One specialty practice group stood out in 2016—the Medicaid Fraud Control Unit (MFCU) of the Georgia Department of Law.

The unit comprises attorneys, investigators, nurses, auditors, analysts and support personnel. Their goals are to investigate and prosecute violations of laws concerning fraud in the administration of the Medicaid program; review complaints in health care facilities that allege abuse or neglect of patients, misappropriation or theft of a patient’s private funds; identify and seek recovery of overpayments made to health care facilities or other providers under the Georgia Medicaid Program and to pursue civil litigation in collection of such overpayment; and to cooperate with investigations and prosecutions of fraud committed by health care providers under federally funded health care programs.

Attorney General Chris Carr, who succeeded Sam Olens as AG in November 2016, reported that the MFCU includes four criminal teams and three civil teams. Each team has one attorney, two investigators, one nurse, one auditor and one analyst.

In 2016, MFCU’s criminal teams received 495 referrals—which included claims of fraud, abuse and neglect. Of those cases investigated, 19 were criminally indicted and 15 convicted with restitution ordered in the amount of $2.6 million.

On the civil side, the MCFU prosecutes lawsuits filed under the whistleblower provisions of the False Claims Act and the Georgia Medicaid Claims Act. In 2016, the civil teams settled 18 cases and recovered $16.2 million in non-global civil case monetary recoveries and $12.7 million in global case recoveries.

Georgia also collected $118 million for its part of a nonprosecution agreement with Tenet Healthcare Inc., which agreed to pay $368 million to the federal government, the state of Georgia and the state of South Carolina to resolve a civil whistleblower case. Olens called it “an unprecedented settlement for the state of Georgia.”

Given the complexity of medical billing, how do you determine among the hundreds of referrals your unit receives if a medical biller has made an inadvertent mistake as opposed to deliberately committed a crime or a civil violation? Or does the intent not matter from a legal perspective?

Intent always matters. A multidisciplinary team, which includes an attorney, investigator, nurse investigator, investigative auditor and intelligence analyst, gathers and develops the evidence. For criminal cases, the investigative team gathers sufficient evidence that the provider acted with criminal intent, that is, evidence “beyond a reasonable doubt” to support a showing of criminal fraud. Similarly, in civil cases, the investigative team gathers evidence which supports the civil standards of proof, that the provider recklessly disregarded Medicaid statutes, regulations, or policies or was deliberately indifferent to those requirements.

The investigative team examines billing data early in the investigation to determine whether there are any billing patterns indicative of fraud. For example, innocent billing errors will result in overpayments and underpayments to the provider. On the other hand, a persistent pattern of overpayments is a typical feature of fraud. Another marker of fraud is a history of the provider failing audits by outside auditors contracted with the Medicaid agency, Department of Community Health and a failure to take corrective action as recommended by those auditors.

How often are MFCU cases settled before trial, and what’s the key to reaching a settlement?

The prevailing wisdom holds that 90 percent of all cases are settled. The key to settlement of cases, whether criminal or civil, is thorough preparation. The state must gather and organize its evidence to show a persuasive case of a serious violation.

It is the unit’s goal in criminal cases to provide discovery promptly in indicted cases and to encourage discussions with defendants and their attorneys well in advance of trial. Prior to indictment, our office may extend an invitation to represented persons to review the evidence of fraud against them. Similarly, in civil cases, the unit seeks transparency with defendants and their attorneys regarding the evidence uncovered throughout the investigation prior to filing a lawsuit.

What is your team’s best time management tool or technique?

Due to the volume of documents, large data files and witnesses, the team must delegate various aspects of the investigation to different team members to promote efficiency. That is why the key to MFCU’s success is the multidisciplinary team, constant communication and the hardworking, talented individuals that make up each team.