U.S. Department of Health and Human Services 
 
Office of Inspector General 
 
 
 
Medicaid Fraud Control Units   
Fiscal Year 2020 Annual 
Report 
 
 
 
 
 
 
 
 
 
 
 
 
 Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections 
March 2021, OEI-09-21-00120 
  U.S. Department of Health and Human Services 
O  ffice of Inspector General 
 
At a Glance 
 
M arch 2021, OEI-09-21-00120 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report  
 
 
 
 
 
 
Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud and patient abuse or neglect.  The 
Department of Health and Human Services Office of Inspector General (OIG) is the designated Federal agency that oversees 
and annually approves Federal funding for MFCUs through a recertification process.  For this report, OIG analyzed the annual 
statistical data on case outcomes (such as convictions, civil settlements and judgments, and recoveries) that 53 MFCUs 
submitted to OIG for fiscal year 2020.  Those MFCUs operated in all 50 States, the District of Columbia, Puerto Rico, and the 
U. S. Virgin Islands.  In June 2020, OIG also administered a survey to all MFCUs about the effects of the COVID-19 pandemic 
on MFCU operations.    TABLE OF CONTENTS 
BACKGROUND  1 
Methodology  2 
CASE OUTCOMES  4 
MFCUs reported that the pandemic created significant challenges for staff, operations, and  4 
court proceedings, which led to lower case outcomes in FY 2020 
MFCUs reported 1,017 total convictions in FY 2020  5 
MFCUs reported criminal recoveries of $173 million in FY 2020  9 
MFCUs reported 786 civil settlements and judgments in FY 2020  9 
MFCUs reported civil recoveries of $855 million in FY 2020  10 
CONCLUSION   12 
APPENDICES   13 
A.  Office of Inspector Generals Priority Outcome: Maximizing the Effectiveness of Medicaid  13 
Fraud Control Units  
B.  Beneficial Practices Described in Office of Inspector General Inspection Reports    14 
C.  Medicaid Fraud Control Unit Case Outcomes and Open Investigation by Provider Type and  21 
Case Type for Fiscal Year 2020 
ACKNOWLEDGMENTS AND CONTACT  28 
ABOUT THE OFFICE OF INSPECTOR GENERAL  29 
ENDNOTES   30 
   
