U.S. Department of Health and Human Services 
Office of Inspector General 
Medicaid Fraud Control  
Units Fiscal Year 2021  
Annual Report 
 
Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections 
March 2022, OEI-09-22-00020  U.S. Department of Health and Human Services 
 
Office of Inspector General 
Report in Brief 
March 2022, OEI-09-22-00020 
Medicaid Fraud Control Units Fiscal Year 2021 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 
su bmitted to OIG for fiscal year 2021.  Those MFCUs operated in all 50 States, the District of Columbia, Puerto Rico, and the 
U.S. Virgin Islands.     
 
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 1 
CASE OUTCOMES .......................................................................................................................................... 4 
MFCUs reported 1,105 total convictions in FY 2021 .................................................................................................... 4 
MFCUs reported criminal recoveries significantly increased to $857 million in FY 2021 ............................. 8 
MFCUs reported 716 civil settlements and judgments in FY 2021 ........................................................................ 9 
MFCUs reported civil recoveries of $826 million in FY 2021 .................................................................................. 10 
CONCLUSION ................................................................................................................................................ 11 
APPENDICES .................................................................................................................................................. 12 
Appendix A: Beneficial Practices Described in Office of Inspector General Inspection Reports ............... 12 
Appendix B: Medicaid Fraud Control Unit Case Outcomes and Open Investigations by Provider Type 
and Case Type for Fiscal Year 2021 .................................................................................................................................. 19 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 26 
Acknowledgments .................................................................................................................................................................. 26 
Contact ........................................................................................................................................................................................ 26 
ABOUT THE OFFICE OF INSPECTOR GENERAL ..................................................................................... 27 
ENDNOTES ................................................................................................................................................... 28 
 
 
   
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) 2021, all 50 States, the District of Columbia, Puerto Rico, 
and the U.S. Virgin Islands operated MFCUs.3, 4           
MFCUs are funded jointly by the 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 2021, combined Federal and State expenditures 
for the Units totaled approximately $314 million, of which approximately $236 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; 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 2021 Annual Report   
OEI-09-22-00020   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 and inspections (hereinafter referred to as inspections) of 
Units, providing technical assistance to Units, and monitoring key statistical data 
about Unit caseloads and outcomes.9    
Annually, OIG reviews each Units application for recertification; approval of this 
application is necessary for the Unit to receive Federal reimbursement.10  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.11   
OIG further assesses a Units performance by conducting inspections of Units that 
may identify findings and lead to OIG making 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 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 2021 Annual Statistical Reports 
that 53 MFCUs submitted to OIG, the recertification materials that the MFCUs 
submitted to OIG, and OIG exclusions data.   
Similar to the Medicaid Fraud Control Units Fiscal Year 2020 Annual Report, we 
analyzed information about the effects of the ongoing COVID-19 pandemic 
(pandemic).  In FY 2020, OIG surveyed MFCUs to assess the impact of the pandemic 
on their operations.  Because the pandemic was still ongoing in FY 2021, we further 
analyzed the MFCUs recertification information submitted in FY 2021 to gain an 
understanding of the pandemics continued impact on their operations.      
We aggregated case outcomes across all Units for FY 2021 and for each of the 
preceding 4 yearsFYs 2017 through 2020.  These outcomes include convictions, civil 
settlements and judgments, and recoveries.  We also calculated the return on 
investment (ROI) for MFCUs.12  We identified the provider types with the highest 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report   
OEI-09-22-00020   Background | 2    
numbers of criminal and civil outcomes in FY 2021 and the numbers of exclusions that 
OIG imposed in FY 2021 on individuals and entities as a result of conviction referrals 
from MFCUs.  We also analyzed MFCU drug diversion cases using data for 
FYs 2017 through 2021.  Additionally, we highlight the beneficial practices described 
in each Units more recent inspections, as described in Appendix A. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the 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 2021 Annual Report   
OEI-09-22-00020   Background | 3    
CASE OUTCOMES 
 
