, state long-term ombudsman and adult protective services staff. Individual MFCUs also offer training for health care workers in residential care facilities, group homes and hospitals, and for home health care aides to recognize and report resident abuse and neglect. Many MFCUs actively participate on state multi-agency task forces and working groups dealing with resident abuse. These task forces meet regularly to exchange information and consider legislation, training efforts and ways to improve public awareness on the subject of resident abuse.

This summer, NAMFCU submitted testimony, at the request of the U.S. Senate Special Committee on Aging about the role of the MFCUs in investigating and prosecuting abuse and neglect cases in long-term care facilities. Currently, a draft letter of support for the bipartisan Patient Safety and Abuse Prevention Act of 2007, a bill to establish a nationwide system of background checks for long-term care workers, is being circulated to MFCU Directors for consideration.

For 30 years, the Medicaid Fraud Control Units have played a national leadership role in detecting and prosecuting health care fraud and resident abuse. The Units have been successful in serving as a deterrent to health care fraud, in identifying program savings, in removing incompetent practitioners from the health care system and in preventing physical and financial abuse of residents in health care facilities.

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