BACKGROUND 
 
 
The function of Medicaid Fraud Control Units (MFCUs or Units) is to investigate and 
prosecute Medicaid provider fraud and patient abuse or neglect.1  The Social Security 
Act (SSA) requires each State to effectively operate a MFCU, unless the Secretary of 
Health and Human Services (HHS) determines that (1) the operation of a Unit would 
not be cost-effective because minimal Medicaid fraud exists in a particular State; and 
(2) the State has other adequate safeguards to protect beneficiaries from abuse or 
neglect.2  In fiscal year (FY) 2020, all 50 States, the District of Columbia, Puerto Rico, 
and the U.S. Virgin Islands operated MFCUs.3, 4           
MFCUs are funded jointly by Federal and State Governments.  Each Unit receives a 
Federal grant award equivalent to 90 percent of total expenditures for new Units and 
75 percent for all other Units.5  In FY 2020, combined Federal and State expenditures 
for the Units totaled approximately $306 million, of which approximately $230 million 
represented Federal funds.6      
As illustrated in Exhibit 1, MFCU cases typically begin as referrals from external 
sources or are generated internally from data mining.7  MFCU staff review referrals of 
possible fraud and patient abuse or neglect to determine the potential for criminal 
prosecution and/or civil action.  If the Unit accepts a referral for investigation, the case 
may result in various possible outcomes.  Criminal prosecutions may result in 
convictions and civil actions may result in civil settlements or judgments.  Both 
criminal prosecutions and civil actions may include the assessment of monetary 
recoveries.  The Office of Inspector General (OIG) has the authority to exclude 
convicted individuals and entities from any federally funded health care program on 
the basis of convictions referred from MFCUs.8  In addition to achieving these case 
outcomes, Units may also make programmatic recommendations to their respective 
State Governments to help strengthen program integrity and efforts to fight patient 
abuse or neglect.   
Exhibit 1: The typical life cycle of a MFCU case. 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Background | 1  Oversight of the MFCU Program 
Reducing Medicaid fraud is a top priority for OIG, and its role in overseeing MFCUs 
helps achieve that priority.  OIG oversees the MFCU grant program by recertifying 
Units, conducting reviews or inspections (hereinafter referred to as inspections) of 
Units,9 providing technical assistance to Units, and monitoring key statistical data 
about Unit caseloads and outcomes.10  Further, OIG has identified enhancing 
Medicaid program integrityincluding efforts to maximize the effectiveness of 
MFCUsas an OIG Priority Outcome.  (See Appendix A for details.) 
OIG reviews each Units application for recertification annuallyOIGs approval of this 
application is necessary for the Unit to receive Federal reimbursement.11  To recertify 
a Unit, OIG performs a desk review to assess the Units compliance with the Federal 
requirements for MFCUs contained in statute, regulations, and OIG policy transmittals.  
OIG also examines the Units adherence to 12 performance standards, such as those 
regarding staffing, maintaining adequate referrals, and cooperating with Federal 
authorities.12   
OIG further assesses a Units performance by conducting inspections of Units that 
may identify findings and make recommendations for improvement.  During an 
inspection, OIG also makes observations regarding Unit operations and practices, and 
may identify beneficial practices that may be useful to other Units.  Finally, OIG 
provides training and technical assistance to Units, as appropriate.  
OIG also provides ongoing technical assistance and guidance to Units.  These 
activities may include conducting outreach, responding to questions from the Units, 
providing training to Units, and issuing policy transmittals to all Units.  OIG also 
collects and presents statistical data reported by each MFCU annually, such as the 
numbers of open cases, indictments, and convictions and amounts of recoveries.  
These data can be accessed on the OIG website in two formats: a statistical chart and 
an interactive map. 
Methodology 
For this report, we analyzed information from the FY 2020 Annual Statistical Reports 
that 53 MFCUs submitted to OIG, the recertification materials that the MFCUs 
submitted to OIG, and OIG exclusions data.  This report also includes information 
collected from a survey that OIG administered to all 53 MFCUs in June 2020 about the 
effects of the COVID-19 pandemic (pandemic) on MFCU operations.13   
We aggregated case outcomes across all Units for FY 2020 and for each of the 
preceding 4 yearsFYs 2016 through 2019.  These outcomes include convictions, civil 
settlements and judgments, and recoveries.  For convictions and recoveries, we 
calculated an average across the 5-year period of FYs 2016 through 2020.  We also 
calculated the return on investment (ROI) for MFCUs.14  We identified the provider 
types with the highest numbers of criminal and civil outcomes in FY 2020 and the 
numbers of exclusions that OIG imposed in FY 2020 on individuals and entities as a 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Background | 2  result of conviction referrals from MFCUs.  We also analyzed MFCU drug diversion 
cases using data for FYs 2016 through 2020.  Additionally, we highlight the beneficial 
practices described in each Units more recent inspections, as described in 
Appendix B.  
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of Inspectors General on Integrity and Efficiency.  
OIG inspections of the MFCUs and this annual report differ from other OIG 
evaluations in that they support OIGs direct administration of the MFCU grant 
program, but they are subject to the same internal quality controls as other OIG 
evaluations, including internal and external peer review.   
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Background | 3  CASE OUTCOMES 
MFCUs reported that the pandemic created significant 
challenges for staff, operations, and court proceedings, which 
led to lower case outcomes in FY 2020 
MFCUs that responded to OIGs June 2020 survey reported that the pandemic created 
significant challenges for staff and operations, which limited case outcomes
particularly criminal outcomes.  For example, as MFCUs initially moved to a telework 
environment, some staff reported experiencing challenges conducting work because 
of limitations with computer equipment and network infrastructure.  Field work was 
also limited.  To help protect staff and members of the public from the pandemic, 
MFCUs reported curtailing some in-person field work, such as interviews of witnesses 
and suspects.  These activities were further limited because of an initial lack of 
personal protective equipment that was needed in order to conduct similar activities 
in nursing homes and other facilities.  According to MFCUs, these cumulative 
challenges slowed the progress of investigations.   
MFCU staff also experienced challenges involving court proceedings, which often 
delayed the prosecution phase of cases.  MFCUs reported that, as a result of the 
pandemic, court systems in general had closed their in-person operations and 
postponed or reduced the number of grand jury proceedings, criminal jury trials, and 
in-person court appearances.  MFCUs reported that some court systems eventually 
began to adopt new methods to facilitate court proceedings, such as routinely using 
video conferences for hearings and limiting court appearances to certain persons, 
such as individuals that were incarcerated.  However, MFCUs reported challenges 
associated with initially transitioning to these new methods.  For example, several 
MFCUs reported challenges with presenting documentary and other evidence through 
video and remote audio technology.   
Although the pandemic had a significant effect on MFCU operations and case 
outcomes, MFCUs reported implementing steps to mitigate the pandemics impact.  
For example, MFCUs developed guidelines to ensure safe in-person interactions
both in the office and in the fieldand to ensure the use of available personal 
protective equipment.  MFCUs also developed practices for interviewing witnesses 
remotely.  To support employee-teleworking, MFCUs reported increasing 
communication among staff and management through regular video meetings, using 
shared team calendars, and having staff complete weekly activity logs.  MFCUs also 
established various approaches to gathering and using information about the 
pandemics effect on Medicaid program integrity.  Some of these approaches 
included establishing a pandemic Medicaid fraud working group, developing a 
repository for information related to the pandemic to triage allegations and efficiently 
allocate resources, and creating a mechanism for tracking pandemic outbreaks in 
nursing homes and other residential facilities.   
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 4  MFCUs reported 1,017 total convictions in FY 2020 
Total convictions resulting from MFCU cases declined from 1,527 in FY 2019 to 
1,017 in FY 2020.  In FY 2020, MFCU cases resulted in 774 convictions for fraud and 
243 convictions for patient abuse or neglect, similar to the distribution in previous 
years.  Exhibit 2 shows the total number of convictions during FYs 2016 through 2020. 
Exhibit 2: Fraud convictions accounted for about three-quarters of all 
FY 2020 convictions. 
 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20162020. 
MFCU convictions lead to the exclusion of individuals and entities from participation 
in federally funded health care programs, broadening the impact of those convictions.  
When MFCUs make referrals to OIG regarding convictions for fraud and patient abuse 
or neglect in their respective States, OIG has the authority to exclude those convicted 
individuals and entities from federally funded health care programs.  Through these 
referrals, MFCUs help ensure that individuals and entities convicted in one State are 
excluded from Medicaid programs in other States, as well as from other Federal 
programs related to health care.15   
In FY 2020, OIG imposed a total of 2,148 exclusions on individuals and entities.  MFCU 
cases were responsible for 928 of those exclusions imposed by OIG.  In addition to 
these 928 MFCU-generated exclusions, MFCUs participated in a large number of joint 
cases with the OIG Office of Investigations that also may have resulted in exclusions. 
Similar to previous years, significantly more convictions for fraud 
involved personal care services (PCS) attendants and agencies 
than any other provider type 
Compared to other provider types, PCS attendants and agencies had the highest 
number of fraud convictions each year during FYs 2016 through 2020.  
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 5  Exhibit 3 shows the number of PCS fraud convictions, as compared to total fraud 
convictions, in FYs 20162020.   
Exhibit 3: Fraud convictions involving PCS attendants and agencies 
accounted for a significant portion of total fraud convictions in                  
FYs 20162020. 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20162020. 
In FY 2020, fraud convictions involving PCS attendants and agencies accounted for 
360 of the total 774 fraud convictions (47 percent).  Additional information on the 
prevalence of Medicaid fraud involving PCS and efforts to combat such fraud can be 
found in OIGs 2020 Top Management and Performance Challenges Facing HHS (page 
14).   
Exhibit 4 shows the provider types with the most fraud convictions in FY 2020.  See 
Appendix C for detailed statistics on the number of convictions and recovery amounts 
for criminal cases, as well as MFCU caseloads and outcomes by provider type. 
 
 
 
 
 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 6  Exhibit 4: Convictions of PCS attendants and agencies for fraud were 
significantly higher than for any other provider type in FY 2020. 
          
*LPN=Licensed Practical Nurse, RN=Registered Nurse, NP=Nurse Practitioner, and PA=Physician Assistant.  
Source: OIG analysis of FY 2020 Annual Statistical Reports. 
MFCUs reported 146 convictions from drug diversion cases in 
FY 2020 
MFCU convictions related to drug diversion declined from 206 in FY 2019 to 146 in 
FY 2020, and associated criminal recoveries totaled $3.16 million in FY 2020.  In a 
Medicaid context, drug diversion cases generally involve the fraudulent billing of 
Medicaid for drugs diverted from legal and medically necessary uses, or the 
fraudulent activities by Medicaid providers related to drug diversion regardless of 
whether the Medicaid program was billed.16  MFCUs may conduct drug diversion 
investigations jointly with other State or Federal agencies, such as OIG or the U.S. 
Drug Enforcement Administration.  Exhibit 5 shows the number of convictions 
associated with drug diversion cases during FYs 2016 through 2020. 
 
 
 
 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 7  Exhibit 5: Convictions from drug diversion cases rose steadily each year 
before the pandemic. 
 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20162020. 
In FY 2020, more convictions for patient abuse or neglect 
involved nurses aides or nurses than any other provider type 
In FY 2020, convictions of nurses aides or nurses accounted for 103 of the total 
243 convictions for patient abuse or neglect (42 percent).  Exhibit 6 shows the 
provider types with the most convictions for patient abuse or neglect.   
Exhibit 6: In FY 2020, convictions of nurses aide and nurses for patient 
abuse or neglect were higher than any other provider type. 
 
