U.S. Department of Health and Human Services 
Office of Inspector General 
Medicaid Fraud 
Control Units 
Fiscal Year 2016 
Annual Report
 
 
 
Daniel R. Levinson 
Inspector General  
 
May 2017 
OEI-09-17-00210 
   
TABLE OF CONTENTS 
 
INTRODUCTION  ..........................................................................................................................1 
CASE OUTCOMES  
In Fiscal Year 2016, Units reported 1,564 convictions, 998 civil settlements      
and judgments, and almost $1.9 billion in criminal and civil recoveries ................4 
Fiscal Year 2016 continued a trend of increasing numbers of convictions; civil 
settlements/judgments were the highest among the last 5 years ..............................6 
APPENDIXES 
A:  Noted Beneficial Practices from Unit Reports Published in  
Fiscal Years 20112016 ...................................................................................10 
B:  Fiscal Year 2016 MFCU Case Outcomes and Open Investigations by      
Provider Type and Case Type ..........................................................................16 
C:  Selected Fiscal Year 2016 Statistical Data .......................................................22 
ACKNOWLEDGMENTS ............................................................................................................26 
ENDNOTES  ................................................................................................................................27 
 
 
 
 
 
   
INTRODUCTION 
The mission of Medicaid Fraud Control Units (MFCUs or Units) is to investigate and prosecute 
under State law Medicaid provider fraud and patient abuse or neglect.1  The Social Security 
Act (the Act) 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 
Units must meet a number of requirements established by the Act and Federal regulations.  For 
example, each Unit must: 
  be a single, identifiable entity of State Government, distinct from the State Medicaid 
agency;4  
  employ an interdisciplinary staff that consists of at least an investigator, an auditor, and 
an attorney;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 
Unit staff review referrals of possible fraud and patient abuse or neglect to determine their 
potential for criminal prosecution and/or civil action.  As illustrated below (Exhibit 1), Unit cases 
may begin as a referral from a single source or from multiple sources.  If accepted by the Unit for 
investigation, these cases may result in various outcomes, including convictions, civil 
settlements, and monetary recoveries.  
 
 
 
 
 
 
 
 
 
 
 
 
 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   1   
INTRODUCTION 
OIG Oversight of the MFCU Program 
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 the 
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) 2016, combined Federal and State expenditures for the Units 
totaled approximately $259 million, $194 million of which represented Federal funds.10  
Strengthening the effectiveness of MFCUs as key partners combatting fraud and abuse is a top 
OIG priority. 
OIG administers 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.12   
In recertifying the Units, OIG annually assesses each Units compliance with the Federal 
requirements for MFCUs contained in statute, regulations, and OIG policy transmittals.  
Additionally, OIG examines Units adherence to 12 performance standards, such as those for 
staffing, maintaining adequate referrals, and cooperation with Federal authorities.13 
On an annual basis, OIG collects and disseminates statistical data reported by the MFCUs 
regarding outcomes such as the number of convictions and amounts of recoveries by Units.  OIG 
maintains statistical data, including an interactive map, about MFCU outcomes on its Web site, 
located here: FY 2016 Interactive Map.14 
OIG also provides ongoing technical assistance and guidance to Units.  The assistance and 
guidance is provided in a variety of ways, including responding to questions from Units and 
more formal activities, such as developing and issuing policy transmittals to all Units. 
Additionally, OIG conducts onsite reviews of some Units each year.  These reviews allow OIG 
staff to examine a Units outcomes from investigating and prosecuting cases, as well as assess a 
Units compliance with Federal laws, regulations, and policies and adherence to performance 
standards.  Public reports based on these reviews contain recommendations from OIG, as 
warranted, for improvement or corrective actions by the Units.  Some reports also contain 
observations by OIG about Units practices.  Appendix A contains a list of beneficial practices 
that OIG cited in onsite review reports published since FY 2011. 
Methodology 
We based the information in this report on an analysis of statistical data submitted by the 
50 MFCUs, as well as materials MFCUs submitted to OIG for recertification.15  We analyzed the 
data submitted by the MFCUs for FYs 2012 through 2016 and requested additional data and 
clarification as needed.  We summarized key case outcomes, such as criminal convictions, civil 
settlements and judgments, and monetary recoveries across all Units.  In addition, for FY 2016, 
we summarized the reported investigations and outcomes by provider type.  We also conducted 
trend analysis on key case outcomes for the 5-year period of FYs 2012 through 2016.   
 
 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   2   
INTRODUCTION 
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 2016 Annual Report (OEI-09-17-00210)   3   
CASE OUTCOMES 
 
In FY 2016, Units reported 1,564 convictions, 998 civil settlements and 
judgments, and almost $1.9 billion in criminal and civil recoveries  
In FY 2016, Units reported 1,564 convictions, just over one-third of which involved personal 
care services attendants.  Seventy-four percent of the 1,564 total convictions involved fraud (e.g., 
billing for services that were not provided) and twenty-six percent involved patient abuse or 
neglect (e.g., assault of a long-term care facility patient).  For the same period, Units reported 
998 civil settlements and judgments, almost half of which involved pharmaceutical 
manufacturers (e.g., the unlawful promotion of certain prescription drugs).  Units also reported 
approximately $1.9 billion in criminal and civil recoveries.  
Over one-third of convictions involved personal care services attendants 
Personal care services (PCS) was the largest category of convictions in FY 2016.  Thirty-five 
percent (552 of 1,564) of the reported convictions were of PCS attendants, representatives of 
PCS agencies, or other home care aides.  Of these 552 reported convictions, 500 involved 
provider fraud and 52 involved patient abuse or neglect.  For example, in one fraud case, a home 
care aide submitted timesheets for services rendered while the patient was in an acute-care 
hospital and, therefore, unable to receive care from the home care aide.  The aide was fined and 
sentenced to 2 years in State prison.   
 
The second largest category of FY 2016 convictions involved nursing care; 11 percent (171 of 
1,564) of total convictions were of licensed practical nurses (LPN), registered nurses (RN), 
physician assistants (PA), or nurse practitioners (NP).  Another 10 percent (153 of 1,564) of total 
convictions were of nurse aides.  These convictions typically involve abuse or neglect, provision 
of services without a license, and services not rendered, among other charges.  Exhibit 2 depicts 
the number of criminal convictions for the five provider types with the most convictions.  
 
