MFCUs are unique in that their circumstances can lead to criminal prosecutions and/or civil lawsuits wherein suppliers are sued underneath the False Claims Act. That dedication is made based on the character and high quality of the proof (i.e., whether there’s ample proof of intent to defraud).
Alternatively, when there may be weak proof of fraud to assist either a criminal or civil case, the MFCU might end up closing an investigation and referring the matter to its state Medicaid program integrity workplace for assortment of overpayments.
Suppliers should be aware that MFCU investigations can lead to simultaneous criminal expenses and civil lawsuits, sometimes often known as “parallel proceedings.” As such, suppliers can face more than one battlefront arising out of the same set of details and face both prison time as well as hefty civil monetary penalties.
On the criminal entrance, every state has a criminal statute particularly criminalizing the realizing or purposeful submission of false or fraudulent claims to Medicaid, generally called “Provider Fraud Investigation Switzerland” or “Medicaid Fraud.” Just like every prosecution, MFCUs also can cost any state crime as may be applicable under the circumstances, equivalent to theft or computer crime.
Medicaid provider fraud prosecuted on the state stage is usually a felony or misdemeanor, relying on the state regulation. In some states, it is a felony no matter the amount concerned.
It is vital to notice that Medicaid fraud cases can be investigated and prosecuted by federal agencies as well. In many instances, such circumstances contain additional features akin to Medicare fraud, personal insurance fraud, or drug diversion. It’s not unusual to see multiagency collaboration amongst MFCUs, the HHS-OIG, the FBI, the DEA and U.S. Attorneys’ Places of work.
On the civil front, most states have enacted some version of a False Claims Act, similar or identical to the federal corollary. False Claims lawsuits allow the government to recover treble damages and impose civil financial penalties.
There is one fundamental difference between a criminal case and a civil case. Criminal cases must exhibit proof of intent to defraud beyond an inexpensive doubt. Civil circumstances, however, require less proof of intent and could be gained by demonstrating by a preponderance of the evidence that a supplier was merely reckless in the submission of false claims to Medicaid.