UTAH MEDICAID FRAUD CONTROL UNIT
The Medicaid Fraud Control Unit (MFCU) investigates and prosecutes Medicaid fraud by providers of medical services, products, and drugs, including patient abuse and neglect. It lowers medical and drug costs for Utah consumers and employers by challenging fraudulent practices that result in overpayments to Medicaid. Cases range from local prosecutions of doctors and facilities that charge Medicaid for services that were not provided to participating in national lawsuits against drug companies that conspire to limit competition for generic drugs.
MISSION
To combat fraud committed by providers against the Medicaid program and protect vulnerable individuals from abuse, neglect, and exploitation.
JURISDICTION
In the late 1970s, the federal government began requiring all states that received Medicaid funding to have Medicaid Fraud Control Units (MFCUs). The Utah MFCU was founded in 1980 and, since that time, has focused on two missions:
- investigate and prosecute fraud committed by providers against the Medicaid program, and
- investigate and prosecute the abuse, neglect, and exploitation of vulnerable individuals (elderly, disabled, Medicaid recipients, etc.)
Due to confusion about the second half of the mission, the MFCU underwent a name revision in 2022 and is now known as the Medicaid Fraud and Patient Abuse Division (serving as the MFCU for the State of Utah). This better describes the division’s focus while acknowledging that Utah maintains an MFCU and is eligible for federal funding.
Medicaid Fraud and Patient Abuse Division
FREQUENTLY ASKED QUESTIONS
What is Medicaid?
Medicaid was established in 1965 by Title XIX of the Social Security Act. Utah implemented its Medicaid program in 1966, which, at the time, focused on acute and long-term care. Today, Utah Medicaid provides coverage for physical health, behavioral health, and dental services, as well as long-term services and support.
Medicaid operates as a partnership program between the federal and state governments. Currently, the federal government shares financial responsibility by matching state costs with federal dollars. Federal requirements outline who and what must be covered in each Medicaid program, and then states can tailor programs to meet state-specific needs. Medicaid contributes significantly to the financing of the U.S. healthcare system, supporting local public health infrastructure, hospitals, mental health centers, at-home care, community clinics, nursing homes, physicians, and many other professions. Today, Medicaid is the nation’s single largest healthcare insurer, covering approximately 71.2 million people in the United States in 2016 – more than 400,000 of whom live in Utah.
What is a Medicaid Fraud Control Unit?
The Social Security Act (SSA) requires each State to effectively operate a Medicaid Fraud Control Unit (MFCU). In Utah, the Medicaid Fraud and Patient Abuse Division, Utah Attorney General’s Office, serves as the MFCU. The function of an MFCU is to investigate and prosecute Medicaid provider fraud and patient abuse, neglect, and exploitation.
Each MFCU receives a federal grant award equivalent to 90 percent of total expenditures for new Units and 75 percent for all other Units. MFCU staff review referrals of possible fraud and patient abuse, neglect, or exploitation to determine the potential for criminal prosecution and/or civil action. If the Unit accepts a referral for investigation, the case may result in various possible outcomes. Criminal prosecutions may result in convictions, and civil actions may result in civil settlements or judgments. Both criminal prosecutions and civil actions may include the assessment of monetary recoveries.
What is Medicaid Fraud?
Examples of Medicaid Fraud include:
- Billing for Services Not Rendered: A provider bills Medicaid for a procedure or service that was not actually provided.
- Billing for Up-Coded Services: A provider misrepresents the diagnosis and symptoms on patient records or selects higher-paying procedure codes to obtain greater reimbursement than allowed.
- Billing for Uncovered Services: A provider bills Medicaid for a service that requires the use of licensed or certified personnel but uses unqualified staff.
- Billing Multiple Claims: A provider submits bills to Medicaid multiple times for the same procedure or service.
- Drug Substitution: A pharmacist fills a recipient’s prescription with a generic drug but bills Medicaid for a higher-cost brand-name drug.
- Kickbacks: A provider offers or pays a kickback to induce someone to refer Medicaid recipients to that provider as patients or clients. Examples of kickbacks include cash, vacations, and gifts.
- Supplemental Charges: A provider charges a Medicaid recipient for a service that is covered by Medicaid and should be billed to Medicaid. The provider then charges the recipient the difference between the provider’s usual fee and what Medicaid pays.
- Inflating the Usual and Customary Charges: A provider might inflate the cost of the procedure, service, or goods provided by charging Medicaid more than usual and customary charges for the same product or service billed to other insurers and the public.
- Opioid Seeking Behavior: A Medicaid recipient who misrepresents or falsely claims a medical condition to obtain opioids from a health care provider.
What are Resident Abuse, Neglect, and Financial Exploitation?
Resident abuse or neglect is any action or failure to act that causes unjustifiable harm to a healthcare facility resident. Abuse or neglect may include any or all of the following:
- Physically assaulting a resident
- Withholding food
- Failing to provide necessary care
- Failing to provide medical treatment or medications
- Taking a vulnerable adult’s money or assets
The Medicaid Fraud and Patient Abuse Division investigates repo