 
 
 
 
 
 
 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   4   
CASE OUTCOMES 
 
Fraud cases accounted for 74 percent of convictions in FY 2016 
Seventy-four percent (1,160 of 1,564) of all convictions involved fraud and twenty-six percent 
(404 of 1,564) involved abuse or neglect.  Of the fraud convictions, almost half involved 
unlicensed providers.  As was the case with convictions overall, PCS attendants accounted for 
the greatest number of fraud convictions (464 of 1,160).  Exhibit 3 depicts the provider types 
with the most convictions by type of case.  Nurse aides was the provider type that accounted for 
the greatest number of patient abuse or neglect convictions (134 of 404).  Appendix B displays 
the case outcomes and open investigations for fraud and abuse or neglect cases by provider type.   
The number of drug diversion convictions increased from FY 2015 
Drug diversion cases involving false or improper claims to the Medicaid program are a 
significant and growing case area for the MFCUs, and OIG began collecting statistical 
information about such cases in FY 2015.  Drug diversion investigations typically involve 
fraudulent billing of the Medicaid program for a drug not delivered to the intended beneficiary 
and diverted from legal and medically necessary uses.  In FY 2016, Units reported 
186 convictions related to drug diversion, or 12 percent of total convictions, and $15.7 million in 
criminal recoveries.  This was an increase from FY 2015, when Units reported 117 convictions 
related to drug diversion, or 8 percent of total convictions.  As with Units other investigations, 
drug diversion cases may be conducted jointly with other State or Federal agencies, such as OIG 
or the U.S. Drug Enforcement Administration.  In one especially egregious case, a doctor was 
convicted at trial on 3 counts of second-degree murder and 23 counts of prescribing addictive 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   5   
CASE OUTCOMES 
 
prescription drugs to persons who had no medical need for them.  Testimony revealed that the 
doctor did not change her prescribing habits after being notified of the death of her patients.  The 
doctor was sentenced to 30 years in prison for homicide. 
Almost half of the civil settlements and judgments involved pharmaceutical 
manufacturers          
Of the 998 civil settlements and judgments that Units reported, 463 (46 percent) involved 
pharmaceutical manufacturers, making it the provider type with the 
greatest number of settlements and judgments.  Pharmaceutical 
manufacturer settlements typically relate to the marketing of prescription 
drugs.  An additional 70 settlements and judgments involved laboratories,  CIVIL CASES 
67 involved medical device manufacturers, and 57 involved retail and 
Units conduct two types of 
wholesale pharmacies.  All Units reported such civil settlements or 
civil cases: global and 
judgments in FY 2016, ranging from 9 to 97 per Unit.   
nonglobal.   
Units reported almost $1.9 billion in recoveries in FY 2016  
A global case is a civil case 
Of the almost $1.9 billion in reported recoveries, $1.5 billion were from  that involves both the 
Federal government and a 
civil recoveries and another $368 million were from criminal recoveries.  
group of States and is 
Units spent $259 million in State and Federal funds in FY 2016.  
Therefore, Units recovered an average of over $7 for every dollar spent.16   coordinated by the National 
Association of Medicaid 
Appendix C displays the amount of criminal and civil recoveries and other 
Fraud Control Units 
outcomes for each State.   
(NAMFCU).    
FY 2016 continued a trend of increasing numbers of 
A nonglobal case is a civil 
convictions; civil settlements/judgments were the 
case that does not involve 
highest among the last 5 years   NAMFCU.    
The number of convictions generally has increased over the past 5 years, 
from 1,349 in FY 2012 to 1,564 in 
FY 2016, a 5-year high.  Civil 
settlements and judgments reached 
a 5-year high of 998 in FY 2016.   
Unit convictions continued to 
increase in FY 2016 
In FY 2016, Units reported a total 
of 1,564 convictions, 7 more than 
reported in FY 2015.  Fraud 
convictions reported by Units 
increased from 1,101 in FY 2015 to 
1,160 in FY 2016, whereas abuse or 
neglect convictions decreased from 
456 in FY 2015 to 404 in FY 2016.  
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   6   
CASE OUTCOMES 
 
As shown in Exhibit 4, both fraud and patient abuse or neglect convictions were higher in 
FYs 2015 and 2016 than in FYs 2012 through 2014.   
One patient neglect conviction in FY 2016 involved the owner of an unlicensed residential care 
facility who failed to staff the facility at night, thereby endangering the facilitys residents.  The 
facility owner was sentenced to 5 years in State prison and was ordered to pay $21,000 in fines. 
The number of FY 2016 OIG exclusions resulting from Unit conviction referrals 
decreased slightly, compared to the prior 2 years 
OIG has the authority to exclude convicted individuals and entities from Federal 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.  After 
reaching a high of 1,337 in 
FY 2014, the number of exclusions 
from convictions referred by Units 
was slightly lower in both 
FYs 2015 and 2016 (1,306 and 
1,284, respectively).  However, as 
shown in Exhibit 5, all 3 recent 
years (FYs 2014 through 2016) 
saw considerably higher numbers 
of exclusions resulting from Unit 
referrals than in either FYs 2012 or 
2013.  In FY 2016, Unit referrals 
accounted for 35 percent of total 
OIG exclusions (1,284 of 3,635).   
 
