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
- 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- Archived: 42 CFR Part 1007, State Medicaid Fraud Control Units (superseded May 21, 2019)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)
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.
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)
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 has Federal grant oversight for the MFCUs, including the responsibility to certify, and annually recertify, each of them. States and territories are required to maintain a MFCU or receive a wavier from the Centers for Medicare & Medicaid Services. The District of Columbia, 50 States, and the territories of Puerto Rico and the U.S. Virgin Islands are certified to operate MFCUs.
Illinois Certification Letter
North Dakota Certification Letter
Puerto Rico Certification Letter
U.S. Virgin Islands Certification Letter
- Archive: Terms and Conditions for FY2024 MFCU Awards
- Archive: Terms and Conditions for FY2023 MFCU Awards
- Archive: Terms and Conditions for FY2022 MFCU Awards
- Archive: Terms and Conditions for FY2021 MFCU Awards
- Archive: Terms and Conditions for FY2020 MFCU Awards
- Archive: Terms and Conditions for FY2018-19 MFCU Awards
- Archive: Terms and Conditions for FY2017 MFCU Awards
- Archive: Terms and Conditions for FY2016 MFCU Awards
- Archive: Terms and Conditions for FY2015 MFCU Awards