The Medicaid Fraud and Elder Abuse Division is a criminal law enforcement unit of the Attorney General’s Office that enforces the Medicaid Fraud Act and the Resident Abuse and Neglect Act. The Division investigates and prosecutes Medicaid providers who commit fraud and/or resident abuse, neglect and exploitation in long-term care facilities. The unit also pursues civil monetary repayment of Medicaid program funds when a Medicaid provider does not provide adequate services to recipients. And the division participates in multi-state cases to recover Medicaid funds that are inappropriately utilized by nationwide Medicaid providers. The Division staff is comprised of attorneys, investigators, auditors and administrative staff. The Division receives 75% of its funding from a federal grant and 25% from the New Mexico legislature.
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Medicaid Fraud & Elder Abuse and Neglect Complaints
Please call 1-800-525-6519 to refer information regarding:
Available Publications by the NMAGO.
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Medicaid Fraud Frequently Asked Questions (FAQs)
The National Association of Medicaid Fraud Control Units provides responses to these frequently asked questions:
What is the Medicaid Program?
Medicaid was enacted by Congress in 1965 to provide medical services to low income and disabled people. It is sometimes confused with Medicare, the federal health insurance program for the elderly. Unlike Medicare, which is federally funded and provides the same benefit coverage throughout the United States, Medicaid is financed by federal and state funds, and is administered by each state. States have different services, program regulations and payments structures.
What is a Medicaid Fraud Control Unit?
A Medicaid Fraud Control Unit (“Unit” or “MFCU”) is a single identifiable entity of state government, annually certified by the Secretary of the United States Department of Health and Human Services. The Unit has either statewide criminal prosecution authority or formal procedures for referring cases to local prosecutorial authorities with respect to the detection, investigation, and prosecution of suspected criminal violations of the Medicaid program.
Must each state have a MFCU?
Under federal law, each state must have a Unit unless the state demonstrates to the satisfaction of the Secretary of the Department of Health and Human Services that a Unit would not be cost effective because minimal fraud exists in the state’s Medicaid program and Medicaid beneficiaries will be protected from abuse and neglect.
What is the jurisdiction of a MFCU?
A Unit’s function is to conduct a statewide program for the investigation and prosecution of health-care providers who defraud the Medicaid program. In addition, the Unit reviews complaints of abuse or neglect against patients in health-care facilities receiving Medicaid funding.
How are MFCUs funded?
MFCUs receive annual grants from the United States Department of Health and Human Services. Grant amounts must be “matched” with state funding.
Who sets the priorities of a MFCU?
Each Attorney General is free to set priorities in his or her state. Given the wide programmatic differences among the states’ Medicaid programs, what is a problem in one state may not be a problem in another. Because criminal prosecution is inherently reactive, established priorities may be modified when a new scheme to defraud is discovered, although priorities must take into account the federal performance standards which require a mix of cases covering all significant provider types. The National Association of Medicaid Fraud Control Units does not set enforcement priorities, refer cases to, or otherwise suggest specific assignments for the individual units.
How do Medicaid fraud cases typically arise?
While specifics may vary from state to state, a primary source of referrals is the single state agency responsible for auditing and reviewing Medicaid provider claims. Another significant source of referrals is MFCUs in other states, which identify fraudulent practices in a particular type of health care service, for example, a national corporation that is submitting false claims for services not provided. Finally, multi-state global settlements may be initiated by the Department of Justice.
How do the multi-state/federal global settlements arise and how are they handled?
Medicaid fraud global settlements generally arise in conjunction with a Department of Justice investigation against a provider in the Medicare program. When resolving these Medicare cases, the federal government, often at the behest of defense counsel, turns to the state MFCUs because it cannot settle the Medicaid portion of the case without the Units. Moreover, defense attorneys are unlikely to settle the case without the affected states because each state has the authority to exclude a convicted provider from its health care programs. The Department of Justice typically contacts the National Association of Medicaid Fraud Units about a potential settlement, and the President of the Association appoints a settlement team pursuant to guidelines passed by the National Association of Medicaid Fraud Control Units Executive Committee. This team usually consists of about three to four members and seeks to maximize Medicaid recoveries. All recoveries and negotiations are based upon a state’s actual damages, calculated by analyzing the provider’s billings. The Medicare cases are often filed as Qui Tam actions that are under seal, and the seal is partially lifted to give the Units the opportunity to gather provider specific information in their states to give to the national negotiating team.
What federal consequences follow a felony conviction for Medicaid fraud?
Under federal regulations, providers who are convicted of a program-related offense are excluded for a minimum of five years from receiving funds from any federally funded health-care program, either as a health-care provider or employee. Often, this sanction has a greater impact on the convicted individual and the provider community at large than the criminal penalties assessed in the case.
What is the National Association of Medicaid Fraud Control Units (NAMFCU)?
The National Association of Medicaid Fraud Control Units (NAMFCU) was initially founded in 1978 to provide a forum for a nationwide sharing of information concerning the problems of Medicaid fraud and to develop effective means to contain such fraud. Providing health-care fraud training to investigative personnel continues to be the organization’s most important and time-consuming function over the years. NAMFCU also coordinates multi-district settlement efforts, including global settlements, in response to requests from the Department of Justice.
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