 
 
 
 
 
 
   
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   7   
CASE OUTCOMES 
 
In FY 2016, Units reported the highest number of civil settlements/judgments 
among the last 5 years  
The number of reported civil settlements 
and judgments has fluctuated over the last 
5 years.  The number of civil settlements 
and judgments averaged 861 in 
FYs 2012 through 2014, then decreased 
to 731 in FY 2015, before increasing 
substantially in FY 2016 to 998.  
Exhibit 6 shows the trend in civil 
settlements and judgments over the past 
5 years.   
Civil recoveries have varied significantly 
over the last 5 years, from a high of 
$2.6 billion in FY 2012, to a low of 
$395 million in FY 2015.  As shown in 
Exhibit 7, civil recoveries in 
FY 2016 were in the mid-range over the 
5-year period, at $1.5 billion.  Over half 
of these recoveries were attributable to 
settlements of global cases against two 
pharmaceutical manufacturers that totaled 
$982 million. 
Since the 1990s, a significant number of 
pharmaceutical companies have been the 
subject of large monetary settlements in 
civil fraud actions.  As a condition of 
those settlements, pharmaceutical 
companies were required to adopt 
corporate integrity agreements, 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.  Many of the large  
   
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   8   
CASE OUTCOMES 
 
pharmaceutical settlements and the associated recoveries involve global civil cases.  Although in 
FY 2015 global recoveries accounted for only 36 percent of civil recoveries, they accounted for 
69 percent in FY 2014 and 81 percent in FY 2016, as shown in Exhibit 8.
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   9  APPENDIXES 
 
Appendix A: Noted Beneficial Practices from Unit Reports Published in FYs 
20112016 
This appendix summarizes beneficial practices identified through OIGs onsite reviews of Units and that 
were included in OIG reports published since FY 2011.  This summary updates Appendix D of Medicaid 
Fraud Control Units Fiscal Year 2015 Annual Report with practices identified in the reviews of the 
following States: Arizona, California, Florida, Maryland, Massachusetts, North Carolina, Oregon, South 
Dakota, Virginia, and Washington.  All of the reports may be accessed at:  http://oig.hhs.gov/reports-
and-publications/oei/m.asp#mfcu. 
State and   Noted Beneficial 
Summary* 
Report Number  Practices 
The Unit attended quarterly meetings between the State Medicaid 
agency and managed care organizations (MCOs) to provide 
guidance about what constituted a quality fraud referral.  The Unit 
Arizona   Outreach 
also provided training to Adult Protective Services staff and 
OEI-07-15-00280  activities 
distributed outreach materials regarding prevention of fraud and 
elder abuse/neglect to law enforcement and community advocacy 
organizations. 
The Unit engaged in outreach activities that built relationships with 
stakeholders and aided the Units mission.  For example, the Unit 
Outreach  director reported that experienced Unit staff often were asked to 
Arkansas  
OEI-06-12-00720  activities  lead training pertaining to Unit work for external stakeholders, such 
as a training session by Unit investigators conducted for the State 
Office of Long Term Care.  
The Unit provided quarterly training conferences for MCO 
MCO fraud 
representatives that resulted in increased MCO fraud referrals to 
referrals 
the Unit. 
The Unit hired a field representative to provide outreach and 
increase the number of fraud referrals sent to the Unit.  The field 
Outreach  representative acted as a liaison between the Unit and other State 
California 
activities   agencies and trained staff from these agencies about Medicaid 
OEI-09-15-00070 
fraud and the Units role in combatting provider fraud and patient 
abuse and neglect. 
Two Unit investigators had workstations at an OIG field office in the 
Colocation of 
San Francisco Bay Area, which facilitated the mutual referral of 
Unit and OIG 
cases and improved communication and cooperation with OIG on 
staff 
joint cases. 
continued on the next page  
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   10   
Noted Beneficial Practices from Unit Reports Published in FYs 20112016 (continued) 
State and   Noted Beneficial 
Summary* 
Report Number  Practices 
Seven Unit staff had workstations at an OIG field office in Miami, 
Colocation of 
which improved communication and cooperation with OIG on joint 
Florida 
Unit and OIG 
OEI-07-15-00340  cases, including Medicaid provider fraud cases generated through 
staff 
the U.S. Department of Justices Medicare Strike Force. 
The Unit implemented an investigative checklist that improved the 
Investigative 
Units case flow.  In addition, Unit attorneys discuss the 
Idaho 
checklist and 
OEI-09-12-00220  investigative case plan for each case with the case investigator 
case plan 
prior to the Units monthly staff meetings.  
The Unit developed an internal boot camp training program for 
New staff  new staff.  Experienced staff gave 1-2 hour lectures on topics such 
Maryland 
OEI-07-16-00140  training  as: civil and criminal investigation procedures, interviewing 
techniques, and understanding medical codes.  
The Unit developed successful partnerships with other State and 
Federal agencies and used clinical experts to facilitate the 
Successful 
investigation and prosecution of drug diversion and other pharmacy 
partnerships  
cases.   
Massachusetts 
OEI-07-15-00390 
Streamlined  The Unit used its Intranet system to streamline its administrative 
administrative  processes, such as periodic supervisory case file reviews and 
processes  supervisory approval to open and close cases.   
The Unit makes workspace available to an OIG Special Agent within 
OIG workspace 
the Unit offices. 
within the Unit 
Michigan 
Streamlined  Unit management and the Michigan Department of Licensing and 
OEI-09-13-00070 
patient abuse or  Regulatory Affairs developed a streamlined process for referring 
neglect referral  cases of patient abuse or neglect.  
process 
The Unit worked with two Minnesota Deputy Attorneys General to 
Legislation that  research and draft legislation that strengthens Minnesotas 
strengthens  background check processes for guardians and conservators.  
Minnesota 
OEI-06-13-00200  background  Additionally, the new legislation requires that the court conduct 
checks   background checks on guardians and conservators every 2 years, 
rather than every 4 years. 
continued on the next page    
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   11   
Noted Beneficial Practices from Unit Reports Published in FYs 2011-2016 (continued) 
State and   Noted Beneficial 
Summary* 
Report Number  Practices 
The Units outreach program consisted of educational classes 
taught by Unit presenters who describe various types of fraud and 
Provider Outreach  abuse or neglect, discuss Federal and State laws regarding fraud 
Nevada 
and Train the  and abuse or neglect, and provide Unit contact information for 
OEI-09-12-00450 
Trainer Programs  reporting Medicaid-related crime.  The Units Train the Trainer 
program was instrumental in the success of the provider outreach 
program.  
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 abuse 
Letter  or neglect.  As a result of this letter, facilities made drug diversion-
OEI-02-12-00180 
 
