U.S. Department of Health and Human Services 
Office of Inspector General 
Medicaid Fraud 
Control Units 
Fiscal Year 2015 
Annual Report
 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
 
September 2016 
OEI-07-16-00050 
 
   
   
TABLE OF CONTENTS 
 
FINDINGS  
Units reported 1,553 convictions, 731 civil settlements, and $744 million in 
criminal and civil recoveries ....................................................................................3 
Convictions over the past 5 years have increased, while the number of civil 
settlements and amount of recoveries have decreased .............................................5 
Many Units made operational improvements in response to OIG 
recommendations .....................................................................................................8 
  APPENDIXES 
A:  Methodology .................................................................................................... 11 
B:  Fiscal Year 2015 MFCU Outcomes and Open Investigations by Provider  
     Type ...................................................................................................................12 
C:  Selected Fiscal Year 2015 Statistical Data .......................................................18 
D:  Noted Beneficial Practices from Unit Reports Published in  
      Fiscal Years 2011-2015 ....................................................................................22 
  ENDNOTES  ....................................................................................................................25 
  ACKNOWLEDGMENTS ................................................................................................26
 
 
 
 
   
INTRODUCTION 
 
The mission of Medicaid Fraud Control Units (MFCUs or Units) is to investigate and prosecute 
Medicaid provider fraud and patient abuse or neglect under State law.1  The Social Security 
Act (SSA) requires each State to operate a MFCU, unless the Secretary of Health and Human 
Services (HHS) determines that (1) 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 Medicaid beneficiaries from abuse or neglect.2  Currently, 49 States and the 
District of Columbia (States) have MFCUs.3  
Each Unit must employ an interdisciplinary staff that consists of at least an investigator, an 
auditor, and an attorney.4  Unit staff review referrals of potential fraud and patient abuse or 
neglect to determine their potential for criminal prosecution and/or civil action.  As illustrated 
below, Unit cases begin as referrals from multiple sources to be processed by the Unit, and result 
in various outcomes, including convictions, settlements, and monetary recoveries. 
 
Units must meet a number of requirements established by the SSA and Federal regulations.  For 
example, each Unit must: 
  be a single, identifiable entity of State government, distinct from the State Medicaid 
agency;5    
  develop a formal agreement, such as a memorandum of understanding (MOU), 
describing the Units relationship with the State Medicaid agency;6  and   
  have either statewide authority to prosecute cases or formal procedures to refer suspected 
criminal violations to an agency with such authority.7   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  1 
   
MFCU Funding 
Each MFCU is funded jointly by its State and the Federal government.  Federal funding for the 
MFCUs is provided as part of the Federal Medicaid appropriation, but it is administered by 
Office of Inspector General (OIG).8  Each Unit receives Federal financial participation 
equivalent to 75 percent of its total expenditures, with State funds contributing the remaining 
25 percent.9  In fiscal year (FY) 2015, combined Federal and State expenditures for the Units 
totaled approximately $251 million, $188 million of which represented Federal funds.10    
Administration and Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to administer the MFCU grant program.11  
To receive Federal reimbursement, each Unit must submit an initial application to OIG for 
approval and be recertified each year thereafter. 
In annually recertifying the Units, OIG evaluates Unit compliance with Federal requirements and 
adherence to performance standards.  The Federal requirements for Units are contained in the 
SSA, regulations, and policy guidance.12  In addition, OIG has published 12 performance 
standards that it uses to assess whether a Unit is performing its responsibilities effectively.13  The 
standards address topics such as staffing, maintaining adequate referrals, and cooperation with 
Federal authorities.   
OIG also performs onsite reviews of the Units.  During these onsite reviews, OIG evaluates 
Units compliance with laws, regulations, and policies, as well as adherence to the 
12 performance standards.  OIG also makes observations about best practices, provides 
recommendations to the Units, and monitors the implementation of the recommendations.   
OIG provides additional oversight including the collection and dissemination of performance 
data, training, and technical assistance.  OIG maintains pertinent information for each MFCU on 
the OIG Web site, including an interactive map with statistical information about each MFCU.14 
Methodology 
We based the information in this report on an analysis of data from three sources:  (1) annual 
statistical report data submitted for FY 2015; (2) quarterly statistical reports for FYs 2011 
through 2014; and (3) onsite review reports published in FYs 2011 through 2015.  Appendix A 
provides details of our methodology. 
Standards   
This study was conducted in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  2   
FINDINGS 
Units reported 1,553 convictions, 731 civil settlements, and  
$744 million in criminal and civil recoveries  
In FY 2015, Units reported 1,553 convictions.  Seventy-one 
percent of these convictions involved fraud and 29 percent 
involved abuse or neglect.  For the same period, Units reported 
731 civil settlements and judgments and $744 million in criminal 
 ANNUAL STATISTICAL 
and civil recoveries.   
REPORTING 
Nearly one-third of convictions involved personal care 
Units annually report to the 
services attendants 
OIG their activities and 
Thirty-one percent (483 of 1,553) of the reported convictions were 
outcomes related to intake, 
of personal care services (PCS) attendants or other home care 
investigation, criminal 
aides.  In one case, a PCS attendant submitted timesheets for 
prosecution, and civil 
services rendered while the patient was hospitalized and unable to 
litigation of provider fraud 
receive care from the PCS attendant.  The attendant continued to 
and patient abuse or 
submit the timesheets even after the individual died.  Eleven  neglect.   
percent (176 of 1,553) of convictions were of nurse aides.    
These outcomes are 
Another 11 percent (166 of 1,553) of convictions were of licensed 
published on the OIG 
nurses, physician assistants (PA), or nurse practitioners (NP).  
website http://oig.hhs.gov/ 
These convictions involved abuse or neglect, provision of services 
fraud/medicaid-fraud-
without a license, and services not rendered, among other charges.  
control-units-
Chart 1 depicts the number of criminal convictions for the five 
mfcu/index.asp. 
provider types with the most convictions.  
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  3 
   
Fraud cases accounted for 71 percent of convictions in FY 2015 
Seventy-one percent (1,097 of 1,553) of all convictions involved fraud and 29 percent 
(456 of 1,553) involved abuse or neglect.  Of the fraud convictions, almost half involved 
unlicensed providers, including PCS attendants and other home care aides.  The provider type 
with the greatest number of fraud convictions was PCS attendants, with 439 convictions (or 65 
percent of all fraud convictions).  Chart 2 depicts the five provider types with the most 
convictions by type of case.  The provider type that had the most abuse or neglect convictions 
was nurse aides, with 160 convictions (or 40 percent of all abuse or neglect convictions).  
Appendix B displays the outcomes for fraud and abuse or neglect cases by provider type.      
 