In FY 2020, Units reported to OIG that the pandemic created significant challenges for 
staff, operations, and court proceedings, which limited case outcomesparticularly 
criminal outcomes.  For example, Units reported that court systems in general had 
closed their in-person operations and postponed or reduced the number of grand 
jury proceedings.  
In FY 2021, MFCUs reported continued operational challenges attributable to the 
pandemic.  Units reported limitations with in-person staff training, restricted access to 
long-term care facilities and/or witnesses, and continued court closures, among other 
challenges.  However, they noted that some of these pandemic-associated challenges 
had begun to subside.  For example, some courts had reopened, allowing 
proceedings to continue, which started to reduce the backlog of prosecutions.  Some 
Units also reported that long-term care facilities had begun to permit in-person 
access, allowing MFCU staff to follow up on referrals of patient abuse and neglect.  
MFCUs reported 1,105 total convictions in FY 2021 
Total convictions resulting from MFCU cases increased from 1,017 in FY 2020 to 
1,105 in FY 2021.  In FY 2021, MFCU cases resulted in 780 convictions for fraud and 
325 convictions for patient abuse or neglect, similar to the distribution in previous 
years.  Exhibit 2 shows the total number of convictions during FYs 2017 through 2021. 
Exhibit 2: Fraud convictions accounted for about 70 percent of all FY 2021 
convictions. 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20172021. 
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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.13    
In FY 2021, OIG imposed a total of 1,689 exclusions on individuals and entities.  MFCU 
cases were responsible for 540 of those exclusions.  In addition to these 540 MFCU-
generated exclusions, MFCUs participated in 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 2017 through 2021.  
Exhibit 3 shows the number of PCS fraud convictions, as compared to total fraud 
convictions, in FYs 20172021.  
Exhibit 3: Fraud convictions involving PCS attendants and agencies 
accounted for a significant portion of total fraud convictions in  
FYs 20172021. 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20172021. 
 
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In FY 2021, fraud convictions involving PCS attendants and agencies accounted for 
329 of the total 780 fraud convictions (42 percent).   
Exhibit 4 shows the provider types with the most fraud convictions in FY 2021.  See 
Appendix B for detailed statistics, by provider type, on the number of criminal 
convictions, civil settlements or judgments, and recovery amounts, as well as the 
number of open investigations. 
Exhibit 4: Convictions of PCS attendants and agencies for fraud were 
significantly higher than for any other provider type in FY 2021. 
 
*LPN=Licensed Practical Nurse, RN=Registered Nurse, NP=Nurse Practitioner, and PA=Physician Assistant.  
Source: OIG analysis of FY 2021 Annual Statistical Reports. 
MFCUs reported 155 convictions from drug diversion cases in 
FY 2021 
MFCU convictions related to drug diversion increased slightly from 146 in FY 2020 to 
155 in FY 2021, and associated criminal recoveries totaled $1.87 million in FY 2021.  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.14  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 2017 through 2021. 
 
 
 
 
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Exhibit 5: Convictions from drug diversion cases increased in FY 2021, after a 
decline during the first year of the pandemic. 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20172021. 
In FY 2021, more convictions for patient abuse or neglect 
involved personal care aides or other home care aides than any 
other provider type 
In FY 2021, convictions of personal care aides or other home care aides accounted for 
69 of the total 325 convictions for patient abuse or neglect (21 percent).  
Exhibit 6 shows the provider types with the most convictions for patient abuse or 
neglect.  
Exhibit 6: In FY 2021, convictions of personal care aides or other home care 
aides for patient abuse or neglect were higher than for any other provider 
type. 
 
*CNA=Certified Nurse Assistant.  
Source: OIG analysis of FY 2021 Annual Statistical Reports. 
 
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MFCUs reported criminal recoveries significantly increased to 
$857 million in FY 2021 
MFCU criminal recoveries increased substantially from $173 million in FY 2020 to 
$857 million in FY 2021.  Total criminal recoveries varied over the 5-year period 
ending in FY 2021.  The increase in criminal recovery amounts in FY 2021 was 
primarily the result of cases prosecuted by MFCUs in the States of Virginia and Texas.  
Those MFCUs reported a combined $714 million in criminal recoveries (approximately 
83 percent of the total reported criminal recoveries).       
Exhibit 7: Criminal recoveries varied during FYs 2017 through 2021. 
 