related referrals to the Unit. 
The Unit developed a supervisory review document called a Joint 
Case management 
New Jersey 
Investigation Plan that includes tasks and deadlines, as well as 
OEI-02-13-00020  tool 
descriptions of significant investigative and legal issues.  
Unit management and the State Medicaid agency worked closely 
Managed care  to develop and implement an improved referral process that 
referrals  ensures that the Unit receives all appropriate fraud referrals 
New Mexico  generated by MCOs.  
OEI-09-14-00240 
The Unit consistently provided program integrity 
Program integrity 
recommendations to the State Medicaid agency during quarterly 
recommendations 
joint protocol meetings. 
Approach to  The Unit established a separate Patient Protection Unit.  This 
patient abuse or  resulted in the allocation of additional resources and expertise to 
neglect cases  patient abuse or neglect cases. 
The Unit developed a list of individuals and entities associated 
Sharing list of 
New York  with ongoing investigations.  The Unit shared this list with the 
ongoing 
OEI-02-11-00440  State Office of the Medicaid Inspector General to facilitate 
investigations 
communication about ongoing investigations.  
The Unit established an Electronic Investigative Support Group 
Use of technology  comprised of staff dedicated to providing technical assistance 
throughout a case.  
continued on the next page    
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   12   
Noted Beneficial Practices from Unit Reports Published in FYs 20112016 (continued) 
State and   Noted Beneficial 
Summary* 
Report Number  Practices 
The Unit partnered with another State agency to create the North 
Carolina Financial Investigators Academy.  The academy provided 
Financial  instruction to financial investigators on topics such as elements of 
North Carolina 
investigator  criminal law, search and seizure procedures, interviewing, and 
OEI-07-16-00070 
training  testifying.  The Unit required all of its newly hired financial 
investigators to attend the academy, regardless of previous 
experience. 
The Unit helped to establish the Ohio Program Integrity Group, 
which combines the knowledge and resources of all the State 
Program integrity 
agencies that are responsible for Medicaid program integrity.  In 
groups 
Ohio  addition, the Unit spearheaded the Managed Care Program 
OEI-07-14-00290  Integrity Group which meets quarterly. 
The Unit employed a special projects team to provide technical 
Use of technology 
support to all of its investigative teams.  
The Unit created a patient abuse and neglect outreach group that 
Oregon  Outreach  provided Unit liaisons to each county in Oregon, attended multi-
OEI-09-16-00200  activities  disciplinary team meetings at the county level, and provided 
outreach about the Units mission and legal authorities. 
The Unit utilized providers previously investigated for Medicaid 
Peer education as 
South Dakota 
fraud to educate peers, as a means of deterrence.  These providers 
OEI-07-16-00170  fraud deterrent 
gave presentations alongside Unit staff at training conferences. 
Unit staff and stakeholders reported that relationships formed 
Tennessee   Involvement on  through participation on task forces, such as the Provider Fraud 
OEI-06-12-00370  various task forces  and Federal Health Care Fraud task forces, were key to the Units 
productivity.  
The Unit instituted an outreach program to ensure that the public 
is aware of the Units presence and mission for the purpose of 
Texas  increasing the number of referrals to the Unit.  The Unit required 
Outreach program 
OEI-06-13-00300  all investigators and investigative auditors to make 12 outreach 
contacts per year. 
 continued on the next page 
   
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   13   
Noted Beneficial Practices from Unit Reports Published in FYs 20112016 (continued) 
State and   Noted Beneficial 
Summary* 
Report Number  Practices 
The Unit required all Unit auditors and investigators to either be 
Certified Fraud 
trained as a Certified Fraud Examiner (CFE) or be in training to 
Examiner Training 
become a CFE. 
The Unit tracked investigators workloads.  The chief investigator 
maintained a spreadsheet documenting the number of cases 
Investigator  assigned to each investigator and the number of hours spent on 
Utah 
workload tracking  each case.  The spreadsheet also monitored the complexity of 
OEI-09-13-00490 
each case, which the Unit took into account when assigning new 
cases to investigators.  
Unit management had discussions among the Unit, the State 
Managed care  Medicaid agency (Utah Department of Health), and MCOs to 
referrals  develop provisions in MCO contracts to ensure that MCOs send 
fraud referrals to the Unit. 
The Unit director created Provider Focus Teams in collaboration 
Provider Focus  with the Program Integrity Unit in the Department of Vermont 
Teams    Health Access.  The teams facilitate existing cases, develop 
Vermont 
provider training, and make program recommendations.  
OEI-02-13-00360 
  The Unit Director helped create the Vermont Elder Justice Working 
Elder Justice 
Group, consisting of representatives from State and Federal 
Working Group 
advocacy, regulatory, and law enforcement agencies.   
The Units partnerships with the Food and Drug Administration, 
Internal Revenue Service, and the Social Security Administration 
Successful 
led to successful Medicaid fraud prosecutions, particularly with 
partnerships   
regard to pharmaceutical manufacturers, and increased Unit 
Virginia  recoveries. 
OEI-07-15-00290 
The Unit used specialty software to improve its ability to process, 
 
track, and analyze evidence collected during the investigation of 
Use of technology   civil cases.  This software also improved communication with 
Federal and State partners, thereby facilitating the investigation 
and prosecution of joint cases. 
continued on the next page    
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   14   
Noted Beneficial Practices from Unit Reports Published in FYs 20112016 (continued) 
State and   Noted Beneficial 
Summary* 
Report Number  Practices 
The Unit worked with the State Medicaid agency to revise both the 
Managed care  MOU between the Unit and the agency and the agencys contracts 
referrals   with MCOs to ensure that the Unit received copies of all MCO 
Washington 
fraud referrals.   
OEI-09-16-00010 
  The Unit used a case closure form to make numerous program 
Program integrity 
integrity recommendations to State agencies and tracked the 
recommendations  
responses to these recommendations in a database.   
Two individuals in the Unit passed examinations to become CFEs 
Improved staff 
and another individual obtained certification as a Certified Coding 
credentials and 
Professional.  In addition, Unit investigators performed outreach at 
West Virginia  Unit outreach 
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 20112016. 
*For more details about these noted practices, please see the respective reports at http://oig.hhs.gov/reports-and-
publications/oei/m.asp#mfcu. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   15   
 