Drug diversion cases accounted for 8 percent of convictions 
Units reported 117 drug diversion convictions and $4.4 million in criminal recoveries in 
FY 2015.  Drug diversion investigations involve fraudulent billing of the Medicaid program for a 
drug not delivered to the intended beneficiary and diverted from legal and medically necessary 
uses.  As with the Units other investigative work, drug diversion cases may be conducted jointly 
with other appropriate State or Federal agencies, such as the OIG Office of Investigations or the 
Drug Enforcement Agency (DEA) (e.g., opioid cases).  In one such case, a pharmacist pleaded 
guilty of conspiracy to fraudulently dispense and distribute controlled substances for dispensing 
over 145,440 pills of oxycodone through fraudulent prescriptions.  The pharmacist was 
sentenced to six months home detention, three years probation, and ordered to pay $4.7 million 
in restitution.   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  4   
Over a third of the civil settlements involved pharmaceutical manufacturers 
Of the 731 civil settlements and judgments Units reported, 279 (38 percent) involved 
pharmaceutical manufacturers, making it the provider type that accounted for the greatest 
percentage of settlements and judgments.  Pharmaceutical manufacturer settlements typically 
were related to the marketing of drugs.  An additional 54 settlements and judgments involved 
retail and wholesale pharmacies.  In one such settlement, a pharmacy automatically refilled 
prescriptions that were not requested by the patients or caregivers.15  This pharmacy was ordered 
to pay the State more than $1.5 million in restitution for the overpayments.  All Units reported 
civil settlements or judgments in FY 2015, ranging from 3 to 69 per Unit.   
Units reported over $700 million recoveries in FY 2015; one Unit accounted for 
over a quarter of these recoveries 
Of the $744 million in recoveries Units reported, $394 million were from civil recoveries and 
another $350 million were from criminal recoveries.  Total recoveries exceeded the $251 million 
in State and Federal funds Units expended in FY 2015.  In fact, on average Units recovered 
almost $3 for every dollar spent.16   
Although the Texas Unit expended only 7 percent of the total expenditures for all MFCUs in 
FY 2015, the Unit reported over a quarter ($210 million of $744 million) of the total recoveries 
reported by Units.  Specifically, Texas accounted for 28 percent of total Unit recoveries and 
59 percent of all Unit criminal recoveries.  Texas reported $207 million in criminal recoveries 
and another $3 million in civil recoveries, or $210 million in total recoveries.  In FY 2015, the 
Texas Unit had several large, multiple defendant cases which all came to fruition within the year.  
This resulted in an unusual number of very large restitution amounts being reported. 
New York, Tennessee, California, Florida, and Wisconsin, combined accounted for 50 percent of 
civil recoveries.  These five States reported $196 million of the $394 million in civil recoveries.  
Appendix C displays the amount of criminal and civil recoveries and other outcomes for each 
State.   
Convictions over the past 5 years have increased, while the 
number of civil settlements and amount of recoveries have 
decreased 
The number of convictions has increased over the past 5 years, from 1,235 in FY 2011 to 
1,553 in FY 2015.  During the same period, civil settlements and judgments decreased from 
908 in FY 2011 to 731 in FY 2015.  Although Units reported over $1.5 billion in civil recoveries 
each year from FY 2011 through FY 2014, Units reported less than $400 million in civil 
recoveries for FY 2015.  This decrease was consistent with national trends in health care civil 
recoveries.  
   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  5   
In FY 2015, Units reported the highest number of convictions in the last 5 years 
In FY 2015, Units reported a total of 1,553 convictions, 235 more than 
reported in FY 2014.  Units had increases in both fraud and abuse or 
neglect convictions, as demonstrated in Chart 3.  Fraud convictions 
increased from 825 in FY 2011 to 1,097 in FY 2015.   
CIVIL CASES 
Although abuse or neglect convictions declined between FY 2011 and 
Units conduct two types of 
FY 2014, abuse or neglect convictions increased from 362 to 456 
civil cases- global and 
between FY 2014 and FY 2015.  One such abuse conviction involved 
nonglobal.   
a nurse in an assisted living facility who was captured on hidden video 
A global case is defined as a 
assaulting a resident who resisted attempts to be dressed.  The nurse 
civil case that involves both 
was sentenced to 2 years of probation and barred from employment in 
the Federal government and 
any Federally funded healthcare program.  
a group of states and is 
coordinated by the National 
Association of Medicaid 
Fraud Control Units 
(NAMFCU).    
A nonglobal case is a civil 
case that does not involve 
NAMFCU.    
   
   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  6   
OIG exclusions resulting from Unit conviction referrals have grown since 2011 
In FYs 2015 and 2014 the number of 
exclusions resulting from Unit 
referrals was significantly higher than 
the number of annual exclusions from 
Unit referrals in FYs 2011 through 
2013, as shown in Chart 4.  OIG has 
the authority to exclude convicted 
individuals and entities from Federally 
funded health care programs and 
maintains a list of all currently 
excluded individuals and entities.17  
Anyone who hires an individual or 
entity on this list may be subject to 
civil monetary penalties.  In FY 2015, 
OIG excluded 4,112 individuals or 
entities; 1,306 (32 percent) resulted 
from convictions referred by Units.       
Civil settlements and judgments have decreased modestly over the last 5 years, 
and civil recovery amounts have decreased significantly  
The number of civil settlements and judgments decreased from 908 in FY 2011 to 731 in 
FY 2015.  Chart 5 shows the decrease in civil settlements and judgments over the past 5 years.  
Civil recoveries averaged $1.9 billion a year for the last 4 years and decreased significantly in 
FY 2015, to a low of $394 million.  Chart 6 shows civil recoveries reported for FYs 2011 
through 2015.   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  7   
The decrease in the Units civil settlements, judgements, and recoveries is part of a national trend 
of declining civil health care fraud complaint settlements, especially those involving large 
pharmaceutical companies.  From the 1990s through the early 2000s, a significant number of 
pharmaceutical companies were the subject of large monetary settlements in civil fraud actions.18  
Many of the large pharmaceutical settlements and the associated recoveries involved global civil 
cases.  Although in FYs 2013 and 2014 global recoveries accounted for 78 and 69 percent of 
civil recoveries, respectively, in FY 2015, global recoveries accounted for only 37 percent of 
total civil recoveries, as shown in Chart 7.   
 
