January 11, 2023

Stricter audits may be on the horizon from the OIG

Written By

Norris Cunningham
Member, Stoll Keenon Ogden PLLC

Long-term care facilities and providers should brace themselves for what may be an uptick in enforcement activity from Medicaid Fraud Control Units (MFCUs) in the coming year.

In 2023, the U.S. Department of Health and Human Services Office of Inspector General (OIG) is expected to issue a report detailing its oversight activities over MFCUs. Each MFCU’s operations are partially funded by federal grants, which in turn necessitates OIG inspections to allow recertification of that funding.

Ahead of this report, it’s fair to speculate MFCUs will be subject to more stringent oversight by the OIG. For nursing homes, this is likely to create a ripple effect that results in MFCUs ramping up their own enforcement measures ahead of any potential assessment from the OIG.

MFCUs investigate providers that intentionally defraud a state’s Medicaid program through fraudulent billing practices. MFCUs also investigate allegations of patient abuse, neglect, drug diversion and exploitation in facilities receiving payments under the Medicaid program, such as nursing homes, facilities for the mentally and physically disabled, and assisted living facilities.

The OIG’s role in the process is to provide oversight, and the OIG maintains that its priority during investigations is the examination of MFCU adherence to 12 performance standards regarding staffing, maintaining adequate referrals and cooperating with federal authorities, to name a few. However, past OIG MFCU annual reports have focused on the trends in both civil and criminal monetary recoveries and the rate of convictions following investigations.

But it is not mere speculation that long-term care facilities may be subject to increased MFCU oversight in the coming year. In 2021, an OIG annual report revealed 1,105 convictions for fraud and abuse or neglect. This represented an increase over the previous year, where 1,017 such convictions came as a result of MFCU oversight over long-term care facilities. Some may be unconcerned with those statistics, as they pale in comparison to the 1,527 similar convictions in 2019. However, MFCUs clearly escalated enforcement measures as the world eased itself out of the COVID-19 pandemic and as OIG audits loom.

So, OIG audits of MFCUs are likely to further implicate long-term care facilities and providers through increased, and more stringent, enforcement. Evidenced by previous OIG annual reports prioritizing increasing monetary recoveries and convictions following investigations, long-term care facilities should brace themselves for increased investigations and enforcement.

***From the January 2023 Issue of McKnight’s Long-Term Care News

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