*CNA=Certified Nurse Assistant.  
Source: OIG analysis of FY 2020 Annual Statistical Reports. 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 8  MFCUs reported criminal recoveries of $173 million in FY 2020 
MFCU criminal recoveries declined from $305 million in FY 2019 to $173 million in 
FY 2020.  Total criminal recoveries varied over the 5-year period ending in FY 2020.  
There was a significant spike in criminal recoveries during FY 2017, which elevated the 
average for FYs 2016 through 2020 (see Exhibit 7).  The spike in criminal recovery 
amounts in FY 2017 was a result of a single, large fraud case with a recovery amount 
totaling $268 million.17   
Exhibit 7: Criminal recoveries varied during FYs 2016 through 2020.  
 
Source: OIG analysis of Annual Statistical Reports for FYs 20162020. 
As an example of a case that resulted in criminal recoveries, the Ohio MFCU worked 
with Federal partners to prosecute six defendants for health care fraud conspiracy.  
The defendants billed Medicaid $48 million for services related to drug and alcohol 
recovery, many of which were not provided, were not medically necessary, or lacked 
proper documentation.  The court ordered the defendants to pay approximately 
$43 million in restitution, with sentences ranging from 1 year of probation to  
7.5 years in prison.18    
MFCUs reported 786 civil settlements and judgments in FY 2020 
In contrast to the decline of criminal convictions in FY 2020, the total number of civil 
settlements and judgments increased from 658 in FY 2019 to 786 in FY 2020.19  As 
shown in Exhibit 8, the total number of civil settlements and judgments increased in 
FY 2020 after a steady decline since FY 2016.  Similar to FY 2019, more civil 
settlements and judgments involved pharmaceutical manufacturers than any other 
provider type in FY 2020.  The number of pharmaceutical civil settlements and 
judgment increased in FY 2020, accounting for 263 of the 786 civil settlements and 
judgments (33 percent).   
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 9  Exhibit 8: The total number of civil settlements and judgments increased in 
FY 2020, after declining from FY 2016 to FY 2019. 
Source: OIG analysis of Annual Statistical Reports for FYs 20162020. 
Medical device manufacturers had the second-highest level of civil settlements and 
judgments (see Exhibit 9). 
Exhibit 9: Pharmaceutical manufacturers had the highest number of civil 
settlements and judgments in FY 2020, followed by medical device 
manufacturers.  
 
*DMEPOS=Durable Medical Equipment, Prosthetics, Orthotics and Supplies.  
Source: OIG analysis of FY 2020 Annual Statistical Reports. 
MFCUs reported civil recoveries of $855 million in FY 2020 
In FY 2020, civil recoveries decreased by 48 percent, from $1.6 billion in FY 2019 to 
$855 million.  As shown in Exhibit 10, civil recoveries were substantially higher in 
FY 2016 and FY 2019, relative to other years.20  In FY 2016, over half of the civil 
recoveries were attributable to two global cases that totaled $982 million.  In FY 2019, 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 10  two global cases accounted for a significant portion of the civil recoveries and totaled 
more than $1.3 billion.   
Exhibit 10: Civil recoveries in FY 2020 were slightly lower than the average 
for FYs 2016-2020. 
Large monetary settlements or judgments may contribute to annual variability. 
     
 
Note: Dollar values are rounded to the nearest tenth.  
Source: OIG analysis of Annual Statistical Reports for FYs 2016-2020. 
 
 
The distribution of global and nonglobal cases in 
Types of Civil Cases 
FY 2020 remained similar to the distribution of  
A global case involves both the 
FY 2019.  Approximately $637 million (or 
Federal Government and a group 
74 percent) of the $855 million in civil recoveries 
of States and is coordinated by 
derived from global cases.21  The remaining  
the National Association of 
$218 million (26 percent) derived from nonglobal 
Medicaid Fraud Control Units.  
cases.   
A nonglobal case is conducted by 
In one global case involving a pharmaceutical  a Unitindividually or with other 
law enforcement partnersand is 
manufacturer, 28 States partnered with Federal 
not coordinated by the National 
agencies to pursue allegations that the 
Association of Medicaid Fraud 
pharmaceutical manufacturer provided kickbacks 
Control Units. 
to health care practitioners in exchange for 
prescribing medications that treat hypertension or Type 2 Diabetes.  As a result of the 
investigation, the pharmaceutical manufacturer agreed to pay a total of  
$678 million$103 million of which was related to State Medicaid programs.22 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Case Outcomes | 11   
CONCLUSION  
 
 
The pandemic created significant challenges for MFCU staff, operations, and court 
proceedings.  However, MFCUs reported taking steps to mitigate the effects of the 
pandemic and, despite challenges, continued to carry out their Medicaid program 
integrity functions in FY 2020.  Overall, MFCUs efforts in FY 2020 contributed to total 
recoveries of $1 billion, with an ROI of $3.36 for every $1 spent.   
MFCUs reported implementing practices to address the challenges caused by the 
pandemic, a few of which we highlight in the Case Outcomes section in this report.  
As in past MFCU annual reports, Appendix B describes the many beneficial practices 
implemented by the MFCUs identified by OIG during our inspections, which other 
MFCUs may want to consider for adoption.  Beneficial practices from inspection 
reports published in FY 2020 include the following:   
  Designating staff as subject matter experts: The Arkansas Unit director 
designated Unit investigators as subject matter experts of specific, common 
provider types for efficient assignment and improved investigation of cases. 
  Creating in-house training videos: The Missouri Units Chief Auditor created 
in-house training videos for Unit investigators and attorneys.  The videos 
contained step-by-step tutorials for creating and using investigative and trial 
tools. 
  Participating in an Elder Abuse Task Force to provide training to law 
enforcement and first responders: To encourage referrals, the Montana Unit 
regularly trained cadets at the Montana Law Enforcement Academy and 
trained other law enforcement and first responder personnel through its 
participation in the Montana Elder Abuse Task Force.  The training focused on 
the Units mission and how the Unit can assist with crimes that law 
enforcement personnel and first responders might encounter.   
In addition to identifying beneficial practices to spur continued improvement, OIG 
annually recognizes the efforts of one MFCU with the Inspector Generals Award for 
Excellence in Fighting Fraud, Waste, and Abuse.  In 2021, the Maine MFCU received 
this award for its high number of case outcomes across a mix of case types, excellent 
partnership with OIG and other Federal partners, and active participation in the 
National Association of Medicaid Fraud Control Units activities.
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Conclusion | 12   
APPENDIX A 
 
Office of Inspector Generals Priority Outcome: Maximizing the 
Effectiveness of Medicaid Fraud Control Units  
It is a top OIG priority to strengthen the effectiveness of MFCUs as key partners in combating fraud and 
abuse.  As part of its oversight, OIG strives to support the MFCUs in ways that maximize their 
effectiveness.  Over the past few years, OIG has engaged in numerous actions to help drive MFCU 
effectiveness.  These include activities in five categories: (1) enhancing OIG oversight; (2) increasing the 
use of data; (3) expanding the MFCU program to better align with a growing and evolving Medicaid 
program; (4) enhancing MFCU training where it can be of greatest assistance to MFCUs; and  
(5) increasing collaboration between MFCUs and OIG.   
To assess the impact of these efforts, OIG has established two key performance indicators:  
(1) indictment rate and (2) conviction rate.  The table below shows these rates for FYs 2016 through 
2020 and the targets that OIG aims to achieve in FYs 2021 through 2022.    
Key Performance  FY 2016  FY 2017  FY 2018  FY 2019  FY 2020  FY 2021  FY 2022 
Indicators  (actual)  (actual)  (actual)  (actual)  (actual)  Target  Target 
Indictment Rate  16.3%  17.2%  16.7%  18.8%  17.2%  19.0%  18.4% 
Conviction Rate  89.6%  88.7%  89.8%  90.3%  87.7%  89.1%  89.0% 
 