Many Units made operational improvements in response to OIG 
recommendations  
Units made improvements in Unit operations in response to recommendations made in OIG 
onsite review reports.  Between FYs 2011 and 2015, OIG published 32 onsite review reports.  In 
these reports, the most common recommendations were in response to a lack of case file 
documentation of supervisory reviews and approvals, late or no required reporting of convictions 
to OIG and the National Practitioner Data Bank (NPDB), deficiencies in Units MOU with State 
Medicaid program integrity units, and Unit policies and procedures.19, 20  Each of the 32 Units 
reviewed received at least one recommendation related to these areas, for a total of 65 
recommendations.  Units made improvements in their operations in response to 62 of these 
recommendations.  In addition to recommendations, some reports noted Unit practices that 
improved Unit operations.   
Twenty-six Units made improvements related to case file documentation  
All 26 Units that received a recommendation related to documentation of supervisory reviews 
and approvals made improvements to address OIG recommendations.  For example, many Units 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  8   
revised their policies and procedures to specify the timeframes and/or documentation required 
for supervisory reviews in case files.  Other Units developed new forms to document supervisory 
reviews.  Supervisory reviews help ensure that cases are opened and closed in a timely manner 
and facilitate case progress. 
Twenty Units made improvements related to required reporting to Federal 
partners  
Twenty of the 23 Units that received a recommendation related to required reporting to OIG and 
NPDB improved their reporting process to address OIG recommendations.  For example, one 
Unit developed an automated case tracking system that sends email reminders to investigators 
and supervisors to send the appropriate notification to OIG when a provider is sentenced.  
Another Unit modified their system to prevent a case from being closed in the system until the 
adverse action has been submitted to NPDB.  As of August 2016, the remaining three Units had 
not reported any improvements to OIG to address these recommendations, and OIG continues to 
follow-up with these Units regarding their implementation status. 
Twelve of these 23 Units did not 
report some or all of their 
convictions or adverse actions to 
Federal partners, as required.  As 
Chart 8 illustrates, the percentage 
of convictions and adverse actions 
Units did not report varied widely.  
Units should report to OIG all 
convictions for the purpose of 
exclusion from Federal health care 
programs within 30 days of 
sentencing.21  Units also should 
report any adverse actions 
resulting from investigations or prosecutions of healthcare providers to the NPDB within 30 
days.22  If a Unit fails to refer convicted providers for exclusion, those providers may continue to 
submit claims and receive payments from Medicaid and other Federal programs.    
Sixteen Units made improvements related to MOUs and policy and procedures  
All 16 Units that received a recommendation related to their MOUs and/or policies and 
procedures made improvements to address OIG recommendations.   
Every Unit that had a recommendation concerning their policies and procedures either updated 
their policies to reflect their current operations, or revised their policies and procedures to 
address the recommendations.  For example, one Unit incorporated written policies regarding 
referral of cases to other agencies into its procedures manual as required; another, implemented 
policies and procedures to ensure the accuracy of claims submitted for Federal reimbursement. 
For every Unit that had a recommendation concerning its MOU, OIG found that the Units MOU 
did not reflect current requirements or practices.  For example, one Units MOU did not include 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  9   
a provision describing the referral process between the Unit and the State Medicaid agency, as 
required.  In addition, the Unit did not have regular communication nor meetings with the State 
Medicaid agency.  Since the onsite review, the Unit has worked to improve the quality and 
frequency of communication with the State Medicaid agency and updated its MOU to include all 
requirements.  
Units employed a variety of practices to improve Unit operations  
Units took many steps on their own initiative to improve Unit operations and outcomes.  These 
were reported to the OIG during onsite reviews conducted between FYs 2011 and 2015.  For 
example, Units described outreach activities that were beneficial to the Units mission. 
Generally, these efforts improved relationships with stakeholders, increased referrals, and raised 
Unit visibility in the health care community.  Other Units noted that their efforts to enhance 
relationships with external State and Federal entities had positive effects.  Appendix D provides 
detailed Unit reported information on the activities and practices to improve Unit operations. 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  10   
APPENDIXES 
 
Appendix A:  Methodology 
We based the information in this report on an analysis of data from three sources:  (1) annual 
statistical report data submitted by each of the 50 State MFCUs for FY 2015; (2) quarterly 
statistical reports for FYs 2011 through 2014; and (3) onsite review reports published in 
FYs 2011 through FY 2015. 
Review of annual statistical reports.  We analyzed the annual statistical reports submitted for 
FY 2015 for all MFCUs and requested additional data and clarification as needed.  We summarized 
key indicators, such as criminal convictions, civil settlements and judgments, and monetary 
recoveries across all Units.  In addition, we summarized the reported investigations by provider 
type.  Finally, we looked for other noteworthy trends in the data.  The data was downloaded on 
April 28, 2016.     
Review of onsite review reports.  We analyzed the onsite review reports published in FY 2011 
through FY 2015 to identify themes reflected in multiple reports.  We combined our review of the 
onsite reports with OIG data on implementation of recommendations.   
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  11   
 
Appendix B:  FY 2015 MFCU Outcomes and Open Investigations  
by Provider Type 
Table B1:  FY 2015 Outcomes:  Number of Convictions, Settlements and Judgments, and Recoveries by 
Provider Type 
Criminal  Civil 
Number of  Amount of  Number of  Amount of 
Provider Type  Convictions  Recoveries  Settlements  Recoveries 
and 
Judgments 
ABUSE OR NEGLECT   
Assisted Living Facility  14  $125,813   0  $0  
Developmental Disability Facility (Residential)  8  $8,570   1  $2,335  
Non-Direct Care  33  $1,545,837   0  $0  
Nurse (LPN, RN, or other licensed), Nurse  78  $80,757  0  $0  
Practitioner, or Physician Assistant 
Nurse Aide (CNA or Other)  160  $231,600  1  $20,000  
Nursing Facilities  31  $1,682,058  6  $2,835,186  
Personal Care Services Attendant or Other  44  $59,734   1  $12,083  
Home Care Aide 
Other Individual or Organization   88  $1,438,566   1  $101,694  
FRAUD:  Inpatient and/or Residential Facility-Based Medicaid Providers and Programs 
Assisted Living Facility  1  $1,465   0  $0  
Hospice  2  $8,186,035   4  $11,873,583  
Hospitals  9  $137,862,282   42  $44,098,432 
Nursing Facilities  9  $512,535   14  $19,927,514  
Other Long Term Care Facility  5  $37,210   0  $0  
FRAUD:  Outpatient and/or Day Services Facility-Based Medicaid Providers and Programs 
Adult Day Center  2  $370,428   3  $899,280  
Developmental Disability Facility  2  $49,281   3  $145,637  
(Non-Residential) 
Dialysis Center  0  $0   4  $16,670,658  
Mental Health Facility (Non-Residential)  11  $5,292,586  7  $8,985,660 
Substance Abuse Treatment Center  11  $410,317   2  $54,593  
Other Facility (Non-Residential)  7  $294,945   6  $2,672,769  
FRAUD - Licensed Practitioners  
Chiropractor  5  $1,403,593   1  $2,983  
Clinical Social Worker  14  $1,330,296   2  $115,000  
Dentist  16  $2,556,478   19  $11,318,559  
Nurse (LPN, RN, or other licensed)  86  $2,962,032   11  $4,430,251  
Nurse Practitioner  0  $0  1  $6,464 
Optometrist  2  $176,185   1  $150,000  
Pharmacist  14  $10,120,661   1  $5,189,784  
    continued on the next page 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  12 
   
