Medicaid Fraud Control Unit Story Archives - West Virginia Public Broadcasting

Medicaid Fraud Unit Experiences Gains Under Attorney General

In October of 2019, the West Virginia Legislature moved the Medicaid Fraud Control Unit from the Department of Health and Human Resources to the Office of the Attorney General.

During a Post Audits Subcommittee meeting Sunday, Audit Manager Mike Jones presented findings comparing three years before the change to three years after. He said the results of the transition were positive.

Jones noted among other changes that the Attorney General’s office pursued the recovery of three times the actual damages, plus costs, as allowed by code. He explained that resulted in a significant increase in the civil recovery orders.

Jones described that as a significant hammer in their negotiations with providers.

“Another change was to conduct both criminal and civil investigations concurrently until a charging decision was made,” he said. “This has allowed the fraud unit to more efficiently transition cases that do not meet the burden of proof required of a criminal case to a civil investigation. This change contributed to an increase in the number of cases closed by the fraud unit.”

Using a chart, Jones explained that the three-year totals for case referrals and cases opened from referrals more than doubled since reorganizing under the Attorney General.

Case referrals increased from 794 under DHHR, to 2046 under the Attorney General. The total cases opened increased from 138 under DHHR to 339, a 145 percent increase.

The second core function of the Fraud Unit is to refer cases of fraud and abuse or neglect for prosecution. The fraud unit increased the total cases referred for prosecution from 38 under the DHHR to 54. The total number of convictions jumped from 14 to 34, a 143 percent increase.

The third core function of the fraud unit is to seek recovery of funds through recovery orders. The fraud unit saw a modest increase of $23,000 in criminal recovery orders. It did experience significant increases in both global and non-global civil recovery orders of approximately $12.5 and $35.5 million respectively.

The Fraud Unit ultimately increased its total recovery orders from approximately $27 million under the DHHR to $75 million under the Attorney General at an increase of 176 percent.

The Medicaid Fraud Recovery Unit only pursues providers like nursing homes or doctors that have defrauded the system. A different unit, still within the DHHR, pursues Medicaid fraud against people who use the system.

State Medicaid Fraud Office Expansion To Include CHIP Fraud Investigations

The Attorney General’s Medicaid Fraud Control Unit is expanding to include investigations of Children’s Health Insurance Program (CHIP) fraud across the state.

CHIP offers health insurance to children whose families earn too much money for Medicaid.

Attorney General Patrick Morrisey said this expansion puts West Virginia’s fraud unit more in line with the majority of states and that investigating claims of CHIP fraud will save taxpayers more money.

“I just view that if you have the ability to save an extra dollar more with really not much effort, why wouldn’t you do that for the taxpayers and for the beneficiaries of the program?” Morrisey said.

The expansion was announced during a Tuesday press conference scheduled by Morrisey, who touted the successes of the fraud control unit under his office over the past three years. During that time the unit was expanded from 12 individuals to 21 with the average amount of civil recoveries from fraud per year climbing 268 percent.

Investigations of Medicaid fraud were previously housed under the West Virginia Department of Health and Human Resources before being placed under the jurisdiction of the Attorney General’s office in 2019.

West Virginia Says It Will Get $1.9 Million in EpiPen Settlement

West Virginia health authorities say the state will get more than $1.9 million from a settlement with drug company Mylan Inc. over its emergency allergy injector.

The Department of Health and Human Resources Medicaid Fraud Control Unit says it resolves allegations that Mylan made false Medicaid statements by classifying EpiPen as a generic instead of brand name product and lowering rebates.

According to West Virginia officials, all 50 states have entered into agreements with Mylan.

Department Inspector General Kathy Lawson says they worked with a team from the National Association of Medicaid Fraud Control Units to resolve the case.

The state unit investigates allegations of health care fraud against the Medicaid program and abuse, neglect or financial exploitation of patients in Medicaid-funded facilities and residents in board and care facilities.