Medicaid Fraud Control Units: Investigation and Prosecution of Fraud and Beneficiary Abuse in Medicaid Personal Care Services

WHY WE DID THIS STUDY

OIG has conducted numerous audits, evaluations, and investigative work involving personal care services (PCS) and offered recommendations for improving program oversight. Medicaid Fraud Control Units (MFCUs or Units) investigate and prosecute Medicaid provider fraud and patient abuse or neglect under State law. We conducted this study to provide data on MFCU investigations, indictments, and convictions involving fraud and patient abuse in Medicaid PCS.

HOW WE DID THIS STUDY

We administered to MFCUs a questionnaire regarding their PCS work for fiscal years (FYs) 2012 through 2015, and we performed a quantitative and qualitative analysis of the results.

WHAT WE FOUND

During the review period, PCS fraud cases were a substantial and growing percentage of MFCU cases and outcomes. In FY 2015, fraud cases involving PCS providers or attendants constituted 12 percent of total investigations. From FY 2012 through FY 2015, fraud cases involving PCS providers or attendants constituted 38 percent of indictments and 34 percent of convictions. During this time, indictments increased 56 percent and convictions increased 33 percent.

MFCUs have made recommendations to States for strengthening PCS oversight, including that Medicaid agencies (1) enroll or register PCS attendants as Medicaid providers or assign each attendant a unique identifier; (2) require background checks for attendants; (3) institute additional documentation requirements; and (4) improve ongoing oversight of PCS providers and the services they deliver.

Finally, in MFCUs' efforts to protect beneficiaries receiving PCS services, they are constrained by their ineligibility to receive Federal funding to investigate and prosecute complaints of beneficiary abuse or neglect in nonfacility settings (such as beneficiaries' homes).

WHAT WE CONCLUDE

The volume and growth of MFCU investigations and prosecutions of PCS fraud suggest that PCS remain vulnerable to fraud and support the need for greater oversight of Medicaid PCS. CMS has made efforts in this area, but MFCUs report that States have generally not implemented the specific recommendations that MFCUs made to them for strengthening program integrity

The recommendations that MFCUs made to States align with recommendations that OIG has made previously to CMS and which OIG continues to support. In addition, to protect beneficiaries from abuse and neglect, it is key that Federal funding authority be expanded so that MFCUs can investigate and prosecute cases of patient abuse and neglect in nonfacility settings.

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