Table B1:  FY 2015 Outcomes:  Number of Convictions, Settlements and Judgments, and Recoveries by 
Provider Type (continued) 
Criminal  Civil 
Number of  Amount of  Number of  Amount of 
Provider Type  Convictions  Recoveries  Settlements  Recoveries 
and 
Judgments 
FRAUD - Licensed Practitioners  (continued) 
Physician Assistant  2  $53,530  0  $0 
Physical Therapist, Speech Therapist,  5  $1,424,259   0  $0  
Occupational Therapist, Radiation Therapist or 
other licensed Non-Mental Health Therapist 
Podiatrist  6  $91,684   4  $106,006  
Psychologist  36  $2,076,320   1  $5,000  
Other Licensed Practitioner  3  $19,860   6  $574,884  
FRAUD - Medical Services 
Ambulance  4  $1,325,342   7  $7,721,420  
Billing services  4  $338,185   7  $676,811  
Durable Medical Equipment, Prosthetics,  33  $12,701,619   30  $4,255,485  
Orthotics and Supplies (DMEPOS) 
Home Health Agency  64  $9,700,493   58  $44,225,917  
Lab (Clinical)  0  $0   6  $137,972  
Lab (Radiology and Physiology)  2  $1,458,316   1  $15,040  
Lab (Other)  0  $0   1  $632,387  
Medical Device Manufacturer  1  $103,174   24  $534,433  
Pain Management Clinic  3  $31,561   0  $0  
Personal Care Services Agency  22  $1,718,223   27  $3,960,381  
Pharmaceutical Manufacturer  1  $0   279  $121,243,710  
Pharmacy (Institutional Wholesale)  0  $0   16  $8,275,962  
Pharmacy (Retail)  17  $2,149,758   38  $42,911,529  
Transportation (Non-Emergency)  12  $1,189,061   11  $2,597,086  
Other Medical Services  27  $4,303,405   7  $749,272  
FRAUD:  Physicians (MD/DO) 
Cardiologist  1  $1,298  1  $3,318,015 
Family Practice Physician  47  $36,696,385  8  $1,107,184 
Internal Medicine Physician  5  $349,064  3  $494,774 
Neurologist  1  $0  1  $13,540 
Obstetrician/Gynecologist  9  $756,601  8  $1,490,525 
Ophthalmologist  0  $0  1  $790,000 
Pediatrician  4  $3,277,110  3  $421,787 
Physical Medicine and Rehabilitation Physician  2  $14,454  2  $98,450 
Psychiatrist  11  $30,587,001  3  $3,916,949 
Radiologist  0  $0  1  $22,653 
continued on the next page 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  13   
Table B1:  FY 2015 Outcomes:  Number of Convictions, Settlements and Judgments, and Recoveries by 
Provider Type (continued) 
Criminal  Civil 
Number of  Amount of  Number of  Amount of 
Provider Type  Convictions  Recoveries  Settlements  Recoveries 
and 
Judgments 
FRAUD:  Physicians (MD/DO) (continued) 
Urologist  1  $11,245  0  $0 
Other MD/DO  21  $12,598,885  16  $3,655,814 
FRAUD:  Other Individual Providers 
Nurse Aide (CNA or Other)  16  $110,144   0  $0  
Optician  1  $0   0  $0  
Personal Care Services Attendant or Other  439  $7,302,038   19  $88,484  
Home Care Aide 
Pharmacy Technician  6  $136,014   0  $0  
Unlicensed Counselor (Mental Health)  34  $3,578,418   1  $500  
Unlicensed Therapist (Non-Mental Health)  1  $1,080   0  $0  
Other Individual Providers  32  $17,863,786   4  $246,010  
FRAUD:  Program Related 
Managed Care Organization   11  $16,058,614   0  $12,202  
Medicaid Program Administration  7  $1,029,136   0  $0  
Other Program Related  10  $3,811,036   6  $10,299,500  
     Total  1,553  $349,606,363  731  $394,105,683 
Source:  OIG analysis of MFCUs Annual Statistical Report data for FY 2015.   
 
