Posted by Winnie Melda on March 14th, 2019

 What are the duties of the Medicaid Fraud Control Units?

Fraud on Medicaid provider cost taxpayers millions of dollars annually. The fraud cases also hinder the integrity of the Medicaid program. The Medicaid Fraud Control Units (MFCUs) of various states have been at the forefront of enforcing health care fraud. The MFCU is the single state government unit that is by the certification of the secretary of the U.S health and Human Services department. The Unit consults investigations and prosecution of statewide health care providers involved in defrauding the Medicaid program.

MFCU also reviews complaints of neglect and abuse of residents in nursing homes. The unit also examines cases of in appropriation of private funds of patients in healthcare facilities. The unit also has the responsibility for investigating fraud in the program administration and providing for the referral for collection to overpayments and single state agencies undertaking these activities. Under the approval of the Inspector General from a federal agency, the unit has the mandate to investigate fraud in health care programs funded by the federal government, such as Medicare. The authority is limited to cases that only relate to Medicaid. The Work Incentive Improvement Act enables MFCUs with the option to investigate any complaints of neglect and abuse among those residing in care facilities. It is with no regard to their source of payment ( National Association of MFCU, 2015).

Healthcare practitioner reporting Medicaid fraud

Healthcare practitioners have to engage in compliance activities so that they can help them address fraudulent activities and inappropriate practice and also the general cases of educational and noncompliance activities. Compliance is all about early prevention and intervention to assists clients get their entitlements correctly and help the practitioners meet their responsibilities and obligations. Healthcare providers are also giving support in resolving issues arising from genuine mistakes. In cases of deliberate fraud, then the criminal investigation will be needed.

 In cases where a practitioner suspects ongoing fraud on Medicare programs, the practitioner will be under no obligation to provide his or her personal details when reporting the fraud. However, in cases where one gives out contact number and name, it will enable the authority to contact the practitioner for additional information when needed. In case the practitioner chooses to remain anonymous, then the authority in charge will still respect the informant’s choice. A healthcare practitioner can report suspected fraud to the Blue Shield and Blue Cross Company or its partners such as the Office of Inspector General, General Bureau of Investigation and the Office of Inspector General. Others are the Department of Human and Health services, Office of Inspector General, Department of Labor, Food and Drug Administration and the State attorneys general(BCBS, 2015).

It is part of Blue Shield’s effort of improving and protecting the healthcare system from losing billions of dollars through fraudulent means. The National Anti-Fraud Department of Blue Cross is taking a campaign nationwide to share how customer’s healthcare providers and physicians can help in fraud prevention and detecting the healthcare sector.

Medicare programs were meant to ensure the medical and health needs of the aging population in the nation. Unfortunately hospitals, doctors, nursing homes and drug companies take advantage of the hard earned tax dollars in making false claims. Medicare fraud schemes include billion fraud, patient referrals kickback, and Medical Necessity Fraud. Others are wheelchair Scams, Fraud for durable medical equipment, nursing home fraud, hospice care fraud and home healthcare fraud. Healthcare practitioners can report cases of Medicare fraud being committed by a hospital, nursing home, doctor, Drug Company or any other health care provider. This way they will be helping the government recover funds and one becomes a whistleblower when up to 30% of funds are recovered. Contacting the legal whistleblower center is free of charge and at any time (legal whistleblower center, 2015).

Comparison of Medicare and Medicaid fraud

News on Medicare fraud indicates that more than 243 people have been arrested and charged with submitting fake billing to Medicare totaling up to 2 million. It is joining of the largest criminal healthcare fraud crackdown in Justice Department History (Routers, 2015).

For the case of the Medicaid fraud, the Medicaid Fraud Control Units (MFCUs handles investigating and prosecuting incidences and cases of neglect and abuses among patients in a healthcare unit. The U.S. Department of Justice is in charge of arresting and prosecuting suspects involved in Medicare fraud. The Department of Justice main focus is to prosecute individuals in criminal activities that jeopardize the health care system by driving up medical bills. It also aims to prevent any wrong doings within the medical department. Federal authorities in their part of increasing efforts in tackling Medicare fraud more than 2, 100 people have been arrested since 2007. The recent arrest brings a total to more than 2,300 individuals who have been billed more than billion.

Both the Medicaid and Medicare fraud result into draining of multi-billion dollars of the system that is now too expensive to maintain. External auditors have a task of reviewing any suspicious patterns of claim and because of the huge volumes some forms of fraud operate for a long duration without detection. Medicare fraud happens to health insurance program for individuals paid through taxes from Americans to people aged 65 and older. It happens when the health suppliers, healthcare providers, and private health companies bill deliberate Medicare services or suppliers that were not for the intended person. For instance when a person uses the Medicare card of another person to obtain health care yet the person does not qualify for the program. The company, group or individual can commit the fraud scheme.

Columbia/HCA, company committed the largest Medicare fraud. The settlement of the case was worth v for civil damages and penalties. The company also paid 0 million for civil restitution and criminal fines and additional 0 million as penalties to resolve claims from cost reporting practices. In total HCA paid .7 billion (HCA, 2003, p. 1). Thus, marking an end to the most comprehensive health care fraud under the investigation of the Justice Department. Medicaid fraud happens to the assistance program that looks into the medical need of low-income people of all ages. Patients are usually not involved in covering the cost of their medical expenses. Sometimes they can be required to pay only a small copayment. Medicare programs serve people above the age of 65 with no consideration of their incomes. It also serves dialysis patients and people with disabilities. The two programs are served by the same organization the Centers for Medicare & Medicaid Services, which is a federal government agency.


Blue Cross Blue Shield (2015) Understanding Healthcare Fraud

National Association of Medicaid Fraud Control Units (2015) Medicaid Fraud Control Units (MFCU). 

Routers and Casella M (June 18, 2015) Authorities arrest 243 people in 2 million Medicare fraud. 

Largest Health Care Fraud Case in U.S. History is Settled, HCA Investigation Nets Record Total of .7 Billion. (2003). 

Whistle Blower Legal Center (2015) Medicare Fraud. 

Carolyn Morgan is the author of this paper. A senior editor at MeldaResearch.Com in legitimate essay writing service. If you need a similar paper you can place your order from research paper services.

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Winnie Melda

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Winnie Melda
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