Calculations:  
Indictment rate = (total number of criminal cases with indictments or charges 
plus number of nonglobal civil cases open, filed, or referred for filing) 
divided by 
(total number of open cases) 
 
  Conviction rate = (total number of criminal cases resulting in a defendant convicted) 
divided by 
(total  number  of  cases  resulting  in  a  defendant  acquitted,  dismissed,  or 
convicted)   
 
To calculate these measures, OIG aggregates data that Units submit through Annual Statistical 
Reports. 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix A | 13   
APPENDIX B 
 
Beneficial Practices Described in Office of Inspector General 
Inspection Reports   
This appendix summarizes MFCU practices that OIG has highlighted as being beneficial to Unit 
operations.  Other Units should consider whether adopting similar practices in their States may yield 
similar benefits.   
All of OIGs MFCU reports are available at https://oig.hhs.gov/reports-and-
publications/oei/m.asp#mfcu.     
A Unit takes steps to maintain an adequate volume and quality of referrals 
STANDARD 4  
from the State Medicaid agency and other sources. 
Arizona  Engaging with Medicaid partners and providing guidance to ensure quality 
OEI-07-15-00280  referrals: MFCU staff attended quarterly meetings with the State Medicaid 
December 2015  agency and Managed Care Organizations (MCOs).  These meetings provided 
guidance to MCOs about what constitutes a quality referral and the types of 
referrals that will result in the Unit opening a case for investigation. 
California  Providing training to MCO representatives to increase fraud referrals: The 
OEI-09-15-00070  Unit provided quarterly training for MCO representatives that resulted in 
February 2016  increased fraud referrals from MCOs to the Unit. 
 