Appendix B: FY 2016 MFCU Case Outcomes and Open Investigations  
by Provider Type and Case Type 
Exhibit B1: FY 2016 Outcomes: Number of Convictions, Settlements and Judgments, and Recoveries by 
Provider Type and Case Type 
Criminal  Civil 
Number of  Amount of  Number of  Amount of 
Provider Type  Convictions  Recoveries  Settlements  Recoveries 
and 
Judgments 
PATIENT ABUSE OR NEGLECT   
Assisted Living Facility  17  $65,735  0  $0  
Developmental Disability Facility (Residential)  12  $7,361   1  $14,599 
Non-Direct Care  29  $811,166  0  $0  
Nurse (LPN, RN, or other licensed), Nurse  82  $177,651  1  $40,582 
Practitioner, or Physician Assistant 
Nurse Aide (CNA or Other)  134  $229,072  0  $0 
Nursing Facilities  17  $16,913  8  $250,000 
Personal Care Services Attendant or Other  52  $247,972  0  $0 
Home Care Aide 
Other Individual or Organization   61  $723,758  0  $0 
FRAUD: Inpatient and/or Residential Facility-Based Medicaid Providers and Programs 
Assisted Living Facility  2  $9,380  1  $93,876 
Developmental Disability Facility (Residential)  0  $0  4  $552,245 
Hospice  2  $5,691,146  3  $3,412,603 
Hospitals  2  $6,363,529  13  $8,376,065 
Mental Health Facility (Inpatient)  1  $0  0  $0 
Nursing Facilities  7  $11,940  6  $19,451,697 
Other Long Term Care Facility  0  $0  2  $354,962 
FRAUD: Outpatient and/or Day Services Facility-Based Medicaid Providers and Programs 
Adult Day Center  2  $0  6  $904,103 
Developmental Disability Facility  2  $2,072,213  1  $45,000 
(Non-Residential) 
Mental Health Facility (Non-Residential)  14  $1,190,135  5  $1,618,793 
Substance Abuse Treatment Center  13  $54,306  0  $0 
Other Facility (Non-Residential)  2  $50,902  8  $5,641,797 
FRAUD: Licensed Practitioners   
Audiologist  1  $60,155  0  $0 
Chiropractor  1  $203,189  3  $85,492 
Clinical Social Worker  24  $2,369,758  2  $54,027 
Dentist  17  $2,663,960  23  $8,793,977 
Nurse (LPN, RN, or other licensed)  80  $12,371,758  9  $58,223 
Nurse Practitioner  7  $53,908  1  $27,896 
    continued on the next page 
 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   16   
Exhibit B1: FY 2016 Outcomes:  Number of Convictions, Settlements and Judgments, and Recoveries by 
Provider Type and Case Type (continued) 
Criminal  Civil 
Number of  Amount of  Number of  Amount of 
Provider Type  Convictions  Recoveries  Settlements  Recoveries 
and 
Judgments 
FRAUD: Licensed Practitioners   (continued) 
Optometrist  2  $127,283  2  $264,304 
Pharmacist  10  $14,725,546  3  $5,943,777 
Physician Assistant  2  $0  0  $0 
Physical Therapist, Speech Therapist,  6  $88,132  5  $201,588 
Occupational Therapist, Radiation Therapist 
or other licensed Non-Mental Health 
Therapist 
Podiatrist  1  $1,178,188  1  $83,678 
Psychologist  20  $1,202,250  1  $95,528 
Other Licensed Practitioner  24  $6,382,423  7  $5,736,751 
FRAUD: Medical Services 
Ambulance  9  $2,251,047  4  $332,535 
Billing Services  4  $917,341  1  $32,408 
Durable Medical Equipment, Prosthetics,  29  $5,014,066  56  $30,978,589 
Orthotics and Supplies (DMEPOS) 
Home Health Agency  48  $118,661,017  29  $9,058,643 
Lab (Clinical)  3  $1,557,683  64  $40,793,287 
Lab (Radiology and Physiology)  15  $1,132,120  1  $793,888 
Lab (Other)  0  $0   5  $838,230 
Medical Device Manufacturer  0  $0  67  $56,517,210 
Pain Management Clinic  6  $1,100  0  $0  
Personal Care Services Agency  36  $4,108,575  53  $2,302,117 
Pharmaceutical Manufacturer  0  $0   463  $1,176,161,182 
Pharmacy (Hospital)  0  $0  1  $9,906 
Pharmacy (Institutional Wholesale)  1  $11,517  27  $7,077,239 
Pharmacy (Retail)  29  $416,410  30  $50,236,115 
Transportation (Non-Emergency)  25  $9,398,553  8  $3,370,062 
Other Medical Services  13  $212,509  5  $4,688,053 
FRAUD: Physicians (MD/Doctor of Osteopathic Medicine, or DO) 
Allergist/Immunologist  1  $176,827  0  $0 
Emergency Medicine Physician  0  $0  1  $3,200,000 
Family Practice Physician  57  $35,811,403  6  $1,115,881 
Internal Medicine Physician  10  $112,220  7  $1,142,697 
Neurologist  1  $55,720  0  $0 
Obstetrician/Gynecologist  0  $0  3  $138,123 
continued on the next page 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   17   
Exhibit B1: FY 2016 Outcomes: Number of Convictions, Settlements and Judgments, and Recoveries by 
Provider Type and Case 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) 
Pediatrician  0  $57,400  1  $512,105 
Psychiatrist  8  $86,934,035  6  $2,161,274 
Radiologist  2  $16,444  0  $0 
Surgeon  0  $0  2  $282,543 
Other MD/DO  14  $11,234,484  23  $4,021,079 
FRAUD: Other Individual Providers 
Nurse Aide (CNA or Other)  19  $64,348  2  $39,733 
Optician  4  $0  2  $34,000 
Personal Care Services Attendant  464  $7,560,502  5  $23,916 
Pharmacy Technician  5  $29,712  0  $0  
Unlicensed Counselor (Mental Health)  22  $703,831  0  $0 
Unlicensed Therapist (Non-Mental Health)  2  $130,640  0  $0  
Other Individual Providers  59  $9,778,506  3  $512,338 
FRAUD: Program Related 
Managed Care Organization   3  $3,251,433  3  $49,290,010 
Medicaid Program Administration  6  $6,165,676  1  $80,000 
Other Program Related  23  $3,583,884  3  $189,384 
Total  1,564  $368,498,733*  998  $1,508,034,109* 
Source: OIG analysis of MFCUs Annual Statistical Report data for FY 2016.   
*This total does not exactly match the total of the rows above because of rounding. 
   
