Medicaid Fraud Investigation

Medicaid Fraud Unit Defense

Medicaid is a state-run program that receives federal funding and oversight. Forty-nine states, as well as the District of Columbia, have Medicaid Fraud Control Units (MFCUs). These units are part of each state’s Attorney General’s office and are designed to ensure no fraudulent activities occur. Unfortunately, there are numerous providers who are accused of engaging in these illegal activities.

Medicaid fraud is a truly unique area of healthcare fraud prosecutions. This area has special teams that focus exclusively on providers who bill Medicaid for health care products and services. There are various things you, as providers, should know regarding Medicaid fraud investigations and prosecutions.

The Medicaid Fraud Investigation Process

Each state’s MFCU is operated under its own state’s laws, as well as federal laws, surrounding investigations and prosecutions. These units are specifically authorized to prosecute providers who engage in fraudulent activities under state Medicaid plans. Although each state has its own set of guidelines, these units typically investigate incidents involving:

  • Billing fraud surrounding the Medicaid program.
  • Abuse and/or neglect of residents in nursing homes or other facilities that receive funding and payments from Medicaid or recipients.
  • The misappropriation of patient funds by such healthcare facilities.

MFCUs are typically composed of a variety of team members. These crews usually include investigators, auditors, and attorneys–each of which plays a critical role in the investigations and prosecutions of the accused. These units are specifically authorized to investigate and prosecute fraud that occurs within the administration of the state’s Medicaid program. In collaboration with the State’s Medicaid program integrity offices, MCFUs are able to investigate conduct surrounding improper billing. In any case, state programs must refer all suspected fraud cases to the MFCU to investigate.

Penalties and Crimes Surrounding Medicaid Fraud

MCFUs are unique. In some instances, their cases can result in criminal prosecution as well as civil lawsuits. These can occur in cases where providers are sued under the False Claims Act. The quality of evidence and the nature of evidence typically determine which penalties are appropriate. When cases do not have strong evidence of fraud, the MFCU may end up closing an investigation or referring the matter to the integrity office for the state to collect overpayments.

Providers should be aware that MFCU investigations pose a real potential of both criminal and civil lawsuits and penalties. Providers can face multiple battles surrounding each incident and can be penalized in both criminal and civil proceedings through the use of the same evidence.

Working with a Strong Criminal Defense Team is In Your Best Interest

If you have been accused of Medicaid fraud, it is crucial that you reach out to a reputable criminal defense team as soon as possible. Our team at Healthcare Fraud Group has extensive experience helping those accused of these crimes beat their charges and get the justice they deserve. If you have been accused of Medicaid fraud, contact our team today at 888-402-4054 to explore the legal options available for you.


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