Hiring an outreach liaison to increase referrals: The Unit hired a field 
representative to provide outreach and increase the number of fraud referrals 
sent to the Unit.  The field representative acted as a liaison between the Unit 
and other State agencies, and trained staff from these agencies about Medicaid 
fraud and the Units role in combating fraud and patient abuse or neglect by 
providers. 
Kansas  Supplementing reviews of referrals for patient abuse or neglect and 
OEI-12-18-00210  enhancing referral coordination: The Units nurse investigator reviewed 
July 2019  complaints about patient abuse or neglect that had been previously closed by 
the States survey and certification agency to determine whether the complaints 
warranted further investigation.  In addition, the nurse investigator arranged for 
the Unit to receive complaints of patient abuse or neglect at the same time the 
States survey and certification agency sent the complaints to local law 
enforcement agencies.  After reviewing the complaints, the nurse investigator 
contacted the law enforcement agencies to help determine whether further 
investigation by those agencies or the Unit was warranted.       
  continued on the next page 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 14  Beneficial Practices Described in Office of Inspector General 
Inspection Reports (continued) 
A Unit takes steps to maintain an adequate volume and quality of referrals 
STANDARD 4  
from the State Medicaid agency and other sources. (continued) 
Kentucky  Engaging with Medicaid partners to encourage fraud referrals and enhance 
OEI-06-17-00030  collaboration: The Unit regularly met with the State Medicaid agency, other 
September 2017  State agencies, and MCOs to encourage fraud referrals and improve 
communication and collaboration.  The results included improved quality, 
completeness, and timeliness of fraud referrals. 
Michigan  Co-developing a streamlined process for referring patient abuse or neglect 
OEI-09-13-00070  cases with a State licensing agency: Unit management and the Michigan 
January 2014  Department of Licensing and Regulatory Affairs developed a streamlined 
process for referring cases of patient abuse or neglect.  This process helped to 
ensure that referrals from the Department of Licensing and Regulatory Affairs 
were consistent with the Units statutory functions, thereby promoting Unit 
efficiency. 
Montana  Participating in an Elder Abuse Task Force to provide training to law 
OEI-12-19-00170  enforcement and first responders: To encourage referrals, the Unit regularly 
March 2020  trained cadets at the Montana Law Enforcement Academy and trained other 
law enforcement and first responder personnel through its participation in the 
Montana Elder Abuse Task Force.  The training focused on the Units mission 
and how the Unit can assist with crimes that law enforcement personnel and 
first responders might encounter.   
New York  Establishing data analytics working groups to improve the Units ability to 
OEI-12-17-00340  data mine: The Unit established data analytics working groups to provide 
September 2018  guidance, training, and an assessment of the Units data mining efforts.  The 
groups include the Data Analytics Tool Group, the Data Sources Groups, the 
Fraud and Abuse Group, and the Governance Group.   
New Mexico  Co-developing a referral process with the State Medicaid agency to ensure 
OEI-09-14-00240  receipt of referrals: Unit management and the State Medicaid agency worked 
February 2015  closely to develop and implement an improved referral process that ensures 
that the Unit receives all appropriate fraud referrals generated by MCOs. 
Ohio  Establishing a program integrity group comprised of personnel from other 
OEI-07-14-00290  Medicaid program integrity entities: The Unit established the Ohio Program 
April 2015  Integrity Group, which combines the knowledge and resources of all the State 
agencies that are responsible for Medicaid program integrity.  In addition, the 
Unit spearheaded the Managed Care Program Integrity Group, which meets 
quarterly. 
  continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 15  Beneficial Practices Described in Office of Inspector General 
Inspection Reports (continued) 
A Unit takes steps to maintain an adequate volume and quality of referrals 
STANDARD 4  
from the State Medicaid agency and other sources. (continued) 
Oregon  Establishing an outreach group to increase referrals for patient abuse or 
OEI-09-16-00200  neglect cases from broader areas of the State: The Unit created a group that 
December 2016  provided outreach to help increase referrals for patient abuse or neglect and 
facilitate Unit work in broader areas of the State.  This group provided outreach 
about the Units mission and legal authorities by establishing Unit liaisons for 
each county in Oregon and attending multidisciplinary team meetings at the 
county level. 
South Dakota  Having providers teach their peers about implications of Medicaid fraud: 
OEI-07-16-00170  The Unit used providers who had previously been investigated for Medicaid 
September 2016  fraud to educate their peers.  These providers gave presentations alongside 
Unit staff at training conferencesthis helped to highlight Medicaid billing 
issues and the implications of Medicaid fraud. 
Washington  Revising its MOU and contracts with State Medicaid partners to ensure the 
OEI-09-16-00010  receipt of fraud referrals from MCOs: The Unit worked with the State 
September 2016  Medicaid agency to revise both the memorandum of understanding between 
the Unit and the agency and the agencys contracts with MCOs to ensure that 
the Unit received copies of all fraud referrals from MCOs. 
A Unit takes steps to maintain a continuous case flow and to complete 
STANDARD 5 
cases in an appropriate timeframe based on the complexity of the cases.  
Arkansas  Designating staff as subject matter experts: The Unit director designated Unit 
OEI-12-19-00450  investigators as subject matter experts of specific, common provider types for 
September 2020  efficient assignment and improved investigation of cases. 
New York  Developing a strategic plan to optimize and prioritize resources: The Unit 
OEI-12-17-00340  developed a written strategic plan to help Unit staff make informed decisions 
September 2018  regarding the optimal use of resources.  The plan provides guidance to 
prioritize certain types of investigations, such as criminal investigations that are 
related to systematic patient abuse and neglect, fraud allegations against 
managed care companies, and fraud investigations of large providers.  The plan 
also establishes a priority for false claims investigations with higher potential for 
monetary recoveries or risk of patient harm. 
Ohio  Establishing a technical support team: The Unit employed a special projects 
OEI-07-14-00290  team to provide technical support to all its investigative teams. 
April 2015 
  continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 16  Beneficial Practices Described in Office of Inspector General 
Inspection Reports (continued) 
A Unit maintains case files in an effective manner and develops a case 
STANDARD 7  management system that allows efficient access to case information and 
other performance data. 
Massachusetts   Using an intranet system to streamline case management: The Unit used its 
OEI-07-15-00390  intranet system to streamline its administrative processes, such as periodic 
June 2016  supervisory reviews of case files.  The Unit found that this helped improve case 
  management and the effectiveness of investigations and prosecutions. 
A Unit cooperates with OIG and other Federal agencies in the 
STANDARD 8 
investigation and prosecution of Medicaid and other health care fraud. 
Alaska  Improving communication with stakeholders to increase joint cases with 
OEI-09-16-00430  Federal partners: Unit stakeholders reported that the MFCU Director made 
September 2017  efforts to improve communication with agencies such as OIG and the State 
  Medicaid agency.  As a result, the number of joint OIG-MFCU cases tripled from 
FY 2012 to FY 2015.  Also, the Unit collaborated with Federal and State partners 
to investigate allegations of PCS fraud that led to convictions and significant 
monetary recoveries. 
California  Co-locating Unit and OIG staff to facilitate referrals and communication: 
OEI-09-15-00070  Unit investigators have workstations at an OIG field officethis facilitated the 
February 2016  mutual referral of cases and improved communication and cooperation with 
OIG on joint cases. 
Florida  Co-locating Unit and OIG staff to improve cooperation on joint cases: Unit 
OEI-07-15-00340  staff have workstations at an OIG field officethis improved communication 
June 2016  and cooperation with OIG on joint cases, including fraud cases generated 
through the U.S. Department of Justice (DOJ) Medicare Strike Force. 
Idaho   Monitoring media sources to report convictions of providers to OIG: The 
OEI-12-18-00320  Units legal secretary monitored media sources for convictions of patient 
August 2019  abuse and neglect cases.  Although the convictions were a result of 
investigations by local authorities and not the Unit, the legal secretary 
reviewed the conviction information and submitted the police reports and 
court documents to OIG.  As a result of those efforts, OIG has excluded seven 
individuals from federally funded health programs. 
Massachusetts   Developing partnerships with law enforcement and clinical experts to 
OEI-07-15-00390  investigate drug cases: The Unit developed partnerships with other State and 
June 2016  Federal agencies and used clinical experts to facilitate the investigation and 
  prosecution of drug diversion and pharmaceutical cases. 
  continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 17  Beneficial Practices Described in Office of Inspector General 
Inspection Reports (continued) 
A Unit cooperates with OIG and other Federal agencies in the 
STANDARD 8  investigation and prosecution of Medicaid and other health care fraud. 
(continued) 
Virginia  Developing partnerships with agencies composed of diverse professional 
OEI-07-15-00290  disciplines: The Units partnerships with the Food and Drug Administration, the 
August 2016  Internal Revenue Service, and the Social Security Administration led to 
successful Medicaid fraud prosecutions, particularly with regard to 
pharmaceutical manufacturers, and increased Unit recoveries. 
A Unit makes statutory or programmatic recommendations, when 
STANDARD 9 
warranted, to the State government.  
Alaska  Making program integrity recommendations to fight PCS fraud: The Unit 
OEI-09-16-00430  made program integrity recommendations to safeguard against PCS provider 
September 2017  fraud, and worked with the State Medicaid agency to implement these 
recommendations. 
Minnesota   Developing legislation to protect Medicaid beneficiaries from abuse: The 
OEI-06-13-00200  Unit helped develop legislation to protect Medicaid beneficiaries by 
March 2014  strengthening background checks for individuals who serve as guardians and 
conservators of Medicaid beneficiaries. 
New Mexico  Partnering with the Medicaid agency to revise MCO contracts and improve 
OEI-09-14-00240  referral coordination: The Unit consistently provided program integrity 
February 2015  recommendations to the State Medicaid agency during quarterly joint protocol 
meetings.  One of these recommendations resulted in the inclusion of language 
in MCO contracts that clarified the State Medicaid agency role in referring to 
the MFCU all verified allegations of fraud, waste, or abuse in a managed care 
setting. 
Washington  Using information from a case closure form to make program integrity 
OEI-09-16-00010  recommendations to State agencies: The Unit used a case closure form to 
September 2016  make numerous program integrity recommendations to State agencies and 
tracked the responses to these recommendations in a database. 
STANDARD 12   A Unit conducts training that aids in the mission of the Unit. 
Kentucky  Implementing a mentoring program to develop Unit attorneys: The Unit 
OEI-06-17-00030  created an executive advisor position to help Unit attorneys develop litigation 
September 2017  skills.  The executive advisor also mentored new attorneys and served as a 
cochair on Unit prosecutions. 
  continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 18  Beneficial Practices Described in Office of Inspector General 
Inspection Reports (continued) 
STANDARD 12   A Unit conducts training that aids in the mission of the Unit. (continued) 
Maryland  Developing an internal boot camp to train new staff: The Unit developed an 
OEI-07-16-00140  internal boot camp training program that helped new staff develop a full 
September 2016  understanding of the Units work.  Experienced MFCU staff gave 1- to 2-hour 
lectures on topics such as civil and criminal investigation procedures, 
interviewing techniques, and understanding medical codes.   
Missouri  Creating in-house training videos: The Units Chief Auditor created in-house 
OEI-12-18-00490  training videos for Unit investigators and attorneys.  The videos contained step-
January 2020  by-step tutorials for creating and using investigative and trial tools. 
New York  Using a moot-court approach for training attorneys: The Unit used moot-
OEI-12-17-00340  court training to train Unit attorneys.  This training helped the Unit attorneys 
September 2018  practice opening arguments to prepare for trial. 
North Carolina  Partnering with another State agency to establish an academy for financial 
OEI-07-16-00070  investigators: The Unit partnered with another State agency to create the 
September 2016  North Carolina Financial Investigators Academy.  The academy provided 
instruction to financial investigators on topics such as elements of criminal law, 
search and seizure procedures, interviewing, and testifying.  The Unit required 
all its newly hired financial investigators to attend the academy, regardless of 
previous experience. 
Wyoming  Using staff from another MFCU to train a new investigator: The Unit used a 
OEI-09-16-00530  MFCU investigator from a neighboring State to help train its newly hired 
September 2017  investigator.  As part of the training, the newly hired investigator observed work 
on active Medicaid fraud cases and met with the MFCUs management and 
attorneys from the neighboring State to discuss progress.  This was a cost-
effective training option for the Unit and furthered a positive working 
relationship with the neighboring MFCU. 
  continued on the next page 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 19  Beneficial Practices Described in Office of Inspector General 
Inspection Reports (continued) 
Beneficial practices not relating directly to a specific performance 
OTHER  
standard. 
Vermont  Co-developing provider focus teams with the State Medicaid agency to 
OEI-02-13-00360  improve program integrity: The Unit director created provider focus teams in 
December 2013  collaboration with the State Medicaid agency.  These teams facilitated existing 
cases, developed training for providers, and made program recommendations.   
 