Source: OIG analysis of Annual Statistical Reports for FYs 20172021. 
As an example, in one case the Virginia MFCU worked with the U.S. Attorneys Office 
to prosecute a doctor who performed services that were not medically necessary, 
performed services without the consent of the patient, and billed for services that 
were not actually performed.  The court ordered the defendant to pay approximately 
$18.6 million in restitution and sentenced the defendant to 59 years in prison.15 
The Texas MFCU also reported that several cases resulted in large criminal recoveries 
in FY 2021.  For example, one case that the Unit prosecuted with the U.S. Attorneys 
Office involved a corporate executive who falsely informed patients with long-term, 
incurable diseases that they had less than 6 months to live and subsequently enrolled 
them in hospice programs.  The court ordered the defendant to pay $120 million in 
restitution and sentenced the defendant to 20 years in prison.16   
 
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MFCUs reported 716 civil settlements and judgments in FY 2021 
The total number of civil settlements and judgments decreased from 786 in 
FY 2020 to 716 in FY 2021.  As shown in Exhibit 8, the total number of civil settlements 
and judgments decreased from FY 2017 to FY 2019, and then increased in FY 2020.  
Similar to FY 2020, more civil settlements and judgments involved pharmaceutical 
manufacturers than any other provider type in FY 2021.  The number of 
pharmaceutical civil settlements and judgments decreased slightly in FY 2021, 
accounting for 257 of the 716 civil settlements and judgments (36 percent).    
Exhibit 8: The total number of civil settlements and judgments varied during 
FYs 2017 through 2021.  
 
Source: OIG analysis of Annual Statistical Reports for FYs 20172021. 
Following pharmaceutical manufacturers, suppliers of durable medical equipment, 
prosthetics, orthotics, and supplies (DMEPOS) had the second-highest number of civil 
settlements and judgments (see Exhibit 9). 
Exhibit 9: Pharmaceutical manufacturers had the highest number of civil 
settlements and judgments in FY 2021, followed by suppliers of DMEPOS. 
 
Source: OIG analysis of FY 2021 Annual Statistical Reports. 
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MFCUs reported civil recoveries of $826 million in FY 2021 
In FY 2021, civil recoveries decreased from $855 million in FY 2020 to $826 million in 
FY 2021.  As shown in Exhibit 10, civil recoveries were substantially higher in FY 2019 
relative to other years.  In FY 2019, 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 2021 were slightly lower than in FY 2020. 
 
Note: Dollar values are rounded to the nearest tenth.  
Source: OIG analysis of Annual Statistical Reports for FYs 20172021. 
 
The distribution of global and nonglobal civil 
Types of Civil Cases 
recoveries in FY 2021 shifted from the 
A global case involves both the 
distribution in FY 2020.  In FY 2021, 
Federal Government and a group 
approximately 46 percent ($379 million) of the 
of States and is coordinated by 
$826 million in civil recoveries derived from 
the National Association of 
nonglobal cases, while in FY 2020 nonglobal 
Medicaid Fraud Control Units.  
recoveries accounted for approximately 
26 percent ($218 million) of the total amount of  A nonglobal case is conducted by 
civil recoveries.17    a Unitindividually or with other 
law enforcement partnersand is 
In one global case involving a pharmaceutical 
not coordinated by the National 
manufacturer, 50 States, the District of Columbia, 
Association of Medicaid Fraud 
and Puerto Rico partnered with Federal agencies 
Control Units. 
to pursue allegations that the pharmaceutical 
manufacture promoted the sale and use of an 
opioid treatment drug to physicians who were improperly prescribing the drug.  In 
addition, the manufacturer allegedly promoted the drug using false and misleading 
claims and took steps to fraudulently delay the entry of generic forms of the drug.  As 
a result of the investigation, the pharmaceutical manufacturer agreed to pay a total of 
$300 million$91 million of which was related to State Medicaid programs.18 
 