   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  14   
Table B2:  Number of Open Investigations at the end of FY 2015 by Provider Type 
Provider Type  Open Criminal  Open Civil  Total Open 
Investigations   Investigations  Investigations 
ABUSE OR NEGLECT   
Assisted Living Facility  205  2  207 
Developmental Disability Facility (Residential)  72  4  76 
Hospice  5  0  5 
Non-Direct Care  193  0  193 
Nurse (LPN, RN, or other licensed), Nurse 
421  1  422 
Practitioner, or Physician Assistant 
Nurse Aide (CNA or Other)  684  1  685 
Nursing Facilities  882  58  940 
Personal Care Services Attendant or Other Home 
254  0  254 
Care Aide 
Other Individual or Organization   443  1  444 
FRAUD:  Inpatient and/or Residential Facility-Based Medicaid Providers and Programs 
Assisted Living Facility  25  8  33 
Developmental Disability Facility (Residential)  27  11  38 
Hospice  35  47  82 
Hospitals  101  200  301 
Inpatient Psychiatric Services for Individuals Under  5  3  8 
Age 21 
Nursing Facilities  173  165  338 
Other Inpatient Mental Health Facility  5  18  23 
Other Long Term Care Facility  14  11  25 
FRAUD:  Outpatient and/or Day Services Facility-Based Medicaid Providers and Programs 
Adult Day Center  78  6  84 
Ambulatory Surgical Center  2  3  5 
Developmental Disability Facility (Non-Residential)  19  7  26 
Dialysis Center  2  30  32 
Mental Health Facility (Non-Residential)  156  42  198 
Substance Abuse Treatment Center  120  17  137 
Other Facility (Non-Residential)  117  45  162 
FRAUD - Licensed Practitioners  
Audiologist  5  2  7 
Chiropractor  38  3  41 
Clinical Social Worker  80  4  84 
Dental Hygienist  7  1  8 
Dentist  387  69  456 
Nurse (LPN, RN, or other licensed)  462  14  476 
Nurse Practitioner  26  7  33 
Optometrist  25  4  29 
Pharmacist  78  45  123 
Physician Assistant  15  0  15 
    continued on the next page 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  15   
Table B2:  Number of Open Investigations at the end of FY 2015 by Provider Type (continued) 
Provider Type  Open  Open Civil  Total Open 
Criminal  Investigations  Investigations 
Investigatio
ns  
FRAUD - Licensed Practitioners  (continued) 
Physical Therapist, Speech Therapist, Occupational  70  7  77 
Therapist, Radiation Therapist or other licensed 
Non-Mental Health Therapist 
Podiatrist  30  5  35 
Psychologist  209  10  219 
Other Licensed Practitioner  99  11  110 
FRAUD - Medical Services 
Ambulance  154  34  188 
Billing services  14  20  34 
Durable Medical Equipment, Prosthetics, Orthotics  270  443  713 
and Supplies (DMEPOS) 
Home Health Agency  605  109  714 
Lab (Clinical)  59  427  486 
Lab (Radiology and Physiology)  9  20  29 
Lab (Other)  12  144  156 
Medical Device Manufacturer  5  478  483 
Pain Management Clinic  45  7  52 
Personal Care Services Agency  198  164  362 
Pharmaceutical Manufacturer  134  3,069  3,203 
Pharmacy (Hospital)  2  11  13 
Pharmacy (Institutional Wholesale)  15  210  225 
Pharmacy (Retail)  161  410  571 
Transportation (Non-Emergency)  217  33  250 
Other Medical Services  50  121  171 
FRAUD:  Physicians (MD/DO) 
Allergist/Immunologist  5  4  9 
Cardiologist  25  9  34 
Emergency Medicine Physician  16  6  22 
Family Practice Physician  372  12  384 
Geriatrician  6  0  6 
Internal Medicine Physician  146  22  168 
Neurologist  34  8  42 
Obstetrician/Gynecologist  79  8  87 
Ophthalmologist  16  6  22 
Pediatrician  36  8  44 
Physical Medicine and Rehabilitation Physician  25  6  31 
Psychiatrist  90  7  97 
Radiologist  10  6  16 
continued on the next page 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  16   
Table B2:  Number of Open Investigations at the end of FY 2015 by Provider Type (continued) 
Provider Type  Open  Open Civil  Total Open 
Criminal  Investigations  Investigations 
Investigatio
ns  
FRAUD:  Physicians (MD/DO) (continued) 
Surgeon  45  2  47 
Urologist  4  0  4 
Other MD/DO  280  70  350 
FRAUD:  Other Individual Providers 
Nurse Aide (CNA or Other)  42  1  43 
Optician  5  2  7 
Personal Care Services Attendant or Other Home  1,620  6  1,626 
Care Aide 
Pharmacy Technician  9  0  9 
Unlicensed Counselor (Mental Health)  106  3  109 
Unlicensed Therapist (Non-Mental Health)  8  0  8 
Other Individual Providers  167  6  173 
FRAUD:  Program Related 
Managed Care Organization   12  70  82 
Medicaid Program Administration  13  10  23 
Other Program Related  53  156  209 
     Total  10,743  6,990  17,733 
Source:  OIG analysis of MFCUs Annual Statistical Report data for FY 2015.   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  17   
Appendix C:  Selected FY 2015 Statistical Data 
Table C1:  Investigations, Indictments or Charges, Criminal Convictions, and Civil Settlements and 
Judgments by State1 
Open  Indicted/Charged  Convictions  Settlements and 
Investigations  (Criminal)  (Criminal)  Judgments (Civil) 
State 
Abuse  Abuse 
or  Abuse or  Abuse or  or 
Fraud  Neglect  Fraud  Neglect  Fraud  Neglect  Fraud  Neglect 
Alabama  39  9  8  9  5  4  5  0 
Alaska  129  1  32  0  15  0  4  0 
Arizona  131  19  56  21  24  24  7  0 
Arkansas  69  41  21  13  11  11  9  5 
California  1,082  643  138  108  59  56  22  0 
Colorado  271  0  8  0  9  0  44  0 
Connecticut  78  4  8  0  6  1  12  0 
Delaware  586  54  28  10  17  24  9  0 
District of 
147  6  11  0  29  1  9  0 
Columbia 
Florida 
531  37  75  24  54  23  26  0 
Georgia  445  11  21  1  12  0  27  0 
Hawaii  72  44  2  1  4  2  4  0 
Idaho  98  10  4  0  3  1  11  0 
Illinois  248  50  41  12  42  13  22  0 
Indiana  1,216  390  47  1  38  6  22  0 
Iowa  270  21  37  21  33  20  11  0 
Kansas  104  8  6  0  15  2  9  0 
Kentucky  72  45  9  13  3  10  14  0 
Louisiana  356  70  84  7  66  7  24  1 
Maine  49  11  0  4  4  4  7  0 
Maryland  319  34  8  4  8  2  10  0 
Massachusetts  444  58  3  1  9  1  20  1 
Michigan  480  46  13  9  23  7  16  0 
Minnesota  417  2  22  2  17  2  13  0 
Mississippi  85  509  6  69  5  55  9  0 
Missouri  162  15  7  4  13  2  29  0 
Montana  25  7  5  1  5  2  6  0 
Nebraska  97  28  8  2  6  6  7  0 
Nevada  61  4  14  0  13  0  9  0 
New Hampshire  26  11  0  4  0  0  13  0 
continued on the next page 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  18   
Table C1:  Investigations, Indictments or Charges, Criminal Convictions, and Civil Settlements and 
Judgments by State (continued) 
Open  Indicted/Charged  Convictions  Settlements and 
Investigations  (Criminal)  (Criminal)  Judgments (Civil) 
State  Abuse  Abuse 
or  Abuse or  Abuse or  or 
Fraud  Neglect  Fraud  Neglect  Fraud  Neglect  Fraud  Neglect 
New Jersey  397  25  24  3  12  6  14  0 
New Mexico  199  4  12  0  7  0  12  0 
New York  652  146  72  43  57  53  69  0 
North Carolina  397  9  13  3  14  4  15  1 
Ohio  986  432  139  36  133  27  16  1 
Oklahoma  197  66  21  20  17  15  10  0 
Oregon  58  6  30  9  30  9  8  0 
Pennsylvania  446  28  114  4  93  2  8  0 
Rhode Island  26  14  5  9  7  3  15  0 
South Carolina  172  44  11  6  15  3  9  0 
South Dakota  38  1  2  0  2  0  5  1 
Tennessee  222  42  10  13  9  12  18  0 
Texas  1,210  146  117  6  68  17  10  0 
Utah  118  20  1  3  2  3  13  0 
Vermont  70  11  9  0  7  1  4  0 
Virginia  378  6  52  2  52  7  21  0 
Washington  179  7  13  3  11  4  13  0 
West Virginia  128  19  6  2  6  3  16  0 
Wisconsin  468  9  11  0  5  0  12  0 
Wyoming  57  3  2  0  2  1  3  0 
   TOTAL  14,507  3,226  1,386  503  1,097  456  721  10 
   GRAND TOTAL  17,733  1,889  1,553  731 
Source:  OIG analysis of MFCUs Annual Statistical Report data for FY 2015.   
1 The information in this table is accurate as of June 9, 2016.  States were able to provide revised data for FY 2015.  Therefore, 
the data in this table differs from the data reported in the Statistical Chart on the website available at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2015-statistical-chart.htm, which was current 
as of February 16, 2016. 
   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  19   
Table C2:  Recoveries and Expenditures by State1  
Recoveries2  Expenditures 
Non-Global 
State  Global Civil 
Criminal  Civil  Total   Total MFCU   Total Medicaid 
Monetary  
Monetary  
Alabama  $422,078   $0   $4,650,800   $5,072,878   $1,357,240   $5,495,672,054  
Alaska  $2,400,512   $0   $60,099   $2,460,611   $1,279,525   $1,223,950,911  
Arizona  $457,175   $0   $1,390,536   $1,847,711   $2,811,988   $10,895,032,291  
Arkansas  $488,655   $164,103   $1,584,347   $2,237,105   $2,460,200   $5,852,914,637  
California  $26,164,226   $2,005,836   $29,732,837   $57,902,899   $32,138,721   $90,614,357,683  
Colorado  $645,090   $307,040   $3,739,443   $4,691,573   $1,651,018   $7,687,605,872  
Connecticut  $48,721   $395,309   $1,582,975   $2,027,005   $2,108,289   $7,597,012,987  
Delaware  $51,940   $0   $993,390   $1,045,330   $1,893,364   $2,023,509,108  
District of 
$263,351   $487,500   $1,519,392   $2,270,243   $2,792,615   $2,520,735,076  
Columbia 
Florida  $26,004,717   $21,582,272   $10,078,140   $57,665,129   $16,910,095   $21,909,678,011  
Georgia  $2,217,127   $5,990,382   $8,104,274   $16,311,783   $4,804,982   $10,245,084,441  
Hawaii  $38,143   $55,000   $16,487   $109,630   $1,317,827   $2,076,761,775  
Idaho  $118,214   $357,125   $321,457   $796,796   $873,359   $1,819,959,694  
Illinois  $650,478   $9,623,544   $6,584,321   $16,858,343   $7,622,227   $17,963,860,929  
Indiana  $2,770,349   $22,763,128   $2,603,929   $28,137,406   $5,916,915   $9,721,569,345  
Iowa  $223,805   $9,924,685   $650,788   $10,799,278   $1,074,819   $4,672,288,367  
Kansas  $571,281   $3,713,967   $99,518   $4,384,766   $1,192,687   $3,193,745,137  
Kentucky  $274,862   $118,497   $2,511,193   $2,904,552   $3,393,619   $9,666,336,070  
Louisiana  $5,072,526   $4,246,258   $8,586,459   $17,905,243   $5,263,527   $8,152,272,103  
Maine  $424,841   $0   $777,418   $1,202,259   $764,429   $2,620,426,632  
Maryland  $4,996,364   $1,246,923   $526,035   $6,769,322   $3,697,014   $9,881,703,513  
Massachusetts  $9,540,716   $6,473,215   $1,558,979   $17,572,910   $5,364,610   $16,164,091,522  
Michigan  $882,447   $475,832   $4,987,244   $6,345,523   $5,630,862   $16,561,360,132  
Minnesota  $551,262   $98,400   $1,268,023   $1,917,685  $1,765,979   $11,294,848,324  
Mississippi  $11,727,836   $873,442   $2,393,747   $14,995,025   $3,473,671   $5,313,720,236  
Missouri  $726,644   $8,717,608   $2,647,957   $12,092,209   $2,345,934   $9,868,941,095  
Montana  $151,974   $0   $68,992   $220,966   $825,259   $1,208,709,907  
Nebraska  $124,231   $64,593   $482,891   $671,715   $894,437   $1,973,545,225  
Nevada  $3,387,397   $1,703,441   $256,843   $5,347,681   $1,932,571   $3,265,706,343  
New Hampshire  $5,610   $179,977   $301,247   $486,834  $780,464   $1,840,725,765  
New Jersey  $708,957  $0   $2,481,039   $3,189,996   $3,867,591   $14,829,609,984  
continued on the next page    
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  20   
Table C2:  Recoveries and Expenditures by State (continued) 
Recoveries  Expenditures 
Non-Global 
State  Global Civil 
Criminal   Civil  Total   Total MFCU   Total Medicaid 
Monetary  
Monetary  
New Mexico  $57,242   $80,701   $213,532   $351,475   $2,124,374   $5,083,042,074  
New York  $2,887,003   $52,555,329   $8,027,331   $63,469,663   $47,301,283   $59,681,117,761  
North 
$7,633,027   $13,418,973   $1,536,510   $22,588,510  $5,350,038   $13,878,014,268  
Carolina 
Ohio  $12,562,704   $378,728   $5,797,800   $18,739,232   $10,109,229   $22,283,505,297  
Oklahoma  $1,034,880   $5,200,000   $815,782   $7,050,662   $2,481,047   $4,948,050,867  
Oregon  $188,867   $0   $408,520   $597,387   $2,220,933   $8,568,555,342  
Pennsylvania  $7,579,541  $0   $4,122,975   $11,702,516   $6,106,400   $24,099,877,747  
Rhode Island  $10,949   $457,198   $101,554   $569,701   $1,204,592   $2,729,259,438  
South 
$405,932   $4,939   $2,278,899   $2,689,770   $1,659,501   $6,027,888,585  
Carolina 
South Dakota  $27,680   $87,047   $75,100   $189,827   $423,692   $860,846,154  
Tennessee  $167,309   $35,756,988   $4,048,551   $39,972,848   $4,478,992   $9,506,550,239  
Texas  $206,588,242   $31,988   $3,437,584   $210,057,814  $17,634,003   $36,147,676,703  
Utah  $194,300   $5,625,000   $409,891   $6,229,191   $1,873,604   $2,300,014,634  
Vermont  $69,453   $93,510   $50,609   $213,572   $858,283   $1,666,066,978  
Virginia  $6,338,686   $335,698   $4,703,483   $11,377,867   $11,091,982   $8,510,779,754  
Washington  $162,701   $3,664,430   $2,151,942   $5,979,073   $4,159,243   $11,074,882,616  
West Virginia  $17,931   $1,724,827   $614,307   $2,357,065  $1,417,821   $3,835,749,849  
Wisconsin  $1,547,374   $29,275,001   $2,728,557   $33,550,932   $1,512,865   $8,212,122,596  
Wyoming  $21,013   $0   $23,435   $44,448   $475,174   $621,092,843  
     TOTAL2  $349,606,363   $250,258,434   $144,107,162   $743,971,959   $250,688,894   $548,190,828,914  
Source:  OIG analysis of MFCUs Annual Statistical Report data for FY 2015.   
1 The information in this table is accurate as of June 9, 2016.  States were able to provide revised data for FY 2015.  Therefore, the data in this table 
differs from the data reported in the Statistical Chart on the website available at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm, which was current as of February 16, 2016.   
2 The civil recoveries Units reported by provider type did not consistently match the civil recoveries reported by case type.  Therefore, the total civil 
recoveries reported in Table B1 does not equal the total recoveries for global and nonglobal civil recoveries reported in Table C2.   
 