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   18   
Exhibit B2: Number of Open Investigations at the End of FY 2016 by Provider Type and Case Type 
Open Criminal  Open Civil  Total Open 
Provider Type 
Investigations   Investigations  Investigations 
PATIENT ABUSE OR NEGLECT   
Assisted Living Facility  191  1  192 
Developmental Disability Facility (Residential)  94  3  97 
Hospice  5  0  5 
Non-Direct Care  167  0  167 
Nurse (LPN, RN, or other licensed), Nurse 
478  1  479 
Practitioner, or Physician Assistant 
Nurse Aide (CNA or Other)  519  0  519 
Nursing Facilities  958  50  1,008 
Personal Care Services Attendant or Other Home 
252  0  252 
Care Aide 
Other Individual or Organization   500  2  502 
FRAUD: Inpatient and/or Residential Facility-Based Medicaid Providers and Programs 
Assisted Living Facility  40  14  54 
Developmental Disability Facility (Residential)  30  10  40 
Hospice  61  52  113 
Hospitals  129  213  342 
Inpatient Psychiatric Services for Individuals Under  5  4  9 
Age 21 
Nursing Facilities  151  230  381 
Other Inpatient Mental Health Facility  16  27  43 
Other Long Term Care Facility  13  7  20 
FRAUD: Outpatient and/or Day Services Facility-Based Medicaid Providers and Programs 
Adult Day Center  74  13  87 
Ambulatory Surgical Center  1  7  8 
Developmental Disability Facility (Non-Residential)  20  8  28 
Dialysis Center  4  36  40 
Mental Health Facility (Non-Residential)  137  37  174 
Substance Abuse Treatment Center  104  25  129 
Other Facility (Non-Residential)  117  51  168 
FRAUD: Licensed Practitioners   
Audiologist  8  2  10 
Chiropractor  33  7  40 
Clinical Social Worker  97  7  104 
Dental Hygienist  4  2  6 
Dentist  407  84  491 
Nurse (LPN, RN, or other licensed)  444  8  452 
Nurse Practitioner  36  4  40 
Optometrist  34  3  37 
Pharmacist  71  44  115 
Physician Assistant  21  0  21 
    continued on the next page 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   19   
Exhibit B2: Number of Open Investigations at the end of FY 2016 by Provider Type (continued) 
Open Criminal  Open Civil  Total Open 
Provider Type 
Investigations   Investigations  Investigations 
FRAUD: Licensed Practitioners   (continued) 
Physical Therapist, Speech Therapist, Occupational  72  19  91 
Therapist, Radiation Therapist or other licensed 
Non-Mental Health Therapist 
Podiatrist  32  4  36 
Psychologist  102  4  106 
Other Licensed Practitioner  175  19  194 
FRAUD: Medical Services 
Ambulance  143  18  161 
Billing Services  29  13  42 
Durable Medical Equipment, Prosthetics, Orthotics  244  445  689 
and Supplies (DMEPOS) 
Home Health Agency  677  78  755 
Lab (Clinical)  68  438  506 
Lab (Radiology and Physiology)  11  28  39 
Lab (Other)  13  108  121 
Medical Device Manufacturer  3  528  531 
Pain Management Clinic  52  6  58 
Personal Care Services Agency  229  21  250 
Pharmaceutical Manufacturer  153  3,235  3,388 
Pharmacy (Hospital)  0  1  1 
Pharmacy (Institutional Wholesale)  14  237  251 
Pharmacy (Retail)  157  594  751 
Transportation (Non-Emergency)  225  22  247 
Other Medical Services  123  159  282 
FRAUD: Physicians (MD/DO) 
Allergist/Immunologist  8  3  11 
Cardiologist  26  13  39 
Emergency Medicine Physician  12  5  17 
Family Practice Physician  316  15  331 
Geriatrician  6  0  6 
Internal Medicine Physician  166  15  181 
Neurologist  32  3  35 
Obstetrician/Gynecologist  38  4  42 
Ophthalmologist  14  7  21 
Pediatrician  37  8  45 
Physical Medicine and Rehabilitation Physician  28  12  40 
Psychiatrist  95  7  102 
Radiologist  10  8  18 
Surgeon  35  2  37 
Urologist  5  0  5 
continued on the next page 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   20   
Exhibit B2: Number of Open Investigations at the end of FY 2016 by Provider Type (continued) 
Open Criminal  Open Civil  Total Open 
Provider Type 
Investigations   Investigations  Investigations 
FRAUD: Physicians (MD/DO) (continued) 
Other MD/DO  286  72  358 
FRAUD: Other Individual Providers 
Nurse Aide (CNA or Other)  70  3  73 
Optician  8  4  12 
Personal Care Services Attendant   1,919  10  1,929 
Pharmacy Technician  9  0  9 
Unlicensed Counselor (Mental Health)  97  0  97 
Unlicensed Therapist (Non-Mental Health)  10  0  10 
Other Individual Providers  274  38  312 
FRAUD: Program Related 
Managed Care Organization   13  99  112 
Medicaid Program Administration  16  15  31 
Other Program Related  45  140  185 
     Total  11,318  7,412  18,730 
Source: OIG analysis of MFCUs Annual Statistical Report data for FY 2016.   
   