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CONCLUSION 
Most MFCU case outcomes were generally consistent with those of the previous year 
and MFCUs reported that the ongoing pandemic continued to present operational 
challenges in FY 2021.  However, despite challenges posed by the pandemic, Units 
continued to carry out their Medicaid program integrity functions.  For instance, 
MFCUs experienced a significant increase in criminal recoveries and nonglobal civil 
recoveries in FY 2021.  Overall, MFCUs efforts in FY 2021 contributed to total 
recoveries of $1.7 billion, with an ROI of $5.36 for every $1 spent.   
As in past MFCU annual reports, Appendix A describes the many beneficial practices 
implemented by the MFCUs as identified by OIG during our inspections, which other 
MFCUs may want to consider for adoption.  Beneficial practices from inspection 
reports published in FY 2021 include the following:   
  Hiring an outreach coordinator to promote the Units mission among its 
stakeholders: The outreach coordinators responsibilities are to promote the 
Louisiana Units mission among nursing homes, rehabilitation facilities, local 
law enforcement agencies, and other State agencies.  The outreach 
coordinator is responsible for: (1) developing supplemental training regarding 
the Units mission and presenting that training to Unit stakeholders;  
(2) coordinating with the Louisiana Department of Justice on press releases; 
and (3) acting as a liaison to receive referrals from stakeholders.    
  Sponsoring combined training events with a neighboring Unit: The Louisiana 
Unit and a neighboring Unit alternated hosting a combined training for 
employees of both Units.  Training events included case studies, statistical 
trends, and roundtable discussions.   
  Notifying referral sources of the Units decision whether to open formal 
investigations of incoming referrals: Through secure electronic channels, the 
South Carolina Unit communicated with the State Medicaid agency and other 
referral sources regarding the Units decision to accept or decline referrals. In 
response, State officials lauded the responsiveness of the Units 
communications.  The Unit followed a similar practice, where appropriate, 
regarding referrals received from private citizens.   
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 2022, the Ohio MFCU received this 
award for its high number of case outcomes across a mix of case types, excellent 
partnership with OIG and other Federal and State partners, and regular contributions 
to the larger MFCU community.   
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Conclusion | 11   
APPENDICES 
Appendix A: 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. 
Kansas  Supplementing reviews of referrals of 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 2021 Annual Report 
OEI-09-22-00020  Appendix A | 12   
Beneficial Practices Described in Office of Inspector General 
Inspection Reports 
A Unit takes steps to maintain an adequate volume and quality of referrals 
STANDARD 4  
from the State Medicaid agency and other sources.  
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. 
Louisiana  Hiring an outreach coordinator to promote the Units mission among its 
OEI-12-20-00650  stakeholders: The outreach coordinators responsibilities are to promote the 
August 2021  Units mission among nursing homes, rehabilitation facilities, local law 
enforcement agencies, and other State agencies.  The outreach coordinator is 
responsible for: (1) developing supplemental training regarding the Units 
mission and presenting that training to Unit stakeholders; (2) coordinating with 
the Louisiana Department of Justice on press releases; and (3) acting as a liaison 
to receive referrals from stakeholders.   
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 may encounter.   
New York  Establishing data analytics working groups to improve the Units ability to 
OEI-12-17-00340  data mine to find potential cases: The Unit established data analytics working 
September 2018  groups to provide 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.   
  continued on the next page 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix A | 13   
Beneficial Practices Described in Office of Inspector General 
Inspection Reports 
A Unit takes steps to maintain an adequate volume and quality of referrals 
STANDARD 4  
from the State Medicaid agency and other sources.  
Ohio  Establishing a program integrity group composed of personnel from other 
OEI-07-14-00290  Medicaid program integrity entities: To improve the quantity and quality of 
April 2015  referrals, the Unit established the Ohio Program Integrity Group, which 
combines the knowledge and resources of all of the State agencies that are 
responsible for Medicaid program integrity.  In addition, the Unit spearheaded 
the Managed Care Program Integrity Group, which meets quarterly. 
Oregon  Establishing an outreach group to increase referrals of 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 of 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 Carolina  Notifying referral sources of the Units decision whether to open formal 
OEI-12-20-00610  investigations of incoming referrals: Through secure electronic channels, the 
September 2021  Unit communicated with the State Medicaid agency and other referral sources 
regarding the Units decision to accept or decline referrals. In response, State 
officials lauded the responsiveness of the Units communications.  The Unit 
followed a similar practice, where appropriate, regarding referrals received from 
private citizens.   
Washington  Revising the Units MOU and contracts with State Medicaid partners to 
OEI-09-16-00010  ensure the receipt of fraud referrals from MCOs: The Unit worked with the 
September 2016  State 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. 
  continued on the next page 
 
