New York State’s Medicaid Fraud Control Unit by the Numbers

Medicaid Fraud Control Units (“MFCUs) have a responsibility to combat Medicaid fraud and patient abuse and neglect.  Toward that end, each MFCU maintains statistical data as to the number of investigations, indictments, and convictions by the MFCUs, as well as the amount of monetary recoveries for both civil and criminal cases.  Each year, a summary of this information is put together as to all MFCUs across the country.  As such, in February 2015, the U.S. Department of Health and Human Services Office of the Inspector General (“HHS OIG), released the fiscal year 2014 state-by-state comparison of the MFCUs.  According to this data, New York ranked 1^st in total recoveries, bringing in $378,434,543, with $2,452,239.00 coming from criminal recoveries and $375,982,304.00 in civil recoveries.  Second on the list was Louisiana with $245,305,060.00 in overall recoveries.  Texas, coming in 3^rd, had total recoveries of $106,075,376.49.  Florida, Illinois, and California were ranked 4^th, 5^th, and 6^th, respectively.  For purposes of the comparison, recoveries constitute the amount of money defendants are required to pay but not necessarily the money actually collected.

While New York has high recoveries, it also has high staffing, with 294 employees.  In fact, New York’s MFCU has the highest number of staff across the entire country, outnumbering the next highest state by almost 100 employees: California MFCU, who is ranked 2^nd for staffing, has 193 employees.  Texas and Florida are next on the list with staffing of 175 and 161 respectively.  Compared to the rest of the country these numbers seem relatively high.  Most other state MFCUs have staff ranging from 4 to 55.  However, large staff size may not necessarily correlate to high recoveries.  For example, Louisiana, who was second on the list in terms of overall recoveries, only has 52 employees, whereas California, ranked 6^th in terms of overall recoveries, has the second highest staff (and more than three times as many employees as Louisiana).

In looking at the three highest staffed MFCUs – New York, California, and Texas – New York seems to fair a little better in terms of end results.  Of New York’s 746 total investigations, 142 resulted in indictments and charges, with 118 of those ending in convictions.  New York also had 66 civil settlements and judgments.  California and Texas had more total investigations than New York (1,194 and 1,303 respectively), but their investigations resulted in less convictions and settlements.  California investigations resulted in 114 indictments and charges, with 97 total convictions and 20 civil settlements and judgments. Texas investigations resulted in 122 indictments and charges, ultimately ending with 90 convictions and 17 civil settlements and judgments.  Again, high staffing numbers do not seem to necessarily correlate with more investigations.  For example, Indiana (with only 55 staff on board) investigated 1,272 cases, and Ohio (with only 89 staff on board) investigated 1,190 cases.

Breaking down the types of investigations a little further, HHS OIG separated the investigations into two categories: fraud and abuse/neglect cases.  Looking specifically at New York, the MFCU more frequently investigated fraud as opposed to abuse or neglect.  There were 618 fraud investigations compared to only 128 abuse/neglect investigations.  With that said, however, in terms of what was ultimately indicted or charged, abused and neglect cases outweighed fraud cases.  There were 62 fraud indictments or charges compared to 80 indictments or charges for abuse or neglect, with 53 ultimate convictions for fraud related crimes and 64 convictions for cases involving abuse or neglect.

New York, California, and Texas, unsurprisingly perhaps, since they have large numbers of staff on board, had the highest MFCU Grant Expenditures, with $45,814,464.43 for New York, $26,158,835.03 for California, and $26,158,835.03 for Texas.  However, as to total Medicaid expenditures, California outspent New York: California came in at $68,248,444,914, with New York closely behind at $53,915,930,694.  Texas was third on the list in total Medicaid expenditures at $32,831,310,090.

From the above statistics, it appears that New York’s MFCU is quite successful in investigating Medicaid fraud, abuse, and neglect.  New York has high staff on board compared to other states, as well has high recovery amounts.  With that said, it appears that New York seems to investigate more cases, but the proportion of those that are actually indicted or charged is relatively small comparatively.

This post was written by David R. Ross, Shareholder of O’Connell and Aronowitz, and Lindsay Zanello.  Mr. Ross served as General Counsel and Director of Audits and Investigations at the OMIG and was also the Acting Medicaid Inspector General under Governors Pataki and Spitzer. Please contact Mr. Ross for more information at dross@oalaw.com.