Medicaid Fraud Control Units (MFCUs)
Medicaid Fraud Control Units (MFCUs) investigate and prosecute Medicaid provider fraud as well as patient abuse or neglect in health care facilities and board and care facilities. MFCUs operate in 50 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. The MFCUs, usually a part of the State Attorney General's office, employ teams of investigators, attorneys, and auditors; are constituted as single, identifiable entities; and must be separate and distinct from the State Medicaid agency. OIG, in exercising oversight for the MFCUs, annually recertifies each MFCU, assesses each MFCU's performance and compliance with Federal requirements, and administers a Federal grant award to fund a portion of each MFCU's operational costs.
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- 42 CFR Part 1007, Revisions to State Medicaid Fraud Control Units Rules
- Source: 84 FR 10700, March 22, 2019
- Archived: 42 CFR Part 1007, State Medicaid Fraud Control Units (superseded May 21, 2019)
- 42 CFR Part 455, Program Integrity: Medicaid (as amended May 21, 2019)
- 45 CFR Part 75, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards (applicable to MFCU grant awards for FY 2016 and future years)
- Social Security Act Provisions
Archived Administrative Requirements and Cost Principles
(applicable to FY 2015 and prior MFCU grant awards) - 42 CFR Part 1007, Revisions to State Medicaid Fraud Control Units Rules
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OIG applies a series of performance standards, developed in accordance with section 1902(a)(61) of the Social Security Act, as part of its oversight of the MFCUs. The standards assist OIG in the certification and recertification of the MFCUs and help to determine whether the MFCUs carry out their duties efficiently and effectively.
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On occasion, OIG issues policy transmittals to provide guidance and instructions to MFCUs. The transmittals may also provide interpretations of Federal regulations, statutes, and other policies as they apply to MFCUs.
- 2010-1 Program Income
- SHO Letter #08-004 CMS policy regarding refunding of Federal share in
false claims actions
- SHO Letter #08-004 CMS policy regarding refunding of Federal share in
- 2014-1 Employment and Reimbursement of Full- and Part- Time Staff and Performance of
Non-MFCU Duties- 89-1 Full-time and Part-time Employees (Archived)
- CMS Survey and Cert Letter 15-42, Guidance to State Survey Agencies (SA) Regarding Release of Information and Data to State Medicaid Fraud Control Units (MFCU)
- 2018-1 MFCU Authority to Receive Federal Funding to Investigate and Prosecute Diversion and Misuse of Pharmaceuticals
- 2020-1 Plea Negotiations and Reporting Convictions to OIG
- 2020-2 Elements of and Process for Submitting and Renewing a Data Mining Application
Archive
On April 27, 2020, OIG rescinded Policy Transmittals 99-01, 99-02, 2001-1, and 2013-1. The guidance provided in these Policy Transmittals has been replaced by Revisions to the State Medicaid Fraud Control Units Rules found at 42 CFR Part 1007.
- 2010-1 Program Income
MFCU Activities and OIG Oversight
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OIG conducts onsite reviews to determine whether Units meet the performance standards and comply with laws, regulations, and policy transmittals. The resulting OIG reports present background on the Units, findings, and recommendations for improvement.
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As part of its responsibilities to combat Medicaid fraud and patient abuse and neglect, each MFCU maintains statistical information. The information includes numbers of investigations, indictments, and convictions by the MFCUs, as well as the amount of monetary recoveries for both civil and criminal cases. The documents below include an annual summary of this information for the MFCU community as well as a chart and interactive map containing detailed information for each MFCU. The statistical information for each MFCU should be interpreted in light of the State-specific organization and authorities governing the MFCU. For more information, please contact the MFCU directly.
- Statistics for Each MFCU
- FY 2019 Chart | Interactive Map
- FY 2018 Chart | Interactive Map
- FY 2017 Chart | Interactive Map
- FY 2016 Chart | Interactive Map
- FY 2015 Chart | Printable Version
- FY 2014 Chart | Printable Version
- FY 2013 Chart | Printable Version
- FY 2012 Chart | Printable Version
- FY 2011 Chart | Printable Version
- FY 2010 Chart | Printable Version
- Annual Statistical Reporting (ASR)
- Statistics for Each MFCU
- Data Mining Applications
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Submit Convictions for Exclusion Submit Convictions for Exclusion is a digital service to assist in the reporting of MFCU conviction information to OIG for purposes of program exclusion under section 1128 of the Social Security Act. MFCU performance standards state that MFCUs should, on a timely basis, transmit to OIG all pertinent information on MFCU convictions.
Submit the MFCU's Annual Statistical Report (ASR) OIG requests that ASR information be provided on the OMB MAX portal no later than November 30.
- State Enforcement Actions
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- Guidance on Acknowledgement of Federal Funding in Accordance with Stevens Amendment
- Implementation of OMB Memorandum on Administrative Relief for Federal Grant Awardees During COVID-19 Pandemic
- General Terms and Conditions
- MFCU Financial Grant Overview
On June 21, 2012, OIG conducted the webcast MFCU Grants Overview. MFCU staff members who would like to view the webcast may email MFCUgrants@oig.hhs.gov to obtain the link and passcode. - SF 424 (includes SF 424a and SF 424b)
- SF 425
- Grant Calendar
- Certification Letters
Other Resources
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- MFCU Financial Grant Overview
MFCU staff members who would like to view a webcast version may email MFCUgrants@oig.hhs.gov to obtain the link and passcode. - MFCU Onsite Review Process
- Cost Allocation and Indirect Cost Rates
- OIG Exclusion Program
- National Practitioner Data Bank MFCU Reporting Requirements
- State Long-Term Care Ombudsman Programs
- Statistical Sampling: A Toolkit for MFCUs
- MFCU Financial Grant Overview