 
 
 
 
 
 
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OEI-09-22-00020  Appendix A | 14   
Beneficial Practices Described in Office of Inspector General 
Inspection Reports 
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 on 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 of its investigative teams. 
April 2015 
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, and to automatically prompt Unit staff to meet 
  specific milestones and document activity in casefiles, as appropriate.  The Unit 
found that this improved 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. 
  continued on the next page 
 
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Beneficial Practices Described in Office of Inspector General 
Inspection Reports 
A Unit cooperates with OIG and other Federal agencies in the 
STANDARD 8 
investigation and prosecution of Medicaid and other health care fraud.   
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. 
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. 
  continued on the next page 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix A | 16   
Beneficial Practices Described in Office of Inspector General 
Inspection Reports 
A Unit makes statutory or programmatic recommendations, when 
STANDARD 9 
warranted, to the State government.   
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. 
Louisiana  Sponsoring combined training events with a neighboring Unit: The Unit and 
OEI-12-20-00650  a neighboring Unit alternated hosting a combined training for employees of 
August 2021  both Units.  Training events included case studies, statistical trends, and 
roundtable discussions. 
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. 
  continued on the next page 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix A | 17   
Beneficial Practices Described in Office of Inspector General 
Inspection Reports 
STANDARD 12   A Unit conducts training that aids in the mission of the Unit.   
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 of 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. 
Beneficial practices not relating directly to a specific performance 
OTHER  
standard. 
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. 
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 2021 Annual Report 
OEI-09-22-00020  Appendix A | 18   
Appendix B: Medicaid Fraud Control Unit Case Outcomes and Open 
Investigations by Provider Type and Case Type for Fiscal Year 2021 
Exhibit B1: 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  13  $60,654  1  $1,000 
Developmental Disability Facility  10  $129,976  1  $128,078 
(Residential) 
Hospice  0  $0  0  $0 
Nondirect Care Staff  19  $181,736  0  $0 
Nurse Aide (CNA or Other)  67  $72,940  0  $0 
Nursing Facilities  11  $43,018  10  $478,976 
Nurse (LPN, RN, or NP) or Physician  58  $162,175  0  $0 
Assistant  
Personal Care Aide or Other Home  69  $175,643  0  $0 
Care Aide 
Other  78  $1,200,312  1  $354 
FraudFacility-Based Medicaid Providers and ProgramsInpatient and/or Residential 
Assisted Living Facility  2  $495  2  $187,895 
Developmental Disability Facility  1  $376,695  1  $90,175 
(Residential)  
Hospice   6  $85,327,396  1  $0 
Hospital  4  $42,717,587  13  $33,816,634 
Inpatient Psychiatric Services for  1  $25,046  0  $0 
Individuals Under Age 21 
Nursing Facility  0  $0  3  $438,176 
Other Inpatient Mental Health Facility  0  $0  2  $3,220,210 
Other Long-Term Care Facility  3  $21,272  1  $34,876 
continued on the next page 
 
