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Audio (MP3) Listen in New Window Presentation (PDF) Open in new window Office of Indiana Attorney General Greg Zoeller The Indiana Medicaid Fraud Control Unit Allen K. Pope, Director Canon LXX of the Council of Nicaea Health Care for the Indigent The Council Of Nicaea - 325 A.D. - Called by Emperor Constantine - The First Ecumenical Council Overview - The Medicaid Fraud Control Unit - Why Medicaid Inherently Vulnerable to Fraud Federally Funded Charitable Healthcare In Indiana - 1964, Medicaid, Medicare - 1978, Medicaid Fraud Control Units - 1982, Indiana’s MFCU MFCU Investigative Jurisdiction IC 4-6-10-1.5(1) (A) Medicaid fraud; (B) misappropriation of a Medicaid patient's private funds; (C) abuse of Medicaid patients; and (D) neglect of Medicaid patients; and Staff - 53 Total - 12 Attorneys - 23 Investigators - 2 Nurse Investigators - 3 Auditors - 2 Information Technology Professionals - 11 Other HIPAA - An MFCU is a Health Oversight Agency - It may obtain and share Protected Health Information without notifying patients or getting their permission. MFCU Collections - MFCU Budget: $4 million (25% state, 75% federal grant) - The MFCU is a law enforcement agency, not a collections agency. - Collections in Calendar Year 2012: $52,340,097.87 2012 Penalties and Sanctions Criminal Penalties: 30 Licensing Sanctions: 116 Civil Judgments and Settlements: 44 Dollars Collected: $52,340,098 Estimated Abusive and Fraudulent Billing Valid: 85% Abusive: 10% Fraudulent: 5% MFCU Annual Totals Indiana’s False Claims Act -? Adopted in 2005. ?- Medicaid FCA split from general FCA this year to accommodate mandated changes. ?- Whistleblowers entitled to 15% to 30% of recoveries. ?- Typically require several years to litigate. Where Indiana’s 416 Medicaid Whistleblower Cases are Pending Alabama, 1 Arkansas, 2 California, 32 Colorado, 3 Delaware, 5 Florida, 7 Georgia, 7 Illinois, 23 Indiana, 15 Kansas, 1 Kentucky, 2 Louisiana, 3 Massachusetts, 71 Michigan, 10 Minnesota, 2 Missouri, 1 Montana, 2 New Jersey, 33 New York, 55 North Carolina, 3 Ohio, 10 Oklahoma, 2 Oregon, 2 Pennsylvania, 43 Rhode Island, 2 South Carolina, 3 Tennessee, 11 Texas, 30 Virginia, 13 Washington, 2 Washington, DC, 12 Wisconsin, 2 NAMFCU - Eight DAGs carry whistleblower litigation in their caseload. - National Association of Medicaid Fraud Control Units coordinates national network of assistance. - Small volunteer teams representing several state MFCUs investigate each qui tam and share results with other MFCUs. Additional Medicaid FCA Changes - SB 559 already made some improvements, changing the seal from 120 days to 60 - matching the federal false claims act, eliminating delays and confusion in federal cases that also included state law claims. Senate Bill 559 - Requires surety bond for new transportation providers - A new Medicaid-specific false claims statute - Made certain changes necessary for the state to maintain its bonus share of false claims recoveries - The state is reimbursed in the approximate amount of a Medicaid relators’ fees, if the state false claims act is as beneficial to the relators as the federal act. Additional Beneficial Improvements - Long-term changes that we think will provide additional efficiencies and clarifications to the law to assist in our efforts to recover state funds. Additional Medicaid FCA Changes - Additional changes will - better facilitate handling of these cases in federal courts - bring more consistency to the timeframes - bring more consistency to procedural requirements - bring more consistency to provisions allowing for enforcement of investigative demands - Those changes could include: - clarification that the AG cannot be dismissed out of a case when the office has not yet exercised right to intervene - MFCU-specific civil investigative demand provisions that are more conducive to how false claims act cases are investigated and litigated - language to ensure that emails are included within the scope of documentary material that can be obtained through civil investigative demands - Those changes could include: - language that directs CID recipients to produce documents as they’re kept in the normal course of business and in their native format, which is how they’re most useful to investigators and how they are generally maintained using current technology - provisions that trigger automatic medical and occupational licensing consequences based on criminal convictions or false claims judgments or settlements involving Medicaid fraud - Those changes could include: - enhancements to summary suspension authority of medical licensing boards in situations where Medicaid provider’s actions threaten public health and safety - provisions that allow courts to limit unrestricted participation in false claims cases by the whistleblower or relator if unrestricted participation would otherwise serve to harass the defendant or cause them undue burden or unnecessary expense Why Medicaid is Vulnerable to Fraud - Three types of Medicaid fraud - Billing for services not rendered - Up-coding - Billing for medically unnecessary services Why Medicaid is Vulnerable - Medicaid’s “Any Willing Provider” Requirement - Providers generally cannot be excluded from the program without a valid, express cause. - This is the Medicaid counterpart to the competitive bidding requirement for public works projects. The MFCU’s Most Critical Partner - FSSA and OMPP - We work with FSSA every day. - We meet formally twice per month. - Primary source of our best criminal fraud referrals. - As of June 17th federal law allows MFCUs and Medicaid agencies to cooperate in more high-tech investigative screening tools to identify patterns of fraud. - Already have an agreement in principle for this which will soon be included in our MOU. - OMPP also excludes providers who have engaged in fraud. - We expect to continue to partner with them in using that very effective fraud prevention tool. Disqualified Personnel - Excluded by HHS-OIG - Unlicensed - Convicted of Disqualifying Crime What is Exclusion? - Effect of Exclusion for Providers: No payment will be made by any Federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. No program payment will be made for anything that an excluded person furnishes, orders, or prescribes. Search the Database of Excluded Individuals - Link to Online Searchable Database for checking: http://exclusions.oig.hhs.gov/ And https://www.epls.gov/ - Link to Online Searchable Database for checking: https://mylicense.in.gov/EVerification/Search.aspx Allen K. Pope, Director Allen.Pope@atg.in.gov 317-234-6662 800-382-1039 http://www.in.gov/attorneygeneral/