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Medicaid Fraud Control Units - MFCUs

Reporting Medicaid Fraud

You may direct complaints of suspected Medicaid fraud to
OIG's Hotline 1-800-HHS-TIPS
(1-800-447-8477) or directly to
an MFCU or  State Medicaid Agency

Medicaid Fraud Control Units (MFCU or Unit) investigate and prosecute Medicaid fraud as well as patient abuse and neglect in health care facilities. OIG certifies, and annually recertifies, each MFCU. OIG collects information about MFCU operations and assesses whether they comply with statutes, regulations, and OIG policy. OIG also analyzes MFCU performance based on 12 published performance standards and recommends program improvements where appropriate. The MFCUs share common characteristics:

  • MFCUs must be "single, identifiable" entities whose professional staff are required to work full-time on MFCU duties.
  • States administer the MFCUs, but they are jointly funded on a matching basis with the Federal Government. (The Federal Government pays 90 percent of a Unit's costs for the first 3 years of a Unit's operation and 75 percent for subsequent years; the States pay the remaining portion.)
  • MFCUs operate on an interdisciplinary model and must employ investigators, auditors, and attorneys.
  • The MFCUs are required to have statewide authority to prosecute cases or to have formal procedures to refer suspected criminal violations to an office with such authority.
  • The MFCUs' investigative authority extends to Medicaid-funded facilities and to "board and care" facilities that do not receive Medicaid funding. OIG, or another agency's Inspector General, may in some circumstances permit the Units to investigate fraud in Medicare or other Federal programs.

Regulations/Statutes

Performance Standards

OIG applies a series of performance standards, developed in accordance with section 1902(a)(61) of the Social Security Act, as part of its oversight of the MFCUs. The standards assist OIG in the certification and recertification of the MFCUs and help to determine whether the MFCUs carry out their duties efficiently and effectively.

OIG has published proposed revisions to the performance standards that are designed to replace and supersede the original standards published in 1994. Along with the text of the proposed revisions, we have included further background on the standards as well as instructions for submitting comments. Comments are requested by December 5, 2011.

Related Links

Policy Transmittals

On occasion, OIG issues policy transmittals to provide guidance and instructions to MFCUs. The transmittals may also provide interpretations of Federal regulations, statutes, and other policies as they apply to MFCUs.

Expenditures & Statistics

As part of its responsibilities to combat Medicaid fraud and patient abuse and neglect, each MFCU maintains statistical information. The information includes numbers of investigations, indictments, and convictions by the MFCUs, as well as the amount of monetary recoveries for both civil and criminal cases. The documents below include an annual summary of this information for the MFCU community and, commencing in fiscal year 2010, a chart and interactive map containing detailed information for each MFCU. The statistical information for each MFCU should be interpreted in light of the State-specific organization and authorities governing the MFCU. For more information, please contact the MFCU directly.

Forms

Other