     
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 19 
   
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  0  $0  3  $1,072,335 
Ambulatory Surgical Center   1  $1,185,800  0  $0 
Developmental Disability Facility  3  $21,360,424  2  $170,980 
(Nonresidential)  
Dialysis Center   0  $0  0  $0 
Mental Health Facility (Nonresidential)   25  $15,438,603  13  $20,705,608 
Substance Abuse Treatment Center   8  $18,050,847  8  $7,078,394 
Other Facility (Nonresidential)   3  $4,952,295  2  $2,577,584 
FraudLicensed Practitioners 
Audiologist   0  $0  2  $161,050 
Chiropractor   2  $31,337  1  $1,559,930 
Clinical Social Worker   4  $288,492  4  $314,376 
Dental Hygienist   0  $0  0  $0 
Dentist   11  $3,338,577  10  $528,864 
Nurse (LPN, RN, or Other Licensed)  83  $2,158,802  2  $13,391 
Nurse Practitioner   7  $52,959,666  0  $0 
Optometrist   0  $0  1  $13,967 
Pharmacist   1  $0  0  $12,928 
Physician Assistant   3  $0  1  $50,000 
Podiatrist   3  $30,780  3  $110,887 
Psychologist   5  $1,372,277  1  $45,000 
Therapist (Non-Mental Health, PT, ST,  5  $3,314,337  0  $0 
OT, or RT) 
Other Practitioner  9  $798,673  8  $1,583,623 
FraudMedical Services 
Ambulance   4  $353,285  1  $34,641 
Billing Services  1  $6,121,756  2  $22,501 
continued on the next page 
 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 20 
   
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   39  $175,626,026  28  $18,412,408 
Lab (Clinical)  4  $4,153,597  32  $22,657,547 
Lab (Radiology and Physiology)   2  $0  2  $6,681,722 
Lab (Other)  0  $0  11  $2,742,327 
Medical Device Manufacturer   0  $0  69  $11,142,557 
Pain Management Clinic   0  $717  3  $3,351,664 
Personal Care Services Agency  20  $5,212,285  4  $626,487 
Pharmaceutical Manufacturer   3  $301,180,450  257  $408,384,612 
Pharmacy (Hospital)   0  $0  0  $11,192,821 
Pharmacy (Institutional Wholesale)   1  $903,346  5  $2,366,360 
Pharmacy (Retail)   14  $4,513,232  23  $4,006,228 
Suppliers of Durable Medical  7  $13,505,016  74  $212,325,368 
Equipment, Prosthetics, Orthotics, and 
Supplies (DMEPOS) 
Transportation (Nonemergency)  17  $111,661  7  $6,791,169 
Other  6  $7,731,296  18  $5,857,413 
FraudOther Individual Providers 
Emergency Medical Technician or  1  $4,429  0  $0 
Paramedic 
Nurses Aide (CNA or Other)  28  $1,284,325  0  $0 
Optician   0  $0  0  $0 
Personal Care Services Attendant   309  $6,448,057  13  $58,238 
Pharmacy Technician   4  $190,039  0  $0 
Unlicensed Counselor (Mental Health)   12  $3,991,040  2  $700,000 
Unlicensed Therapist (Non-Mental  2  $6,694  1  $1,061 
Health) 
Other  53  $26,808,477  3  $24,280 
continued on the next page 
 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 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 
FraudPhysicians (MD/DO) by Medical Specialty 
Allergist/Immunologist  1  $75,402  1  $2,149,256 
Cardiologist  0  $0  2  $127,356 
Emergency Medicine  1  $18,198  2  $197,703 
Family Practice   22  $8,388,888  9  $2,504,848 
Geriatrician   0  $0  0  $0 
Internal Medicine   4  $81,750  7  $5,149,946 
Neurologist   0  $0  2  $138,318 
Obstetrician/Gynecologist   2  $20,844,613  3  $281,649 
Ophthalmologist   2  $763  0  $0 
Pediatrician   0  $0  6  $1,583,148 
Physical Medicine and Rehabilitation   2  $234,325  0  $0 
Psychiatrist   4  $4,667,727  1  $244,303 
Radiologist   0  $0  1  $1,490,515 
Surgeon   1  $4,973,432  3  $170,815 
Urologist   0  $0  0  $0 
Other MD/DO   15  $3,221,406  9  $3,033,316 
FraudProgram Related 
Managed Care Organization (MCO)   0  $0  14  $6,573,536 
Medicaid Program Administration   0  $0  1  $10,600,000 
Other  9  $206,091  3  $163,774 
TOTAL  1,105  $856,634,176  716  $826,183,179 
 
 
 
