Legislature hears performance report regarding West Virginia’s Medicaid Fraud Control Unit

By Matthew Young, RealWV

CHARLESTON, W.Va. – The State Legislature’s Post Audits Subcommittee, during day-one of the September Interim Session on Sunday, heard the results of a  performance report pertaining to the Medicaid Fraud Control Unit (MFCU). The report was delivered by Audit Manager Mike Jones, with the Post Audits Division.

“During the 2019 Legislative Session, SB 318 reorganized the MFCU from under the DHHR (Department of Health and Human Resources) to the Attorney General’s Office (AGO),” Jones began, before explaining that the bill also granted authority to the Legislative Auditor to conduct a three-year comparative-study of the unit’s performance under both the DHHR and the AGO. 

All 50 states, as well as all U.S. territories utilize a MFCU to investigate both provider and administration fraud, complaints of abuse or neglect, and misappropriation of patient’s funds. The federal government provides 75% of the funding required for each MFCU, while each individual state or territory contributes 25%.

Post Audits Division Audit Manager Mike Jones participates during the Sept. 10 meeting of the Legislature’s Post Audits Subcommittee.

Jones further explained that the AGO made “three key changes” to West Virginia’s MFCU since becoming its custodian. Those changes include the establishment of an outreach program, the enforcement of the “treble damages clause” – the W.Va. state code which allows plaintiffs to receive up to three times their actual financial damages – and the execution of concurrent civil and criminal investigations. 

“The operational changes implemented by the AGO have contributed to improved outcomes in each of the core functions of the unit,” Jones added. 

Jones referenced a significant increase in both referrals and open-investigations as evidence of the unit’s increased success under the purview of the AGO. The unit has also experienced a significant increase in indictments and convictions, as well as financial recovery-orders.

“The three-year totals for criminal recovery orders, and global and non-global civil recovery orders, all saw increases since reorganizing under the Attorney General,” Jones said, noting that expenditure for the unit have “decreased by approximately half-a-million dollars” under the AGO. 

“In conclusion, the Attorney General’s implementation of an outreach program, concurrent criminal and civil investigations, and enforcement of the treble damages clause has resulted in significant improvements in comparison to the fraud unit’s performance under the DHHR,” Jones said.

The first to question Jones was House Speaker and Committee Chair Roger Hanshaw, R-Clay, who – while referencing pre-and-post-pandemic timeframes – asked, “Was your office able to ascertain any identifiable distinguishing features between those two periods of time that might account for the overall increase in activity that we’ve seen?”

Jones chose not to answer, rather forwarding Hanshaw’s question to the AGO. 

“What was the goal of moving it (MFCU) from DHHR to the AGO?” Del. Kayla Young, D-Kanawha, asked. “Is the intention of the organization to make money, or to stop fraud?”

While Jones did not know the answer to Young’s first question, he cited the prevention of fraud as the answer to her second.

“So we got a 230% increase in referrals, but only 20 more convictions?” Young then asked, to which Jones responded simply, “Yes.”

Del. Kayla Young, D-Kanawha, asks a question during the Sep. 10 meeting of the Legislature’s Post Audits Subcommittee.

Brent Wolfinbarger, senior deputy Attorney General, then addressed the committee to provide additional information regarding the MFCU. 

“I would say that the AGO is pleased by the report,” Wolfinbargar began. “The various operational changes the AGO had implemented resulted in significant improvements across measurable outcomes when compared to how the unit did under DHHR.”

Committee Co-chair and Senate President Craig Blair, R-Berkeley, then asked, “Is there anything we can do to improve upon this? Are there any holes in what we’ve doing?”

In response, Wolfinbargar discussed the possibility of amending the statute-requirements in neglect cases in order to achieve more desirable outcomes for prosecutors. 

The Post Audits Subcommittee will meet again during next month’s Interim Legislative session, scheduled for Oct. 15 – 17.

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