State of Indiana Office of the Attorney General Greg Zoeller

1. State of IndianaOffice of the Attorney GeneralGreg Zoeller Medicaid Fraud Control Unit http://www.in.gov/attorneygeneral/2453.htm

2. MFCU Sources of Investigations Self-Disclosing Providers RACs The Medicaid Agency Whistleblowers What types of referrals do we expect in the near future? http://www.in.gov/attorneygeneral/2453.htm

3. Self-Disclosure The federal false claims act provides a reduced penalty for providers who self-disclose. The minimum court assessment is reduced from three times to two times the amount of damages the government sustained because of the false claim. See 31 USC 3729(a)(2) http://www.in.gov/attorneygeneral/2453.htm

4. Self-Disclosure HHS-OIG has adopted formal requirements for providers wishing to take advantage of the option to self-disclose. The requirements appear in a notice published in the Federal Register. 63 FR 58399 http://www.in.gov/attorneygeneral/2453.htm

5. Self-Disclosure The Indiana Medicaid Fraud Control Unit does not have formal requirements for self-disclosure, but we do look with favor on providers that self-disclose. http://www.in.gov/attorneygeneral/2453.htm

6. RACs Section 6411 of the new federal Affordable Care Act (ACA) requires States and territories to establish Medicaid Recovery Audit Contractor (RAC) programs. Medicaid RACs are tasked with identifying and recovering Medicaid overpayments and identifying underpayments. http://www.in.gov/attorneygeneral/2453.htm

7. RACs RACs receive a percentage of their recoveries as compensation. There is an obvious incentive to closely review high-dollar revenue sources. http://www.in.gov/attorneygeneral/2453.htm

8. New Medicaid Agency Regulations 42 C.F.R. § 455.23 Suspension of payments in cases of fraud. (a) Basis for suspension. (1) The State Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending . . .. (2) The State Medicaid agency may suspend payments without first notifying the provider of its intention to suspend such payments. http://www.in.gov/attorneygeneral/2453.htm

9. New Medicaid Agency Regulations 42 C.F.R. § 455.23 Suspension of payments in cases of fraud. (d) Referrals to the Medicaid fraud control unit. (1) Whenever a State Medicaid agency investigation leads to the initiation of a payment suspension in whole or part, the State Medicaid Agency must make a fraud referral to [the] Medicaid fraud control unit http://www.in.gov/attorneygeneral/2453.htm

10. New Medicaid Agency Regulations 42 C.F.R. § 455.23 Suspension of payments in cases of fraud. (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments . . . if any of the following are applicable: (1) [The MFCU has] specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation. http://www.in.gov/attorneygeneral/2453.htm

11. New Medicaid Agency Regulations 42 C.F.R. § 455.23 Suspension of payments in cases of fraud. (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments . . . if any of the following are applicable: (3) The State determines, based upon the submission of written evidence by the individual or entity that is the subject of the payment suspension, that the suspension should be removed. http://www.in.gov/attorneygeneral/2453.htm

12. New Medicaid Agency Regulations 42 C.F.R. § 455.23 Suspension of payments in cases of fraud. (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments . . . if any of the following are applicable: (4) Recipient access to items or services would be jeopardized by a payment http://www.in.gov/attorneygeneral/2453.htm

13. New Medicaid Agency Regulations 42 C.F.R. § 455.23 Suspension of payments in cases of fraud. (e) Good cause not to suspend payments. A State may find that good cause exists not to suspend payments . . . if any of the following are applicable: (6) The State determines that payment suspension is not in the best interests of the Medicaid program. http://www.in.gov/attorneygeneral/2453.htm

14. Whistleblowers Relators bringing qui-tam cases continue to be the most valuable sources of information leading to the most substantial MFCU recoveries. http://www.in.gov/attorneygeneral/2453.htm

15. MFCU Collections The MFCU is a law enforcement agency, not a collections agency. Collections in Latest State Fiscal Year (July 1, 2010 to June 30, 2011): $36,098,607.66 http://www.in.gov/attorneygeneral/2453.htm

16. Recipients of Kickbacks September 16 Washington Post headline: Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud Sen. Charles E. Grassley (Iowa), the ranking Republican on the Judiciary Committee, said in a written statement that it takes “two sides to perpetuate this fraud” and that both need to be held accountable. http://www.in.gov/attorneygeneral/2453.htm

17. Recipients of Kickbacks September 16 Washington Post headline: Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud “Otherwise, regardless of how big of a civil settlement a drug company makes, the incentive to cheat the taxpayers will still be in place for those willing to take part.” http://www.in.gov/attorneygeneral/2453.htm

18. Recipients of Kickbacks September 16 Washington Post headline: Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud Lewis Morris, chief counsel to the HHS inspector general, said doctors need to know there are repercussions.“If you don’t focus on doctors, this is a problem that will never end,” he said. http://www.in.gov/attorneygeneral/2453.htm

19. A Shortage of Fraud-Fighting Resources September 16 Washington Post headline: Doctors avoid penalties in lawsuits against medical firms alleging kickbacks, fraud He also acknowledged that he has the resources to focus only on the most glaring cases. http://www.in.gov/attorneygeneral/2453.htm

20. Recent Indiana MFCU Changes • Since 2005, the MFCU has added 300 whistleblower, qui-tam lawsuits to its caseload. • Those qui-tams are assigned to six DAGs. • Indiana-Only Cases • Multi-State Cases in Which Indiana DAGs are on the National Investigation or Litigation Team • Multi-State Cases in Which Indiana DAGs are Supporting a National Investigation or Litigation Team http://www.in.gov/attorneygeneral/2453.htm

21. Excluded Employees and Contractors Medicaid providers must not bill Medicaid (or Medicare) for services (professional or otherwise) provided by an individual who has been excluded by HHS-OIG. To check on current and prospective employees and contractors, follow the link at http://oig.hhs.gov/exclusions/index.asp http://www.in.gov/attorneygeneral/2453.htm

22. Unlicensed Employees and Contractors Medicaid providers must not bill Medicaid (or Medicare) for professional services provided by an individual who is unlicensed or whose license is suspended. To check on current and prospective employees and contractors, follow the link at https://mylicense.in.gov/everification/Search.aspx http://www.in.gov/attorneygeneral/2453.htm

23. In General Areas that the MFCU feels may have received too little emphasis in recent years, and that may receive increased MFCU review in the near future. http://www.in.gov/attorneygeneral/2453.htm

24. Drug Diversion The MFCU patient-neglect investigators continue to aggressively review allegations involving the diversion of drugs from patients who are vulnerable and who require the strongest pain medications. Continuous improvement in the control of stored drugs, inadvertently, continues to increase the temptation to divert drugs after they are dispensed to patients, especially non-communicative patients. http://www.in.gov/attorneygeneral/2453.htm

25. Indiana Medicaid Fraud Control Unit www.in.gov/attorneygeneral Find the MFCU under the “Criminal Justice” link. 317-915-5300 Alllen.Pope@atg.in.gov http://www.in.gov/attorneygeneral/2453.htm