 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 22 
   
Exhibit B2: Number of open investigations at the end of FY 2021 by provider type and case type 
  OPEN INVESTIGATIONS 
PROVIDER TYPE    Criminal  Civil  Total 
Patient Abuse or Neglect 
Assisted Living Facility  210  7  217 
Developmental Disability Facility (Residential)  224  4  228 
Hospice   8  0  8 
Nondirect Care Staff  131  0  131 
Nurse Aide (CNA or Other)  354  3  357 
Nursing Facilities   972  68  1,040 
Nurse (RN, LPN, or NP) or Physician Assistant   298  2  300 
Personal Care Aide or Other Home Care Aide   272  0  272 
Other  816  6  822 
FraudFacility-Based Medicaid Providers and ProgramsInpatient and/or Residential 
Assisted Living Facility  38  12  50 
Developmental Disability Facility (Residential)  34  7  41 
Hospice  69  31  100 
Hospital   70  219  289 
Inpatient Psychiatric Services for Individuals Under  8  9  17 
Age 21  
Nursing Facility  120  201  321 
Other Inpatient Mental Health Facility  17  26  43 
Other Long-Term Care Facility  12  16  28 
FraudFacility-Based Medicaid Providers and ProgramsOutpatient and/or Day Services 
Adult Day Center   83  3  86 
Ambulatory Surgical Center   3  11  14 
Developmental Disability Facility (Nonresidential)   33  15  48 
Dialysis Center   0  61  61 
Mental Health Facility (Nonresidential)   369  66  435 
Substance Abuse Treatment Center   155  52  207 
Other Facility (Nonresidential)   85  79  164 
continued on the next page 
 
 
 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 23 
   
Exhibit B2: Number of open investigations at the end of FY 2021 by provider type and case type 
(continued) 
  OPEN INVESTIGATIONS 
PROVIDER TYPE    Criminal  Civil  Total 
FraudLicensed Practitioners 
Audiologist   7  3  10 
Chiropractor   23  4  27 
Clinical Social Worker   70  3  73 
Dental Hygienist   2  2  4 
Dentist   263  67  330 
Nurse (LPN, RN, or Other Licensed)  485  8  493 
Nurse Practitioner   72  10  82 
Optometrist   20  12  32 
Pharmacist   60  23  83 
Physician Assistant   27  0  27 
Podiatrist   23  13  36 
Psychologist   78  15  93 
Therapist (Non-Mental Health, PT, ST, OT, or RT)  95  31  126 
Other Practitioner   121  17  138 
FraudMedical Services 
Ambulance   53  44  97 
Billing Services   52  88  140 
Home Health Agency   558  104  662 
Lab (Clinical)   112  538  650 
Lab (Radiology and Physiology)   27  54  81 
Lab (Other)  36  191  227 
Medical Device Manufacturer   3  673  676 
Pain Management Clinic   54  15  69 
Personal Care Services Agency   171  11  182 
Pharmaceutical Manufacturer   65  2,354  2,419 
Pharmacy (Hospital)   1  3  4 
Pharmacy (Institutional Wholesale)   10  207  217 
Pharmacy (Retail)   353  916  1,269 
Transportation (Nonemergency)  260  24  284 
Suppliers of Durable Medical Equipment, Prosthetics,  167  552  719 
Orthotics, and Supplies (DMEPOS) 
Other  79  312  391 
continued on the next page 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 24 
   
 
Exhibit B2: Number of open investigations at the end of FY 2021 by provider type and case type 
(continued) 
  OPEN INVESTIGATIONS 
PROVIDER TYPE    Criminal  Civil  Total 
FraudOther Individual Providers 
Emergency Medical Technician or Paramedic   0  1  1 
Nurse Aide (CNA or Other)  73  0  73 
Optician   1  4  5 
Personal Care Services Attendant   1,693  22  1,715 
Pharmacy Technician   16  0  16 
Unlicensed Counselor (Mental Health)   71  4  75 
Unlicensed Therapist (Non-Mental Health)   11  1  12 
Other  405  47  452 
FraudPhysicians (MD/DO) by Medical Specialty 
Allergist/Immunologist   7  2  9 
Cardiologist   16  17  33 
Emergency Medicine   22  34  56 
Family Practice   226  40  266 
Geriatrician   3  1  4 
Internal Medicine   134  33  167 
Neurologist   21  4  25 
Obstetrician/Gynecologist  29  8  37 
Ophthalmologist   18  15  33 
Pediatrician   46  9  55 
Physical Medicine and Rehabilitation   23  7  30 
Psychiatrist   68  14  82 
Radiologist   7  18  25 
Surgeon   36  16  52 
Urologist   4  3  7 
Other MD/DO  185  88  273 
FraudProgram Related 
Managed Care Organization (MCO)  18  81  99 
Medicaid Program Administration   13  12  25 
Other  145  123  268 
Total  11,019  7,796  18,815 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report 
OEI-09-22-00020  Appendix B | 25 
   