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   21   
 
Appendix C: Selected FY 2016 Statistical Data 
Exhibit C1: Investigations, Indictments or Charges, Criminal Convictions, and Civil Settlements and 
Judgments by State* 
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  43  21  7  16  3  17  11  0 
Alaska  140  1  18  0  29  0  11  0 
Arizona  133  38  46  30  61  14  11  0 
Arkansas  118  29  16  6  20  7  20  6 
California  1,169  566  147  84  98  75  32  0 
Colorado  223  3  7  0  12  0  97  0 
Connecticut  81  1  3  0  6  0  19  0 
Delaware  603  32  5  15  11  8  10  0 
District of 
126  3  1  0  6  1  10  0 
Columbia 
Florida  606  58  61  17  41  10  21  0 
Georgia  479  16  17  2  14  1  18  0 
Hawaii  405  36  6  0  4  1  13  0 
Idaho  110  6  3  0  3  0  9  0 
Illinois  281  48  53  18  46  11  13  0 
Indiana  1,264  481  18  9  37  10  26  1 
Iowa  267  42  42  38  37  26  22  0 
Kansas  141  17  6  0  7  0  11  0 
Kentucky  77  40  26  4  10  9  16  0 
Louisiana  406  86  64  22  69  6  16  0 
Maine  74  14  2  7  0  3  12  0 
Maryland  294  87  2  5  5  4  20  0 
Massachusetts  437  48  15  0  4  0  33  2 
Michigan  472  39  14  5  14  10  26  0 
Minnesota  392  5  62  3  42  0  12  0 
Mississippi  101  426  14  40  6  58  14  0 
Missouri  153  18  21  2  20  1  16  0 
Montana  46  9  4  3  4  2  13  0 
Nebraska  92  7  7  2  10  2  21  0 
Nevada  413  4  14  0  14  0  15  0 
New Hampshire  32  34  0  2  0  1  9  0 
continued on the next page 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   22   
 
Exhibit 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  379  25  8  6  21  4  13  0 
New Mexico  181  3  6  0  6  0  15  0 
New York  589  118  71  42  88  32  80  0 
North Carolina  378  9  15  5  22  3  23  0 
Ohio  1,017  443  102  20  110  16  16  0 
Oklahoma  206  48  28  9  15  10  16  0 
Oregon  87  7  28  2  24  6  13  0 
Pennsylvania  451  35  83  2  81  0  11  0 
Rhode Island  76  14  5  10  2  8  12  0 
South Carolina  146  49  6  7  9  6  16  0 
South Dakota  40  6  3  0  1  0  19  1 
Tennessee  242  31  22  13  21  19  22  0 
Texas  1,236  131  97  12  51  9  21  0 
Utah  106  28  1  6  0  4  29  0 
Vermont  53  8  8  2  15  1  17  0 
Virginia  409  3  40  3  38  4  21  0 
Washington  193  8  6  1  9  1  17  0 
West Virginia  143  15  19  1  6  4  21  0 
Wisconsin  344  23  0  0  7  0  18  0 
Wyoming  55  2  0  1  1  0  11  0 
TOTAL  15,509  3,221  1,249  472  1,160  404  988  10 
GRAND TOTAL  18,730  1,721    1,564  998 
Source: OIG analysis of MFCUs Annual Statistical Report data for FY 2016.   
* The information in this table is accurate as of February 15, 2017.  
   