 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  21   
Appendix D:  Noted Beneficial Practices from Unit Reports Published in 
FYs 2011-2015 
Noted Beneficial Practices from Unit Reports Published in FYs 2011-2015 
State and   Noted Beneficial 
Report Number  Practices  Summary1 
The Unit engaged in outreach activities that built 
relationships with stakeholders and aided the Units 
mission.  For example, the Unit director reported that 
Arkansas  
Outreach activities  experienced Unit staff often were asked to lead training 
OEI-06-12-00720 
pertaining to Unit work for external stakeholders, such as a 
training session by Unit investigators conducted for the 
Office of Long Term Care.  
The Unit implemented an investigative checklist that 
Investigative 
Idaho  improved the Units case flow.  In addition, Unit attorneys 
checklist and case 
OEI-09-12-00220  discuss the investigative case plan for each case with the 
plan 
case investigator prior to the Units monthly staff meetings.  
The Unit makes workspace available to an OIG Special 
OIG workspace 
Agent within the Unit offices. 
within the Unit 
Michigan 
Streamlined  Unit management and the Michigan Department of 
OEI-09-13-00070 
patient abuse or  Licensing and Regulatory Affairs developed a streamlined 
neglect referral  process for referring cases of patient abuse or neglect.  
process 
The Unit worked with two Minnesota Deputy Attorneys 
General to research and draft legislation that strengthens 
Legislation that 
Minnesota  Minnesotas background check processes for guardians and 
strengthens 
OEI-06-13-00200  conservators.  Additionally, the new legislation requires 
background checks  
that the court conduct background checks on guardians 
and conservators every 2 years, rather than every 4 years. 
The Units outreach program consisted of educational 
classes taught by Unit presenters who describe various 
types of fraud and abuse or neglect, discuss Federal and 
Provider Outreach 
Nevada  State laws regarding fraud and abuse or neglect, and 
and Train the 
OEI-09-12-00450  provide Unit contact information for reporting Medicaid-
Trainer Programs 
related crime.  The Units Train the Trainer program was 
instrumental in the success of the provider outreach 
program.  
continued on the next page 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  22   
Noted Beneficial Practices from Unit Reports Published in FYs 2011-2015 (continued) 
State and   Noted Beneficial 
Report Number  Practices  Summary 
The Unit sent a letter to nursing facilities and assisted living 
New Hampshire  Drug Diversion  facilities explaining that drug diversion is a form of patient 
OEI-02-12-00180  Letter  abuse or neglect.  As a result of this letter, facilities made 
 