Co-developing a working group with State and Federal partners to improve 
health care for the elderly: The Unit director helped create the Vermont Elder 
Justice Working Group, which consisted of representatives from State and 
Federal advocacy groups, regulatory agencies, and law enforcement agencies.  
The groups mission was to improve health care for the elderly living in long-
term care facilities by improving communication among stakeholders and law 
enforcement agencies. 
Virginia  Using specialty software to better analyze, maintain, and share 
OEI-07-15-00290  documentary evidence: The Unit used specialty software designed to read the 
August 2016  text in a document, analyze it for keywords, and systematically code it 
according to criteria established by an analyst.  This improved the Units abilities 
to process and track evidence collected during investigations and to share that 
evidence with Federal and State partners working on joint cases. 
   
 
 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix B | 20   
APPENDIX C 
 
Medicaid Fraud Control Unit Case Outcomes and Open Investigations 
by Provider Type and Case Type for Fiscal Year 2020 
Exhibit C1: Number of convictions, settlements and judgments, and recoveries by provider type and 
case type 
  CRIMINAL  CIVIL 
Settlements 
Amount of  and  Amount of 
PROVIDER TYPE  Convictions  Recoveries  Judgments  Recoveries 
Patient Abuse or Neglect 
Assisted Living Facility  8  $45,093  1  $4,788 
Developmental Disability Facility  10  $13,956  1  $0 
Hospice  0  $0  0  $0 
Nondirect Care Staff  10  $79,421  0  $0 
Nurse Aide (CNA or Other)  56  $282,430  0  $0 
Nursing Facilities  11  $55,069  9  $1,366,143 
Nurse (LPN, RN, or NP) or Physician  47  $59,574  0  $0 
Assistant  
Personal Care Aide or Other Home  39  $323,264  0  $0 
Care Aide 
Other  62  $1,485,814  1  $144,440 
FraudFacility-Based Medicaid Providers and ProgramsInpatient and/or Residential 
Assisted Living Facility  1  $1,147,322  2  $577,506 
Developmental Disability Facility  1  $37,075  0  $0 
(Residential)  
Hospice   2  $347,035  2  $1,282,364 
Hospital  10  $23,679,690  44  $50,697,061 
Inpatient Psychiatric Services for  0  $0  12  $20,163,475 
Individuals under Age 21 
Nursing Facility  1  $0  9  $23,895,840 
Other Inpatient Mental Health Facility  0  $0  23  $10,336,054 
Other Long-Term Care Facility  0  $0  4  $423,604 
continued on the next page 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 21 
  Number of convictions, settlements and judgments, and recoveries by provider type and case type 
(continued) 
  CRIMINAL  CIVIL 
Settlements 
Amount of  and  Amount of 
PROVIDER TYPE  Convictions  Recoveries  Judgments  Recoveries 
FraudFacility-Based Medicaid Providers and ProgramsOutpatient and/or Day Services 
Adult Day Center  1  $32,633  4  $661,119 
Ambulatory Surgical Center   0  $0  1  $5,613 
Developmental Disability Facility  2  $68,425  2  $40,349 
(Nonresidential)  
Dialysis Center   0  $0  0  $0 
Mental Health Facility (Nonresidential)   21  $10,255,952  11  $17,373,695 
Substance Abuse Treatment Center   9  $24,799,396  7  $4,738,537 
Other Facility (Nonresidential)   8  $1,911,689  7  $3,993,545 
FraudLicensed Practitioners 
Audiologist   0  $0  0  $0 
Chiropractor   1  $100,180  1  $30,418 
Clinical Social Worker   10  $1,943,242  4  $628,193 
Dental Hygienist   0  $0  3  $131,154 
Dentist   13  $2,560,572  18  $4,932,636 
Nurse (LPN, RN, or Other Licensed)  52  $1,161,395  6  $246,432 
Nurse Practitioner   9  $7,170,015  1  $11,156 
Optometrist   1  $95,000  1  $6,073 
Pharmacist   11  $7,074,522  1  $171,713 
Physician Assistant   2  $2,390  0  $0 
Podiatrist   1  $57,240  1  $366,125 
Psychologist   7  $1,378,172  2  $43,511 
Therapist (Non-Mental Health, PT, ST,  7  $1,151,551  3  $96,118 
OT, or RT) 
Other Practitioner  12  $911,342  9  $742,815 
FraudMedical Services 
Ambulance   2  $851,987  1  $385,000 
Billing Services  4  $1,193,307  7  $3,156,236 
continued on the next page 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 22 
  Number of convictions, settlements and judgments, and recoveries by provider type and case type 
(continued) 
  CRIMINAL  CIVIL 
Settlements 
Amount of  and  Amount of 
PROVIDER TYPE  Convictions  Recoveries  Judgments  Recoveries 
FraudMedical Services (continued) 
Home Health Agency   21  $4,948,195  9  $15,195,008 
Lab (Clinical)  0  $0  19  $4,133,672 
Lab (Radiology and Physiology)   0  $0  2  $16,176 
Lab (Other)  1  $257,500  4  $1,882,218 
Medical Device Manufacturer   0  $0  54  $3,123,112 
Pain Management Clinic   2  $1,331,324  7  $4,274,810 
Personal Care Services Agency  21  $4,700,311  7  $3,190,996 
Pharmaceutical Manufacturer   0  $0  263  $549,147,525 
Pharmacy (Hospital)   0  $0  0  $0 
Pharmacy (Institutional Wholesale)   0  $0  6  $6,710,024 
Pharmacy (Retail)   17  $6,573,002  34  $20,366,201 
Suppliers of Durable Medical  5  $4,214,477  45  $2,567,637 
Equipment, Prosthetics, Orthotics, and 
Supplies (DMEPOS) 
Transportation (Nonemergency)  20  $7,192,516  7  $11,672,105 
Other  8  $399,633  42  $15,329,992 
FraudOther Individual Providers 
Emergency Medical Technician or  1  $3,604  0  $0 
Paramedic 
Nurses Aide (CNA or Other)  11  $33,224  0  $0 
Optician   0  $0  1  $263,489 
Personal Care Services Attendant   339  $6,065,610  10  $48,663 
Pharmacy Technician   4  $201,747  0  $0 
Unlicensed Counselor (Mental Health)   11  $1,232,139  2  $59,000 
Unlicensed Therapist (Non-Mental  2  $4,367  0  $0 
Health) 
Other  53  $12,900,713  2  $9,099 
continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 23 
  Number of convictions, settlements and judgments, and recoveries by provider type and case type 
(continued) 
  CRIMINAL  CIVIL 
Settlements 
Amount of  and  Amount of 
PROVIDER TYPE  Convictions  Recoveries  Judgments  Recoveries 
FraudPhysicians (MD/DO) by Medical Specialty 
Allergist/Immunologist  0  $0  0  $0 
Cardiologist  1  $9,662  2  $1,154,369 
Emergency Medicine  4  $5,405  0  $0 
Family Practice   22  $27,154,788  11  $3,550,748 
Geriatrician   0  $0  0  $0 
Internal Medicine   11  $1,895,411  5  $1,129,229 
Neurologist   1  $3,100  1  $253,273 
Obstetrician/Gynecologist   2  $25,864  3  $252,725 
Ophthalmologist   1  $24  3  $1,540,423 
Pediatrician   2  $72,555  1  $50,000 
Physical Medicine and Rehabilitation   1  $48,030  1  $2,007,377 
Psychiatrist   4  $531,104  6  $1,523,751 
Radiologist   0  $0  0  $0 
Surgeon   0  $0  2  $348,130 
Urologist   0  $0  1  $150,000 
Other MD/DO   16  $3,081,223  7  $1,700,435 
FraudProgram Related 
Managed Care Organization (MCO)   0  $0  21  $48,728,862 
Medicaid Program Administration   0  $0  0  $0 
Other  5  $34,336  10  $7,770,320 
TOTAL  1,017  $173,194,614  786  $854,801,084 
 
