More Essential Data From CMS
Timothy Powell, CPA, CHCP
April 24, 2023
The Centers for Medicare & Medicaid Services (CMS) just keep putting out the data, and we want to keep you aware of both the data
The agency still recovered more than $1 billion from healthcare providers.
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) just published its annual survey of how well or poor Medicaid Fraud Control Units (MFCUs) across the country performed in 2020, during the ongoing COVID-19 pandemic.
Each state has its own MFCU to prosecute criminal and civil fraud. I promise that you do not want a MFCU to be calling or subpoena-ing you unexpectedly. The MFCUs reported that the pandemic created significant challenges for staff, operations, and court proceedings, which led to worse case outcomes in the 2020 fiscal year. But during that time, the MFCUs still recovered over $1 billion from healthcare providers, marking a 48 percent drop.
As MFCUs initially moved to a telework environment, some staff reported experiencing challenges conducting work because of limitations with computer equipment and network infrastructure. To help protect staff and members of the public from the pandemic, MFCUs reported curtailing some in-person field work, such as interviews of witnesses and suspects. These activities were further limited because of an initial lack of personal protective equipment that was needed in order to conduct similar activities in nursing homes and other facilities. Basically, COVID made for a bad recovery year by the MFCUs. Courts were closed for a while as well, slowing the prosecutorial process.
The report further demonstrated how lucrative the MFCU agencies are, despite the pandemic. For every dollar spent on the administration of a MFCU, it rakes in $3.36. In 2020, the MFCUs excluded 928 individuals or entities from participation in federal healthcare programs. There were 786 civil settlements and judgments; the vast majority of judgments involved pharmaceutical manufacturers. Convictions decreased drastically, going from 1,564 in 2019 to 1,017 in 2020. Interestingly, looking at the types of providers convicted or penalized, the vast majority were personal care service attendants and agencies, which were affected at a rate five times higher than that of the next most common provider type – nurses (LPNs, RNs, NPs, and PAs).
The Maine MFCU received the Inspector General’s Award for Excellence in Fighting Fraud, Waste, and Abuse for its high number of case outcomes across a mix of case types.
OIG also established desired performance indicators for 2021. OIG expects the MFCUs to maintain an indictment rate of 19 percent and a conviction rate of 89.1 percent.
The OIG report foreshadows 2021 MFCU actions:
While Medicare is strictly a federal program, Medicaid is funded with federal and state tax dollars. Therefore, each state’s regulations germane to Medicaid can vary. Medicaid fraud can be prosecuted as a federal or a state crime.
Programming Note: Listen to Knicole Emanuel’s live RAC report every Monday during Monitor Mondays, 10 a.m. Eastern.
The Centers for Medicare & Medicaid Services (CMS) just keep putting out the data, and we want to keep you aware of both the data
Learn how providers can avoid falling into the trap of making clinically suspect diagnoses. The U.S. Department of Health and Human Services (HHS) Office of
Please log in to your account to comment on this article.
Stop revenue leakage and boost hospital performance by mastering risk adjustment and HCCs. This essential webcast with expert Cheryl Ericson, RN, MS, CCDS, CDIP, will reveal how inaccurate patient acuity documentation leads to lost reimbursements through penalties from poor quality scores. Learn the critical differences between HCCs and traditional CCs/MCCs, adapt your CDI workflows, and ensure accurate payments in Medicare Advantage and value-based care models. Perfect for HIM leaders, coders, and CDI professionals. Don’t miss this chance to protect your hospital’s revenue and reputation!
Struggling with ICD-10-CM coding for diabetes and complications? This expert-led webcast clarifies complex combination codes, documentation gaps, and sequencing rules to reduce denials and ensure compliance. Dr. Angela Comfort will provide actionable strategies to accurately link diabetes to complications, improve provider documentation, and optimize reimbursement—helping coders, CDI specialists, and HIM leaders minimize audit risks and strengthen revenue integrity. Don’t miss this chance to master diabetes coding with real-world case studies, key takeaways, and live Q&A!
Uncover critical guidance. Kay Piper provides an interactive review on coding guidelines and more in the AHA’s fourth quarter 2025 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Uncover critical guidance. Kay Piper provides an interactive review on coding guidelines and more in the AHA’s third quarter 2025 ICD-10-CM/PCS Coding Clinic in an easy to access on-demand webcast.
Struggling with CMS’s 3-Day Payment Window? Join compliance expert Michael G. Calahan, PA, MBA, CCO, to master billing restrictions for pre-admission and inter-facility services. Learn how to avoid audit risks, optimize revenue cycle workflows, and ensure compliance across departments. Critical for C-suite leaders, providers, coders, revenue cycle teams, and compliance teams—this webcast delivers actionable strategies to protect reimbursements and meet federal regulations.
Providers face increasing Medicare audits when using skin substitute grafts, leaving many unprepared for claim denials and financial liabilities. Join veteran healthcare attorney Andrew B. Wachler, Esq., in this essential webcast and master the Medicare audit process, learn best practices for compliant billing and documentation, and mitigate fraud and abuse risks. With actionable insights and a live Q&A session, you’ll gain the tools to defend your practice and ensure compliance in this rapidly evolving landscape.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
Copyright © 2025 ICD10monitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
