OIG Takes Back $48M in Fraudulent Medicaid Payments as Nursing Homes Lead List of Open Cases

Despite the second straight year of declines in overall recoveries, the Department of Health and Human Services’ (HHS) top watchdog arm took back nearly $50 million in Medicaid reimbursements from nursing homes in fiscal 2018.

The HHS Office of the Inspector General (OIG) this week reported a haul of $48.7 million from nursing providers accused of fraud, with about $36.4 million coming from 15 civil settlements and judgments — and the remaining $12.3 million stemming from eight criminal convictions.

That’s a significant rise from fiscal 2017, when the total fraud recoveries sat at about $1.4 million.


The nationwide network of Medicaid Fraud Control Units (MFCUs) also collected nearly $1.5 million in recoveries related to patient abuse or neglect cases: $68,168 associated with 24 criminal convictions, and $1.3 million from 21 civil settlements and judgments.

Those figures came amid overall declines in both the total dollar value of Medicaid recoveries and the number of settlements. Civil recoveries in fiscal 2018, which ended last September 30, fell to $545 million, down from the previous two fiscal years — while the 810 settlements and judgments were below the previous five-year average of 888, and well below the cycle high of 998 in fiscal 2016.

In addition, the amount of cash collected from criminal cases dipped from $693 million in 2017 to $314 million, though the OIG noted that many of the fluctuations over time could simply be coincidental.


“The occurrence of large monetary settlements in certain years and the timing of these settlements contributes to this variability,” the agency wrote in its report.

Nursing homes also led the way among all provider types for open investigations into facility-based providers, according to the OIG report. As of the end of fiscal 2018, MFCUs had 1,071 active criminal cases and 61 open civil cases against SNFs regarding abuse or neglect, for a total of 1,132 — easily surpassing home care investigations at 329. In addition, nursing facilities edged out hospitals — by just one case — to take the dubious title of most active criminal and civil fraud investigations at 329.

Overall in 2018, the MFCUs banned 974 individuals or companies from Medicare and Medicaid eligibility, while collecting $859 million in Medicaid cash from providers. That works out to $2.92 in recovered money for every dollar spent on the units’ work, the OIG noted.

“Reducing Medicaid fraud is a top priority for OIG, and its role in overseeing MFCUs helps achieve that priority,” the watchdog arm wrote in its report.

Each state — along with the District of Columbia, Puerto Rico, and the U.S. Virgin Islands — has its own MFCU, jointly funded by the federal and state- or territory-level governments. In fiscal 2018, these oversight agencies received $221 million in funding from the federal government, the majority of their combined $294 million budget.

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