drug diversion-related referrals to the Unit. 
The Unit developed a supervisory review document called a 
New Jersey  Case management  Joint Investigation Plan that includes tasks and deadlines, 
OEI-02-13-00020  tool  as well as descriptions of significant investigative and legal 
issues.  
Unit management and the State Medicaid agency worked 
closely to develop and implement an improved referral 
Managed care 
process that ensures that the Unit receives all appropriate 
referrals 
fraud referrals generated by Managed Care Organizations 
New Mexico 
(MCO).  
OEI-09-14-00240 
The Unit consistently provided program integrity 
Program integrity 
recommendations to the State Medicaid agency during 
recommendations 
quarterly joint protocol meetings. 
Approach to  The Unit established a separate Patient Protection Unit.  
patient abuse or  This resulted in the allocation of additional resources and 
neglect cases  expertise to patient abuse or neglect cases. 
The Unit developed a list of individuals and entities 
Sharing list of 
associated with ongoing investigations.  The Unit shared 
New York 
ongoing 
OEI-02-11-00440  this list with the Office of the Medicaid Inspector General 
investigations 
to facilitate communication about ongoing investigations.  
The Unit established an Electronic Investigative Support 
Use of technology  Group comprised of staff dedicated to providing technical 
assistance throughout a case.  
The Unit helped to establish the Ohio Program Integrity 
Group which combines the knowledge and resources of all 
Program integrity  the State agencies that are responsible for Medicaid 
groups  program integrity.  In addition, the Unit spearheaded the 
Ohio 
Managed Care Program Integrity Group which meets 
OEI-07-14-00290 
quarterly. 
The Unit employed a special projects team to provide 
Use of technology 
technical support to all of the investigative teams.  
Unit staff and stakeholders reported that relationships 
Tennessee   Involvement on  formed through participation on task forces, such as the 
OEI-06-12-00370  various task forces  Provider Fraud and Federal Health Care Fraud task forces, 
were key to the Units productivity.  
continued on the next page 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  23   
Noted Beneficial Practices from Unit Reports Published in FYs 2011-2015 (continued) 
State and   Noted Beneficial 
Report Number  Practices  Summary 
The Unit instituted an outreach program to ensure that 
the public is aware of the Units presence and mission 
Texas  Outreach  for the purpose of increasing the number of referrals 
OEI-06-13-00300  program   to the Unit.  The Unit required all investigators and 
investigative auditors to make one outreach contact 
per month, or 12 contacts per year.  
The Unit required all Unit auditors and investigators to 
Certified Fraud 
either be trained as a Certified Fraud Examiner (CFE) or be 
Examiner Training 
in training to become a CFE. 
The Unit tracked investigators workloads.  The chief 
investigator maintained a spreadsheet documenting the 
number of cases assigned to each investigator as well as 
Investigator 
Utah  the number of hours spent on each case.  This spreadsheet 
workload tracking 
OEI-09-13-00490  also monitored the complexity of each case, which the Unit 
took into account when assigning new cases to 
investigators.  
Unit management had discussions among the Unit, the 
Managed care  State Medicaid agency (Utah Department of Health), and 
referrals  MCOs to develop provisions in MCO contracts to ensure 
that MCOs send fraud referrals to the Unit. 
The Unit director created Provider Focus Teams in 
collaboration with the Program Integrity Unit in the 
Provider Focus 
Department of Vermont Health Access. The teams facilitate 
Teams   
existing cases, develop provider training, and make 
Vermont 
program recommendations.  
OEI-02-13-00360 
  The MFCU Unit Director helped create the Vermont Elder 
Elder Justice  Justice Working Group, consisting of representatives from 
Working Group  State and Federal advocacy, regulatory, and law 
enforcement agencies.   
Two individuals in the Unit passed examinations to become 
Improved staff 
Certified Fraud Examiners and another individual obtained 
credentials and 
certification as a Certified Coding Professional.  In addition, 
West Virginia  Unit outreach 
Unit investigators performed outreach at nursing homes.  
OEI-07-13-00080 
Managed care  The Unit began meeting with MCO administrators to obtain 
referrals.  
referrals  
Source:  OIG analysis of other observations in MFCU reports published in FYs 2011-2015. 
1 For more details about these noted practices and observations please see the respective reports at http://oig.hhs.gov/reports-
and-publications/oei/m.asp#mfcu. 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  24   
ENDNOTES 
 
