HHS Proposal Seeks to Enhance Medicaid Fraud Investigations


Department of Health and Human Services seeks to expand the definition of patient abuse to include financial abuse.

A recent proposal by the US Department of Health and Human Services (HHS), in conjunction with the US Centers for Medicare and Medicaid Services (CMS), would make several statutory changes to State Medicaid Fraud Control Units (MFCUs), according to apress releasefrom HHS.

HHS seeks to alter how the units define a provider to encompass all providers who are required to enroll in a state Medicaid program, which includes ordering and referring physicians. These changes would give empower the MFCU to investigate and prosecute providers, even if they did not provide the services included under a Medicaid payment claim.

The proposal would expand the definition of patient abuse and neglect to also include financial abuse, while giving fraud units the power to review complaints involving the misappropriation of patient funds, according to HHS.

The proposed rule would amend the regulation governing fraud control units. In addition to incorporating statutory changes that affect these units, it will also affect policy and practice changes that have occurred since the regulation was initially issued in 1978.

The proposed changes include codifying the delegated authority of the Office of Inspector General (OIG) and MFCU, along with their functions, disallowances, and responsibilities. The changes would also address any issues related to organization, staffing, recertification, prosecutorial authority, and MFCU’s relationship with Medicaid agencies.

Units would have to participate in regular meetings or communication with the federal office to help boost the relationship between these fraud teams and the OIG.

“We believe that requiring regular meetings or communication with OIG investigators and with the Federal prosecutors will strengthen relationships, enhance the effectiveness of fraud investigations and prosecutions, and ultimately improve the integrity of the Medicaid program,” the CMS proposal stated.

Since the program was established, it has only undergone a pair of prior amendments. Overall, the proposed rule addresses new authorities for the fraud units, federal matching rates for ongoing operating costs, and state requirements for maintaining a unit.

Comments on the rule are due by November 21, 2016.

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