Medicaid:

Results of Certified Fraud Control Units

HRD-87-12FS: Published: Oct 21, 1986. Publicly Released: Nov 20, 1986.

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In response to a congressional request, GAO reviewed state-certified Medicaid fraud control units to determine: (1) their expenditures for fiscal years (FY) 1984 and 1985, including federal and state governments' share of the expenses; (2) their results, including convictions, fines and restitution, and overpayments identified; and (3) changes that could strengthen their fraud control efforts.

GAO found that: (1) total federal and state expenditures for the fraud units were about $43 million and $47 million in FY 1984 and 1985, respectively; (2) during calendar years 1984 and 1985, the fraud units opened 2,693 and 2,871 cases, reported 68 and 108 convicted providers, had $3.6 million and $4 million in restitution, and identified $14.7 million and $7.3 million in overpayments, respectively; (3) although it was difficult to document and quantify the deterrent effects, six units' analyses concluded that, Medicaid providers' billings usually decreased once they became aware of ongoing investigations; and (4) in addition to increasing and training fraud units' staffs, administrators suggested that improving fraud unit investigations, patient abuse statutes, and potential fraud referrals from the state Medicaid agencies would improve their fraud control efforts.

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