Efforts by state Medicaid Fraud Control Units continued to face pandemic-related operational challenges in fiscal year 2021 but still managed to recover $1.7 billion, according to a new report.
State MFCUs secured 13 criminal convictions related to patient abuse or neglect in assisted living communities last year, recovering $60,654. Units also secured one settlement / judgment, recovering $1,000, according to the Medicaid Fraud Control Units Fiscal Year 2021 Annual Report, released Tuesday.
Comparatively, nursing facilities accounted for 11 criminal convictions that led to the recovery of $43,018, and 10 civil actions that amounted to $478,976 in recoveries.
Two criminal convictions for fraud in assisted living community-based Medicaid providers and programs also were secured, leading to the recovery of $495. Units also secured two civil settlements / judgments to recover $187,895.
There were no criminal convictions for fraud in nursing facilities, but three civil actions resulted in the recovery of $438,176.
At the end of fiscal year 2021, 210 criminal investigations and seven civil investigations in assisted living communities related to patient abuse or neglect remained open. State MFCUs also are continuing 38 assisted living community-based Medicaid providers and program criminal investigations and 12 civil investigations. An additional 38 criminal and 12 civil invitations for fraud in assisted living communities remain open.
Similar to the report issued in 2021 covering 2020, the OIG analyzed information on the effects of the ongoing pandemic. In 2021, MFCUs reported continued pandemic-related operational challenges, including limitation with in-person staff training, restricted access to long-term care facilities and court closures.
MFCUs reported a total of 1,195 convictions in FY 2021, up from 1,017 in 2020. In 2021, MFCU cases resulted in 780 total convictions for fraud and 325 convictions for patient abuse or neglect, similar to previous years.
Medicaid Fraud Recoveries
MFCU criminal recoveries increased substantially, from $173 million in fiscal year 2020 to $857 million in fiscal year 2021. That increase was attributed to cases prosecuted in Virginia and Texas, where MFCUs reported a combined $714 million in criminal recovery — 83% of criminal recovery dollars.
Civil settlements and judgments, on the other hand, decreased from 2020 to 2021. MFCUs reported 716 civil settlements and judgments in 2021, down from 786 the year before. Civil recoveries, in turn, decreased from $855 million in 2020 to $826 million in 2021.
Other facility, program, provider types
The OIG report also details abuse, neglect and fraud cases and outcomes related to other types of facilities, programs and providers.
Similar to previous years, significantly more convictions for fraud involved personal care services attendants and agencies than other provider types. Personal care attendants accounted for the highest number of fraud convictions each year from 2017 to 2021. In 2021, fraud convictions involved personal care attendants and agencies accounted for 329 (42%) of the total 780 fraud cases.
Personal care aides and home care aides also accounted for more convictions for patient/resident abuse or neglect compared with other provider types. In 2021, those convictions accounted for 69 (21%) of the total 325 convictions for abuse or neglect.
In assisted living communities, there were 13 convictions of personal care aides for patient abuse or neglect, compared with 11 convictions in nursing facilities.
