States Medicaid Agencies Might Soon Have New Tools to Investigate Whistleblower Allegations

Currently, state Medicaid Fraud Control Units (MFCUs) have limited resources and capabilities to use statistical models and data mining technologies to identify patterns of health care fraud. These limitations have appeared even when whistleblowers have successfully uncovered possible widespread fraudulent business practices. However, this all might soon change under a recently proposed federal rule.

The US Department of Health and Human Services Office of Inspector (HHS-OIG) has proposed to allow MFCUs to use federal funds to conduct data mining on Medicaid claims. Under the proposed HHS-OIG rule, MFCUs would have to clear specific hurdles before receiving the federal funds, including delineating the duration of the data mining.

This would be a huge step forward for our country’s fraud-fighting efforts. Whistleblowers regularly birddog substantial evidence of massive health care fraud schemes. This proposed rule would supply the MFCUs with the necessary tools to fully unearth the identified fraud.

Once federal funding for data mining has been granted, MFCUs will be required to provide information on an annual basis regarding the costs associated with data mining, the total number of fraud cases resulting from data mining, the outcome of the cases, and the amount of recoveries obtained. If the MFCUs effectively utilize these funds to actively investigate qui tam actions, the reported outcomes could be quite substantial.

For more information about qui tam law and Medicare fraud, contact Nolan and Auerbach, P.A.