Medicaid Fraud Control Units
Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as abuse or neglect of residents in health care facilities and board and care facilities and of Medicaid enrollees in noninstitutional or other settings. MFCUs operate in each of the 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. MFCUs, usually a part of the State Attorney General's office, employ teams of investigators, attorneys, and auditors; are constituted as single, identifiable entities; and must be separate and distinct from the State Medicaid agency. OIG, in exercising oversight for the MFCUs, annually recertifies each MFCU, assesses each MFCU's performance and compliance with Federal requirements, and administers a Federal grant award to fund a portion of each MFCU's operational costs.
Program Requirements and Standards
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- 42 CFR Part 1007, Revisions to State Medicaid Fraud Control Units Rules
- Source: 84 FR 10700, March 22, 2019
- Archived: 42 CFR Part 1007, State Medicaid Fraud Control Units (superseded May 21, 2019)
- 42 CFR Part 455, Program Integrity: Medicaid (as amended May 21, 2019)
- 45 CFR Part 75, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards except as amended by 2 CFR part 200 as stated in the General Terms & Conditions of the grant award.
- Social Security Act Provisions
Archived Administrative Requirements and Cost Principles
(applicable to FY 2015 and prior MFCU grant awards) - 42 CFR Part 1007, Revisions to State Medicaid Fraud Control Units Rules
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The terms and conditions of the award include all legally enforceable requirements pertaining to the award, whether included in statute, regulation, policy guidance, or this award document.
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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.
Performance Standards, 89 FR 76431 (effective September 18, 2024)
- Performance Standards, 77 FR 32645 (Archived)
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On occasion, OIG and other Federal agencies issue policy transmittals (designated below by year and sequence of publication) and other guidance materials applicable to MFCUs. The materials provide interpretations or implement Federal regulations and statutes.
- 2024-1 Obtaining HHS-OIG Approval for Extended Authority to Investigate and Prosecute Medicare and Other HHS Federal Health Care Program Fraud
- 2021-1 Expanded Authority for Cases of Patient Abuse or Neglect in Noninstitutional Settings: Frequently Asked Questions
- November 13, 2020 Prohibition on Federal Funding of Certain Telecommunication & Video Surveillance Services or Equipment
- 2020-3 MFCU Authority to Receive Federal Funding to Investigate and Prosecute Diversion and Misuse of Pharmaceuticals
- May 7, 2020 Guidance on Acknowledgement of Federal Funding in Accordance with Stevens Amendment
- 2020-2 Elements of and Process for Submitting and Renewing a Data Mining Application
- 2020-1 Plea Negotiations and Reporting Convictions to OIG
- August 28, 2015 CMS Survey and Cert Letter 15-42, Guidance to State Survey Agencies (SA) Regarding Release of Information and Data to State Medicaid Fraud Control Units (MFCU)
- 2014-1 Employment and Reimbursement of Full- and Part- Time Staff and Performance of Non-MFCU Duties
- 2010-1 Program Income
- SHO Letter #08-004 CMS policy regarding refunding of Federal share in false claims actions
Archive
Archived policy transmittals and other guidance are found here. OIG archives policy transmittals and other policy guidance when the guidance has been updated, been replaced by regulation, or become obsolete.
MFCU Activities and OIG Oversight
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OIG conducts periodic reviews and inspections of individual MFCUs to determine whether Units meet the performance standards and comply with laws, regulations, and policy transmittals. The resulting OIG reports present background on the Units, observations, findings, and recommendations for improvement.
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These reports summarize the activities and accomplishments of all Units for the fiscal year, as well as trends over recent years.
Annual Summary of Grant Expenditures and Statistics
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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 as well as 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.
- Statistics for Each MFCU
- FY 2023 Chart | Interactive Map
- FY 2022 Chart | Interactive Map
- FY 2021 Chart | Interactive Map
- FY 2020 Chart | Interactive Map
- FY 2019 Chart | Interactive Map
- FY 2018 Chart | Interactive Map
- FY 2017 Chart | Interactive Map
- FY 2016 Chart | Interactive Map
- FY 2015 Chart | Printable Version
- FY 2014 Chart | Printable Version
- FY 2013 Chart | Printable Version
- FY 2012 Chart | Printable Version
- FY 2011 Chart | Printable Version
- FY 2010 Chart | Printable Version
- Annual Statistical Reporting (ASR)
- Statistics for Each MFCU
- Data Mining Applications
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Reporting MFCU Convictions
Federal regulations state that MFCUs should, on a timely basis, transmit to HHS-OIG all pertinent information on MFCU convictions. MFCUs must use the Exclusion Referrals portal to transmit this information.
Submit the MFCU's Annual Statistical Report (ASR)
OIG requests that ASR information be provided through the ASR Portal no later than November 30.
- State Enforcement Actions
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OIG administers the MFCU awards, which are non-discretionary grants to each of the States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Eligibility and funding are specified in the statute and regulation referenced above. Following are resources to aid the MFCUs throughout the lifecycle of the grant. If you have any questions, please reach out to the grants management officer listed on your notice of award.
- Grant Calendar
- Grants.gov Standard forms commonly used by the MFCUs are found at this link, including SF 424M (application for Federal assistance for non-discretionary grants); SF-424A (budget summary); and SF-425 (Federal Financial Report-FFR)
- HHS Division of Payment Management
- Certification Letters
Other Resources
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- MFCU Financial Grant Overview
- MFCU Onsite Review Process
- Cost Allocation and Indirect Cost Rates
- OIG Exclusion Program
- National Practitioner Data Bank MFCU Reporting Requirements
- State Long-Term Care Ombudsman Programs
- Statistical Sampling: A Toolkit for MFCUs
- OIG Resource Guide for Using Diagnosis Codes in Health Insurance Claims to Help Identify Unreported Abuse or Neglect
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