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   23   
Exhibit C2: Recoveries and Expenditures by State* 
Recoveries  Expenditures 
Non-Global 
State  Global Civil 
Criminal  Civil  Total   Total MFCU   Total Medicaid 
Monetary  
Monetary  
Alabama  $113,178   $0   $16,921,363   $17,034,541   $1,379,111   $5,657,488,854  
Alaska  $1,804,185   $0   $1,288,904   $3,093,089   $1,394,058   $1,929,110,081  
Arizona  $6,514,601   $0   $4,010,571   $10,525,172   $2,770,174   $11,343,767,402  
Arkansas  $204,922   $976,797   $8,085,098   $9,266,817   $2,437,992   $6,337,245,143  
California  $27,240,288   $5,585,684   $103,375,056   $136,201,028   $32,469,156   $86,608,583,280  
Colorado  $899,190   $4,413,980   $9,304,300   $14,617,470   $2,178,699   $8,289,970,721  
Connecticut  $63,457   $2,693,048   $18,029,857   $20,786,363   $2,135,726   $7,790,671,895  
Delaware  $197,534   $199,894   $1,615,472   $2,012,900   $1,989,706   $2,003,364,878  
District of 
$83,344,915   $6,151,303   $1,710,850   $91,207,067   $2,812,205   $2,935,002,292  
Columbia 
Florida  $101,059,813   $6,072,461   $58,413,444   $165,545,718   $17,316,568   $22,457,578,621  
Georgia  $2,634,624   $16,249,785   $12,686,801   $31,571,210   $4,719,262   $10,283,904,205  
Hawaii  $91,071   $0   $1,765,033   $1,856,104   $1,622,502   $2,271,886,352  
Idaho  $15,126   $0   $2,640,039   $2,655,166   $833,297   $1,794,759,439  
Illinois  $4,605,086   $650,000   $30,223,829   $35,478,915   $7,137,131   $20,172,293,337  
Indiana  $2,739,336   $1,464,844   $32,724,220   $36,928,401   $6,484,688   $10,901,014,576  
Iowa  $230,695   $3,402,374   $7,023,005   $10,656,073   $1,133,997   $4,914,249,752  
Kansas  $47,736   $300,000   $8,927,256   $9,274,992   $1,337,183   $3,421,881,490  
Kentucky  $131,735   $24,224,084   $23,279,694   $47,635,513   $3,415,842   $9,893,628,407  
Louisiana  $10,770,898   $11,280,735   $18,323,027   $40,374,660   $5,710,826   $8,837,228,184  
Maine  $650   $0   $24,386,418   $24,387,068   $910,641   $2,636,443,851  
Maryland  $129,969   $336,355   $9,930,035   $10,396,359   $3,843,664   $10,819,233,860  
Massachusetts  $54,616   $4,814,263   $77,975,202   $82,844,082   $5,394,276   $17,865,505,404  
Michigan  $191,390   $1,440,225   $30,681,104   $32,312,718   $5,053,299   $17,438,676,650  
Minnesota  $1,181,413   $2,750   $24,945,482   $26,129,645   $2,367,287   $11,544,958,884  
Mississippi  $7,814,578   $531,040   $11,476,226   $19,821,844   $3,406,068   $5,563,413,438  
Missouri  $479,804   $526,359   $12,488,713   $13,494,876   $2,215,566   $10,201,941,673  
Montana  $45,403   $0   $1,548,360   $1,593,763   $679,021   $1,446,698,958  
Nebraska  $15,080,673   $1,021,119   $3,341,351   $19,443,143   $934,567   $2,092,993,865  
Nevada  $593,799   $65,500   $1,730,172   $2,389,471   $2,093,050   $3,520,421,319  
New Hampshire  $8,214   $0   $2,050,785   $2,058,999   $770,510   $2,076,589,333  
New Jersey  $1,269,801   $0   $46,051,017   $47,320,818   $3,899,420   $15,080,356,828  
continued on the next page    
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   24   
Exhibit 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  $50,413   $2,688,923   $3,465,867   $6,205,203   $2,190,671   $5,537,037,048  
New York  $157,846   $83,441,327   $145,266,934   $228,866,107   $47,018,833   $62,909,519,309  
North 
$11,875,419   $5,497,242   $63,043,469   $80,416,129   $5,944,944   $12,821,165,394  
Carolina 
Ohio  $23,031,251   $613,899   $40,365,343   $64,010,493   $11,278,343   $22,485,693,773  
Oklahoma  $1,642,636   $5,852,102   $13,974,669   $21,469,407   $2,433,434   $4,698,727,448  
Oregon  $937,896   $412,500   $8,962,548   $10,312,944   $2,380,639   $8,814,205,907  
Pennsylvania  $1,722,619   $0   $40,418,181   $42,140,800   $7,415,937   $28,220,307,793  
Rhode Island  $9,003   $273,609   $6,090,923   $6,373,535   $1,326,223   $2,626,681,914  
South 
$793,391   $534,152   $15,168,293   $16,495,835   $1,704,531   $6,230,510,941  
Carolina 
South Dakota  $1,094   $309,560   $2,009,259   $2,319,912   $438,343   $875,472,076  
Tennessee  $1,451,883   $11,160,515   $93,223,123   $105,835,521   $4,828,604   $9,928,469,426  
Texas  $53,618,692   $956,471   $73,682,086   $128,257,249   $18,832,570   $41,068,187,142  
Utah  $53,620   $7,856,124   $2,123,664   $10,033,408   $2,056,785   $2,251,931,573  
Vermont  $271,096   $829,519   $6,806,872   $7,907,487   $928,835   $1,768,236,337  
Virginia  $2,499,780   $5,520,880   $25,868,433   $33,889,093   $11,445,452   $8,927,198,595  
Washington  $122,620   $2,748,078   $52,435,513   $55,306,211   $4,534,668   $11,458,035,943  
West Virginia  $488,454   $1,227,123   $3,556,154   $5,271,732   $1,257,637   $3,813,616,346  
Wisconsin  $104,688   $60,000,000   $20,967,132   $81,071,820   $1,342,631   $8,026,421,926  
Wyoming  $107,632   $0   $1,328,341   $1,435,973   $493,574   $637,273,743  
     TOTAL  $368,498,733   $282,324,622   $1,225,709,487   $1,876,532,842   $258,698,147   $571,229,555,606  
Source: OIG analysis of MFCUs Annual Statistical Report data for FY 2016.   
*The information in this table is accurate as of February 15, 2017.   
 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   25   
ACKNOWLEDGEMENTS 
This report was prepared under the direction of Blaine Collins, Regional Inspector General for 
Evaluation and Inspections in the San Francisco regional office, and Michael Henry and Abigail 
Amoroso, Deputy Regional Inspectors General in the San Francisco regional office; and in 
consultation with Richard Stern, Director of the Medicaid Fraud Policy and Oversight Division.   
Matthew DeFraga served as the team leader for this study.  Other Office of Evaluation and 
Inspections staff from the San Francisco regional office who conducted the study include 
Christina Lester and Linda Min.  Other Medicaid Fraud Policy and Oversight Division staff who 
provided support include Susan Burbach and Jordan Clementi.  Central Office staff who 
provided support include Christine Moritz.  Other OIG staff who provided support include 
Jessica Swanstrom.  
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   26   
ENDNOTES 
 
 
1 The Act  1903(q)(3).  Regulations at 42 CFR  1007.11(b)(1) add that a Units responsibilities may include 
reviewing complaints of misappropriation of patients private funds in residential health care facilities.  Unit 
investigations of patient abuse and neglect are limited to incidents occurring in: (1) health care facilities that receive 
Medicaid payments, or (2) board and care facilities, which are residential settings that receive payment on behalf of 
two or more unrelated adults who reside in the facility and for whom nursing care services or a substantial amount 
of personal care services are provided.  The Act   1903(q)(4). 
2 The Act  1902(a)(61). 
3 North Dakota and the territories of American Samoa, Guam, the Northern Marianas Islands, Puerto Rico, and the 
U.S. Virgin Islands have not established Units. 
4 The Act  1903(q)(2); 42 CFR  1007.9(a). 
5 The Act  1903(q)(6); 42 CFR  1007.13. 
6 42 CFR  1007.9(d). 
7 The Act  1903(q)(1). 
8 The Act  1903(a)(6). 
9 Ibid. 
10 OIG analysis of FY 2016 MFCU annual statistical reporting data. 
11 The Act  1903(a)(6).  The Act authorizes the Secretary of HHS to award grants to the Units; the Secretary 
delegated this authority to the OIG. 
12 42 CFR  1007.15. 
13 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).   
14 The FY 2016 Interactive Map may be accessed at: http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/maps/interactive-map2016.asp.  OIG also maintains a FY 2016 Statistical Chart, which may be accessed at:  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2016-statistical-chart.pdf. 
15 Prior to FY 2014, Units submitted data on a quarterly basis, through Quarterly Statistical Reports.  Beginning in 
FY 2015, Units submitted data on an annual basis, through Annual Statistical Reports.  Materials Units submit for 
recertification include a response to a recertification questionnaire and an annual report that details the Units 
activities. 
16 Return on investment was calculated by dividing Unit recoveries by the total MFCU grant expenditures.  The 
calculation included settlements and judgments on global cases coordinated by NAMFCU. 
17 According to the Act  1128, 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 March 2, 2017. 
Medicaid Fraud Control Units FY 2016 Annual Report (OEI-09-17-00210)   27