 
 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 24 
  Exhibit C2: Number of open investigations at the end of FY 2020 by provider type and case type 
  OPEN INVESTIGATIONS 
PROVIDER TYPE    Criminal  Civil  Total 
Patient Abuse or Neglect 
Assisted Living Facility  241  6  247 
Developmental Disability Facility   161  5  166 
Hospice   3  0  3 
Nondirect Care Staff  126  0  126 
Nurse Aide (CNA or Other)  426  5  431 
Nursing Facilities   863  52  915 
Nurse (RN, LPN, or NP) or Physician Assistant   313  1  314 
Personal Care Aide or Other Home Care Aide   270  0  270 
Other  843  6  849 
FraudFacility-Based Medicaid Providers and ProgramsInpatient and/or Residential 
Assisted Living Facility  57  11  68 
Developmental Disability Facility (Residential)  41  6  47 
Hospice  76  34  110 
Hospital   75  202  277 
Inpatient Psychiatric Services for Individuals under  11  12  23 
Age 21  
Nursing Facility  136  209  345 
Other Inpatient Mental Health Facility  19  39  58 
Other Long-Term Care Facility  29  29  58 
FraudFacility-Based Medicaid Providers and ProgramsOutpatient and/or Day Services 
Adult Day Center   76  4  80 
Ambulatory Surgical Center   3  8  11 
Developmental Disability Facility (Nonresidential)   31  14  45 
Dialysis Center   0  68  68 
Mental Health Facility (Nonresidential)   354  59  413 
Substance Abuse Treatment Center   140  51  191 
Other Facility (Nonresidential)   103  66  169 
continued on the next page 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 25 
  Exhibit C2: Number of open investigations at the end of FY 2020 by provider type and case type 
(continued) 
  OPEN INVESTIGATIONS 
PROVIDER TYPE    Criminal  Civil  Total 
FraudLicensed Practitioners 
Audiologist   6  2  8 
Chiropractor   26  6  32 
Clinical Social Worker   80  6  86 
Dental Hygienist   2  3  5 
Dentist   309  52  361 
Nurse (LPN, RN, or Other Licensed)  491  7  498 
Nurse Practitioner   83  5  88 
Optometrist   33  9  42 
Pharmacist   62  23  85 
Physician Assistant   31  0  31 
Podiatrist   27  10  37 
Psychologist   61  17  78 
Therapist (Non-Mental Health, PT, ST, OT, or RT)  92  32  124 
Other Practitioner   132  15  147 
FraudMedical Services 
Ambulance   60  42  102 
Billing Services   31  79  110 
Home Health Agency   674  130  804 
Lab (Clinical)   104  490  594 
Lab (Radiology and Physiology)   22  41  63 
Lab (Other)  36  193  229 
Medical Device Manufacturer   4  666  670 
Pain Management Clinic   57  21  78 
Personal Care Services Agency   197  10  207 
Pharmaceutical Manufacturer   161  2,690  2,851 
Pharmacy (Hospital)   1  4  5 
Pharmacy (Institutional Wholesale)   11  227  238 
Pharmacy (Retail)   320  911  1,231 
Transportation (Nonemergency)  254  25  279 
Suppliers of Durable Medical Equipment, Prosthetics,  177  569  746 
Orthotics, and Supplies (DMEPOS) 
Other  79  341  420 
continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 26 
   
Exhibit C2: Number of open investigations at the end of FY 2020 by provider type and case type 
(continued) 
  OPEN INVESTIGATIONS 
PROVIDER TYPE    Criminal  Civil  Total 
FraudOther Individual Providers 
Emergency Medical Technician or Paramedic   3  1  4 
Nurse Aide (CNA or Other)  72  1  73 
Optician   1  6  7 
Personal Care Services Attendant   1,719  16  1,735 
Pharmacy Technician   21  0  21 
Unlicensed Counselor (Mental Health)   69  5  74 
Unlicensed Therapist (Non-Mental Health)   6  1  7 
Other  441  48  489 
FraudPhysicians (MD/DO) by Medical Specialty 
Allergist/Immunologist   8  3  11 
Cardiologist   15  13  28 
Emergency Medicine   17  26  43 
Family Practice   277  31  308 
Geriatrician   1  0  1 
Internal Medicine   147  23  170 
Neurologist   29  4  33 
Obstetrician/Gynecologist  26  5  31 
Ophthalmologist   17  12  29 
Pediatrician   46  8  54 
Physical Medicine and Rehabilitation   32  13  45 
Psychiatrist   87  18  105 
Radiologist   9  17  26 
Surgeon   32  13  45 
Urologist   3  3  6 
Other MD/DO  338  82  420 
FraudProgram Related 
Managed Care Organization (MCO)  22  84  106 
Medicaid Program Administration   23  11  34 
Other  164  118  282 
Total  11,645  8,075  19,720 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Appendix C | 27 
   
