MEDICAID FRAUD CONTROL UNIT
The Medicaid Fraud Control Unit (MFCU) is a federally and state funded unit within the Department of the Attorney General that is charged with conducting criminal and civil investigations and prosecutions of (1) provider fraud against the Medicaid Program, (2) fraud in the administration of the Medicaid Program, and (3) abuse and neglect of Medicaid beneficiaries and residents of board and care facilities.
MFCUs across the nation employ multi-disciplinary teams of skilled and experienced investigators, attorneys, and auditors to conduct investigations into suspected fraud, abuse, and neglect. These investigations are initiated based on complaints, referrals, and information received from various sources, including the Medicaid Program, managed care organizations, Adult Protective Services, and the public. Hawai‘i’s Oahu-based MFCU is responsible for conducting investigations and prosecutions throughout the State and frequently works with other federal, state, and local law enforcement agencies to ensure that any suspected criminal or civil wrongdoing within MFCU jurisdiction is thoroughly investigated and prosecuted accordingly.
WHAT IS MEDICAID FRAUD?
Medicaid fraud is generally defined as the billing of the Medicaid Program, either directly or through one of the state’s managed care organizations (AlohaCare, HMSA, Kaiser, ‘Ohana, or UnitedHealthcare), for medicine, supplies, equipment, or services that are unnecessary, duplicative, not provided, more expensive than was provided, or otherwise not covered by the Medicaid Program.
The MFCU’s authority to investigate and prosecute fraud is targeted toward Medicaid providers and the administration of the Medicaid Program. The MFCU does not have the authority to investigate or prosecute fraud committed by Medicaid beneficiaries unless the beneficiary is colluding with a provider to commit the fraud.
Examples of providers include:
- Adult day care facilities
- Adult family homes
- Ambulance and transportation companies
- Assisted living facilities
- Medical Clinics
- Home health care providers
- Medical equipment manufacturers
- Medical equipment suppliers
- Nursing homes
- Pharmaceutical manufacturers
- Pharmacies or other dispensers
- Physician Assistants
Examples of fraud include:
- Billing for medicine, supplies, equipment, or services not rendered or provided
- Billing for medically unnecessary medicine, supplies, equipment, or services
- Diversion and misuse of pharmaceuticals
- Duplicate billing (submitting multiple claims for a single item or service)
- Unbundling (submitting separate claims for medicine, supplies, equipment, or services that are part of a package or bundle)
- Upcoding (billing at a higher rate than what is allowed for a particular item or service)
- See Medical assistance fraud; penalties (Hawaii Revised Statutes § 346-43.5)
- See also Actions for false claims to the State; qui tam actions (Hawaii Revised Statutes §§ 661-21 and -22)
WHAT IS ABUSE AND NEGLECT?
Abuse or neglect generally refers to the physical abuse, neglect, or financial exploitation (theft) of Medicaid beneficiaries committed by care facilities, paid caregivers, and other providers in institutional or non-institutional (home health care) settings. This also includes the abuse or neglect of residents of board and care facilities, regardless of whether such facilities are funded by Medicaid.
REPORT SUSPECTED FRAUD, ABUSE, OR NEGLECT
Click on the appropriate link below to be taken to the MFCU’s online complaint portal for Medicaid Fraud, Abuse, or Neglect.
CONTACT THE MFCU
IMPORTANT: IF YOU OR ANYONE YOU KNOW IS HAVING A MEDICAL EMERGENCY OR IS IN IMMEDIATE DANGER OF PHYSICAL HARM, CALL 9-1-1. PLEASE DO NOT CLICK ON EITHER OF THE ABOVE LINKS OR ATTEMPT TO CONTACT THE MFCU.