The Office of Inspector General, by impartial evaluation, investigation and reporting, seeks to ensure the
integrity of department programs and operations including the fair, accurate and nondiscriminatory
delivery of benefits and services to qualified state residents.

Medicaid Fraud Control Unit (MFCU)

Mission Statement

The mission of the Medicaid Fraud Control Unit (MFCU) is to protect West Virginia’s vulnerable citizens and the integrity of its health care program. In fulfillment of that mission, the MFCU investigates allegations of fraud in the Medicaid program and allegations of criminal abuse, neglect, or financial exploitation of residents in health care facilities or board and care homes.

What is the Medicaid Fraud Control Unit?

The Medicaid Fraud Control Unit (MFCU) is the single entity of West Virginia state government that is certified annually by the Secretary of the U.S. Department of Health and Human Services to conduct statewide investigations of health care providers that defraud the Medicaid program. In addition, the MFCU investigates complaints of criminal abuse or neglect in any health care facility, as well as allegations of misappropriation of patients' private funds in Medicaid facilities. The unit is also charged with the investigation of fraud in the administration of the Medicaid program.

The MFCU is authorized by Section 1, Article 7, Chapter 9 of the West Virginia State Code and §1007 of Title 42 of the Code of Federal Regulations.

What is Medicaid Provider Fraud?

Medicaid providers include doctors, dentists, hospitals, nursing facilities, home and community-based services, pharmacies, clinics, counselors, personal care, and any other individual or company that is paid by the Medicaid program to provide health care services. If a provider intentionally misrepresents the services rendered, and therefore increases the reimbursement from West Virginia Medicaid, provider fraud has occurred.

Medicaid provider fraud costs taxpayers hundreds of millions of dollars every year. In addition to the monetary impact, Medicaid fraud can also impact patient care. Unsuspecting patients may be subjected to unnecessary or unsafe procedures, or may have false diagnoses inserted into their medical records.

Some Examples of Medicaid Provider Fraud

  • Billing for a service not actually performed, known as phantom billing
  • Billing for a more expensive service than was actually rendered, known as upcoding
  • Billing for several services that should be combined into one billing, known as unbundling
  • Billing twice for the same service
  • Dispensing generic drugs and billing for brand-name drugs
  • Remuneration to induce or reward patient referrals or the generation of business involving any item or service payable by Medicaid, known as a kickback.
  • Bribery
  • Billing for unnecessary services
  • Falsifying cost reports
  • Mispresenting the qualifications of a licensed provider, known as falsifying credentials

What is Abuse, Neglect and Financial Exploitation?

"Abuse" means the intentional infliction of bodily injury on an incapacitated adult.

"Neglect" means the unreasonable failure by a caregiver to provide the care necessary to assure the physical safety or health of an incapacitated adult.

"Financial exploitation" means the intentional misappropriation or misuse of funds or assets of an elderly person (65 or older), protected person (as deemed by the court) or incapacitated adult.

"Incapacitated adult" means any person 18 years of age or older who, by reason of advanced age, physical, mental or other infirmity is unable to carry on the daily activities of life necessary to sustaining life and reasonable health.

REPORT HEALTH CARE CRIMES

  1. COMPLETE THE ONLINE REPORTING FORM
  2. Call the TIPLINE at 1-888-Fraud-WV (1-888-372-8398)
  3. Write us:
Department of Health and Human Resources
Medicaid Fraud Control Unit
Office of Inspector General
408 Leon Sullivan Way
Charleston, West Virginia 25301

Important Links

REPORT HEALTHCARE CRIMES

Director

Trina Crowder, MLS, CFE

Administrative Services Assistant

Jennifer A. Rutherford

Office Assistant

Vacant

Contact Information:

408 Leon Sullivan Way

Charleston, WV 25301

Phone: (304) 558-1858

Fax: (304) 558-3498