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Matt DeFraga served as the team leader for this study, and Kira Evsanaa served as the 
lead analyst.  Office of Evaluation and Inspections (OEI) staff who provided support 
include Susan Burbach, Jordan Clementi, Kevin Farber, Christina Lester, Petra Nealy, 
and Keith Peters. 
We would also like to acknowledge the contributions of other Office of Inspector 
General (OIG) staff, including Alexis Crowley, Lonie Kim, Tracy Meder, Jessica 
Swanstrom, and Angela Tvarozek.   
This report was prepared under the direction of Blaine Collins, Regional Inspector 
General for Evaluation and Inspections in the San Francisco regional office, and Abby 
Amoroso and Michael Henry, Deputy Regional Inspectors General, in consultation 
with Richard Stern, Director of the Medicaid Fraud Policy and Oversight Division. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC  20201 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Acknowledgments and Contact | 28   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network 
of audits, investigations, and inspections conducted by the following operating 
components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  About OIG | 29   
ENDNOTES 
 
 
 
1 Social Security Act (SSA)  1903(q)(3)(4).  Regulations at 42 CFR  1007.11(b)(1) add that a Units responsibilities may include 
reviewing complaints of misappropriation of patients private funds in residential health care facilities.  Unit investigations of 
patient abuse and neglect are limited to incidents occurring in (1) health care facilities that receive Medicaid payments and 
(2) board and care facilities, which are residential settings that receive payments on behalf of two or more unrelated adults 
who reside in the facility and receive nursing care services or a substantial amount of personal care services (PCS).  SSA  
1903(q)(4).  As of December 27, 2020, MFCUs may also receive Federal financial participation to investigate and prosecute 
abuse or neglect of Medicaid beneficiaries in a noninstitutional or other setting.  Consolidated Appropriations Act, 2021, P.L. 
No. 116-260, Division CC,  207. 
2 SSA  1902(a)(61). 
3 The SSA authorizes the Secretary of HHS to award grants (SSA  1903(a)(6)) and to certify and annually recertify Units (SSA  
1903(q)).  The Secretary delegated this authority to OIG.  See also 42 CFR  1007.15.  Units must meet several requirements 
established by the SSA and Federal regulations.  For example, each Unit must (1) be a single, identifiable entity of State 
Government, separate and distinct from the State Medicaid agency (SSA  1903(q)(2); 42 CFR  1007.5(a) and 1007.9(a)); (2) 
employ an interdisciplinary staff that consists of at least an investigator, an auditor, and an attorney (SSA  1903(q)(6); 42 CFR  
1007.13); (3) develop a formal agreement, such as a memorandum of understanding, describing the Units relationship with the 
State Medicaid agency (42 CFR  1007.9(d)); and (4) have either statewide authority to prosecute cases or formal procedures to 
refer suspected criminal violations to an agency with such authority (SSA  1903(q)(1); 42 CFR  1007.7).  
4 The territories of American Samoa, Guam, and the Northern Mariana Islands have not established Units.  Puerto Rico and the 
U.S. Virgin Islands received certification to operate in FY 2019 and North Dakota received certification to operate in FY 2020.   
5 SSA  1903(a)(6).  For a Units first 3 years of operation, the Federal Government contributes 90 percent of funding and the 
State contributes 10 percent.  Thereafter, the Federal Government contributes 75 percent and the State contributes 25 percent. 
6 OIGs analysis of MFCU Annual Statistical Reports from FY 2020. 
7 42 CFR  1007.20.  MFCUs must receive approval from OIG to conduct data mining.  As of February 2021, 21 MFCUs were 
approved for data mining.  OIG, Data Mining Applications, https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/data-
mining.asp.  Accessed on February 2, 2021. 
8 SSA  1128; 42 U.S.C.  1320a-7.  See also OIG, Background Information, https://oig.hhs.gov/exclusions/background.asp.  
Accessed on March 12, 2021. 
9 These inspections were conducted onsite before the COVID-19 pandemic.  Because of the pandemic, OIG has since 
conducted inspections in a remote, virtual format. 
10 OIG provides information on MFCU operations and outcomes but does not direct or encourage MFCUs to investigate or 
prosecute a specific number of cases.  MFCU investigators and prosecutors should apply professional judgment and discretion 
in determining what criminal and civil cases to pursue. 
11 42 CFR  1007.15. 
12 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).   
13 The survey collected information about (1) operational challenges that the MFCUs may have encountered during the 
pandemic, (2) how MFCUs addressed those challenges, and (3) practices that helped MFCUs address those challenges.  In 
addition, the survey collected information from MFCUs about their broader needs for training.  
 
 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Endnotes | 30 
   
 
14 To calculate the ROI for MFCUs, we first calculated the total recoveries by adding the $173 million in criminal case recoveries 
to the $855 million in civil case recoveries.  We then divided the $1 billion in total recoveries by the total MFCU grant 
expenditures of $306 million, resulting in the overall ROI of $3.36 for every $1 spent. 
15 OIG, LEIE Downloadable Databases, https://oig.hhs.gov/exclusions/exclusions_list.asp.  Accessed on January 22, 2021.  The list 
of OIG-excluded individuals or entities can be found on the OIG website.   
16 OIG, State Fraud Policy Transmittal 2020-3, MFCU Authority to Receive Federal Funding to Investigate and Prosecute Diversion 
and Misuse of Pharmaceuticals, October 28, 2020.  This transmittal describes the situations when Units are eligible to receive 
Federal financial participation to investigate and prosecute drug diversion cases. 
17 One large, 268-million-dollar case prosecuted in FY 2017 accounted for about 39 percent of all criminal recoveries in 
FY 2017.  The Texas MFCU prosecuted this case, which involved a doctor and other codefendants who defrauded Medicaid and 
Medicare by improperly recruiting individuals and falsifying medical documents. 
18 United States Department of Justice, Last of Six Sentenced in Scheme to Defraud Medicaid of Millions, June 16, 2020.  
https://www.justice.gov/usao-ndoh/pr/last-six-sentenced-scheme-defraud-medicaid-millions.  Accessed on February 9, 2021. 
19 Our data collection did not identify a specific cause for the rise in civil case outcomes, but one explanation could have been 
efforts to refocus prosecutive and court resources on civil cases during a time when criminal court proceedings were curtailed 
or stayed.   
20 The spikes in civil recoveries in FYs 2016 and 2019 significantly elevated the average for civil recoveries in FYs 20162020. 
21 To calculate the percentages for civil global and nonglobal recoveries, we used the total civil recoveries of  
$854,801,085 and rounded the dollar value to the nearest tenth.  Total civil recoveries accounted for $855 million and global 
cases accounted for $637 million in FY 2020. 
22 Wisconsin Department of Justice, $678 Million National Kickback Settlement with Novartis Pharmaceuticals, September 24, 
2020.  https://www.doj.state.wi.us/sites/default/files/news-media/9.21.20_Novartis.pdf.  Accessed on February 8, 2021. 
Medicaid Fraud Control Units Fiscal Year 2020 Annual Report 
OEI-09-21-00120  Endnotes | 31