Medicaid Fraud

The Medicaid Fraud Control Units report was just released. Here are a few highlights:

  1. 1,564 convictions (slightly up from 1,557 the year before).
  2. Almost $1.9 billion in recoveries. The total cost of recovery was “$259 million in State and Federal Funds” making it “an average of over $7 for every dollar spent.”
  3. The provider type with the most convictions was “PCS Attendant, PCS Agency, or other Home Care Aide” with 552.
    1. The next provider type was “Nurse (LPN, RN, or other licensed), PA, or NP) with 171.
    2. “Nurse Aid” came after that with 153.
    3. Followed by “Family Practice Physician” with 57.
    4. And coming in last was “Home Health Agency” with 48.  
  4. 74% of the convictions involved fraud, 26% involved abuse or neglect.
  5. Pharmaceutical manufacturers accounted for “almost half of the civil settlements and judgments.”
  6. There were 998 civil settlements/judgments, the highest number in the last five years.

That sums up the most interesting data from this year’s report. The one that stands out the most to me is that pharmaceutical manufacturers accounted for “almost half of the civil settlements and judgments.” The report provides some insight:

Pharmaceutical manufacturer settlements typically relate to the marketing of prescription drugs. An additional 70 settlements and judgments involved laboratories, 67 involved medical device manufacturers, and 57 involved retail and wholesale pharmacies.  

The context is helpful, especially knowing that most of the settlements/judgments were because of marketing related issues. As always, if you have specific questions about compliance, data availability, the nuances of a particular source, or the best place to find the data you’re looking for, please don’t hesitate to reach out to me directly at or to call me at 800-780-5901, Extension 103.  

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