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 49 States and the District of Columbia. 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.
Program Requirements and Standards
Regulations/Statutes
- 42 CFR Part 1007, State Medicaid Fraud Control Units
- 42 CFR Part 455, Program Integrity: Medicaid
- 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
Performance Standards
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.
Policy Transmittals
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.
- 99-01 Investigation, Prosecution, and Referral of Civil Fraud Cases
- 99-02 Public Disclosure Requests and Safeguarding of Privacy Rights
- 2000-1 Extended Investigative Authority
- 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
- 2013-1 MFCU Authority in Personal Care Waiver Cases
- 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)
- 2014-2 Plea Negotiations and the Definition of Convictions; Reporting Convictions for Exclusion Purposes
- 90-1 Definition of Convictions and Plea Negotiations (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)
- 2016-1 Elements of and Process for Submitting and Renewing a Data Mining Application
MFCU Activities and OIG Oversight
Onsite Review Reports
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.
OIG Annual Reports
Expenditures & Statistics
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
- Annual Statistical Reporting (ASR)
Data Mining Applications
Reporting MFCU Information to OIG
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.
State Enforcement Actions
Grants Management
- 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
- Budget Calendar
Other Resources
Training
- 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
Directory of MFCU Directors
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