1 SSA  1903(q).  Regulations at 42 CFR  1007.11(b)(1) add that the Units responsibilities may include reviewing 
complaints of misappropriation of patients private funds in residential health care facilities.   
2 SSA  1902(a)(61). 
3 North Dakota and the territories of American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the 
U.S. Virgin Islands have not established Units. 
4 SSA  1903(q)(6); 42 CFR 1007.13. 
5 SSA  1903(q)(2); 42 CFR 1007.9.(a) 
6 42 CFR  1007.9(d).   
7 SSA  1903(q)(1).  
8 SSA 1903(a)(6)(B). 
9 Ibid. 
10 OIG, MFCU Statistical Data for Fiscal Year 2015.  Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-
units-mfcu/expenditures_statistics/fy2015-statistical-chart.htm on February 18, 2016. 
11 SSA  1903(a)(6)(B).  The SSA authorizes the Secretary of HHS to award grants to the Units; the Secretary 
delegated this authority to the OIG.   
12 On occasion, OIG issues policy transmittals to provide guidance and instructions to MFCUs.  
13 77 Fed. Reg. 32645 (June 1, 2012). 
14 The MFCU interactive map with statistical information can be found at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/maps/interactive-map2015.asp.  
15 National Association of Medicaid Fraud Control Units (NAMFCU), Medicaid Fraud Report. January/February 
2015.  Accessed at http://namfcu.net/assets/files/newsletters/15JanFeb.pdf on May 2, 2016.  
16 Return on investment was calculated by dividing unit recoveries by the total grant expenditures.  The calculation 
included settlements on cases coordinated by NAMFCU. 
17 According to SSA  1128, 42 USC  1320a-7, OIG is required to exclude from participation in all Federal health 
care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid 
fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, the 
Childrens Health Insurance Program, or other State health care programs; patient abuse or neglect; felony 
convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating 
to unlawful manufacture, distribution, prescription, or dispensing of controlled substances. OIG Exclusions 
Background Information. Accessed at http://oig.hhs.gov/exclusions/background.asp on April 21, 2016.  
18 As a condition of those settlements, pharmaceutical companies were required to adopt corporate integrity 
agreements that were designed to prevent future abusive practices.  Other corporations have adopted voluntary 
compliance programs, promoted by OIG, which may have further reduced the incidence of fraud allegations.   
19 Congress enacted legislation leading to the creation of the NPDB, a national collection program for data on health 
care fraud and abuse, in an effort to restrict the ability of incompetent physicians and dentists to move from State to 
State without disclosure or discovery of the physicians previous damaging or incompetent performance.  Accessed 
at https://www.npdb.hrsa.gov/resources/aboutGuidebooks.jsp on June 9, 2016. 
20 The Units are required to have an MOU with the State Medicaid agency as a formal agreement between the two 
entities.  According to Performance Standard 10, MOUs should be updated regularly and should reflect current 
practice, among other indicators. 
21 77 Fed. Reg. 32648 (June 1, 2012). 
22 45 CFR  60.5.  In addition to Federal regulations, the Performance Standards also require Units to report to 
NPDB.  Performance Standard 8(g) states that the Unit should report qualifying cases to the Healthcare Integrity & 
Protection Databank [HIPDB], the National Practitioner Data Bank, or successor data bases. Examples of final 
adverse actions include, but are not limited to, convictions, civil judgments (but not civil settlements), and program 
exclusions.  See SSA  1128E(g)(1) and 45 CFR  60.3. 
 
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  25 
   
ACKNOWLEDGEMENTS 
This report was prepared under the direction of Brian Whitley, Regional Inspector General for 
Evaluation and Inspections in the Kansas City regional office, and Jennifer King, Deputy 
Regional Inspector General; and in consultation with Richard Stern, Director of the Medicaid 
Fraud Policy and Oversight Division.   
Conswelia McCourt served as the team leader for this study.  Other Office of Evaluation and 
Inspections staff from the Kansas City regional office who conducted the study include Michala 
Walker and Abbi Warmker.  Other Medicaid Fraud Policy and Oversight Division staff who 
provided support include Susan Burbach and Jordan Clementi.  Central Office staff who 
provided support include Joanne Legomsky.  Other OIG staff who provided support include 
Jessica Swanstrom.   
Medicaid Fraud Control Units FY 2015 Annual Report (OEI-07-16-00050)  26