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Linda Min served as the team leader for this study, and Matt DeFraga served as the 
lead analyst.  Office of Evaluation and Inspections (OEI) staff who provided support 
include Susan Burbach, Jordan Clementi Gerken, Robert Gibbons, Christina Lester, 
Petra Nealy, Keith Peters, and China Tantameng. 
We would also like to acknowledge the contributions of other Office of Inspector 
General (OIG) staff, including Alexis Crowley, Lonie Kim, Jessica Swanstrom, and Sara 
Swisher. 
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 2021 Annual Report   
OEI-09-22-00020  Acknowledgments and Contact | 26    
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 2021 Annual Report   
OEI-09-22-00020  About the Office of Inspector General | 27    
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.  Units may investigate 
patient abuse and neglect 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 2021.  
 
7 42 CFR  1007.20.  MFCUs must receive approval from OIG to conduct data mining.  As of January 2022, 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 January 27, 2022.  
 
8 SSA  1128; 42 U.S.C.  1320a-7.  See also OIG, Background Information, https://oig.hhs.gov/exclusions/background.asp.  
Accessed on January 27, 2022.  
 
9 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. 
 
10 42 CFR  1007.15. 
 
11 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  
   
12 To calculate the ROI for MFCUs, we first calculated the total recoveries by adding the $857 million in criminal case recoveries 
to the $826 million in civil case recoveries.  We then divided the $1.7 billion in total recoveries by the total MFCU grant 
expenditures of $314 million, resulting in the overall ROI of $5.36 for every $1 spent. 
 
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report   
OEI-09-22-00020  Endnotes | 28    
 
13 OIG, LEIE Downloadable Databases, https://oig.hhs.gov/exclusions/exclusions_list.asp.  Accessed on January 27, 2022.  The list 
of OIG-excluded individuals or entities can be found on the OIG website.   
 
14 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 in which Units are eligible to receive 
Federal financial participation to investigate and prosecute drug diversion cases.  
 
15 United States Department of Justice, Former Chesapeake OB/GYN Sentenced to 59 Years in Prison, May 18, 2021.  
https://www.justice.gov/usao-edva/pr/former-chesapeake-obgyn-sentenced-59-years-prison.  Accessed on March 1, 2022.  
Office of the Attorney General of Virginia, Medicaid Fraud Control Unit Annual Report 2020-2021.  
https://www.oag.state.va.us/34-resource/mfcu/181-mfcu-publications.  Accessed on March 1, 2022. 
 
16 United States Department of Justice, Owner of Texas Chain of Hospice Companies Sentenced for $150 Million Health Care 
Fraud and Money Laundering Scheme, December 16, 2020.  https://www.justice.gov/opa/pr/owner-texas-chain-hospice-
companies-sentenced-150-million-health-care-fraud-and-money.  Accessed on February 9, 2022. 
 
17 To calculate the percentages for civil global and nonglobal recoveries, we used the total civil recoveries of  
$826,183,179 and rounded the dollar value to the nearest tenth.  Global cases accounted for $447.5 million (54 percent) in 
FY 2021.  
 
18 National Association of Medicaid Fraud Control Units, Indivior plc and Indivior Inc. Pay $300 Million to Settle Allegations of 
Improper Marketing and Sale of Suboxone, April 27, 2021. 
https://www.namfcu.net/assets/files/Indivior%20Press%20Release%20-%20NAMFCU.pdf.  Accessed on January 27, 2022.  
 
Medicaid Fraud Control Units Fiscal Year 2021 Annual Report   
OEI-09-22-00020  Endnotes | 29