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.

MFCU In The News

Medicaid Fraud Control Unit Recovers $5.3M

The West Virginia Department of Health and Human Resources (DHHR) Medicaid Fraud Control Unit today announced several significant accomplishments for 2016.

According to Inspector General Kathy Lawson, in state fiscal year 2016, the Unit investigated and delivered more cases to prosecutors than in any previous year. The Unit also obtained a record number of criminal convictions, as well as its highest-ever number of civil settlements. Recoveries totaled more than $5.3 million – nearly three times the Unit’s annual budget – and actual collections were nearly 10 percent higher than expenditures.

The Unit participated in the U.S. Department of Justice’s 2016 Health Care Fraud Takedown, in which state and federal authorities across the country charged approximately 300 defendants with various fraud schemes. The Unit filed Medicaid fraud charges in excess of $500,000 against six co-defendants in Berkeley County as its contribution to the Takedown. These six cases resulted from a referral from Medicaid’s Office of Program Integrity. The Unit also worked with the National Association of Medicaid Fraud Control Units (NAMFCU) on cases against large corporations involving multiple states.

Lawson says the success of the Unit is made possible through the combined efforts of investigators, a nurse investigator, attorneys, and a forensic auditor. Unit staff continue to develop professional expertise, with an additional staffer recently obtaining certification as a fraud examiner. The Unit’s success also is attributable to the collaboration and cooperation with other law enforcement agencies including HHS-OIG, the FBI, the DEA, and the West Virginia State Police, as well as the United States Attorney’s Offices in both districts of West Virginia.

Among other highlights of 2016, Deputy Director Richelle Garlow was selected to speak at NAMFCU’s Annual Training Conference in Omaha, Nebraska. Garlow gave a presentation detailing the Unit’s investigation and prosecution of a Randolph County social worker employed by a nursing home, who stole more than $50,000 from 13 of the facility’s residents and committed nearly $43,000 in Medicaid fraud.

The Medicaid Fraud Control Unit, through DHHR’s Office of Inspector General, investigates and prosecutes or refers for prosecution allegations of health care fraud committed against the Medicaid program, allegations of the criminal abuse, neglect or financial exploitation of patients in Medicaid-funded facilities, and the abuse and neglect of residents in board and care facilities. Additionally, the Unit is responsible for investigating fraud in the administration of the Medicaid program. The mission of the Medicaid Fraud Control Unit is to protect West Virginia’s vulnerable citizens and the integrity of its health care programs.

If you want to report Medicaid provider fraud or patient abuse, neglect or financial exploitation, please call 1-304-558-1858 or toll free at 1-888-FRAUD-WV (1-888-372-8398).


Medicaid Fraud Control Unit Receives Data Mining Authorization

The West Virginia Department of Health and Human Resources Medicaid Fraud Control Unit today announced that it has received a waiver from the federal government permitting the Unit to conduct data mining activities. Data mining is the process of identifying fraud through the screening and analysis of data.

According to Kathy Lawson, Inspector General, the waiver allows the Unit to proactively evaluate Medicaid claims using data analytics and statistical modeling to uncover patterns and activities which may be indicative of fraud. Without a waiver, state Medicaid Fraud Control Units are prohibited from using federal matching funds for such activities and instead must rely on referrals from other sources.

West Virginia joins only nine other states that have successfully obtained the waiver from the U.S. Health and Human Services, Office of Inspector General. Funding for these data mining activities will come largely from federal matching funds.

The Medicaid Fraud Control Unit, through DHHR’s Office of Inspector General, investigates and prosecutes or refers for prosecution allegations of health care fraud committed against the Medicaid program and allegations of the criminal abuse, neglect or financial exploitation of patients in Medicaid-funded facilities and residents in board and care facilities. Additionally, the MFCU is responsible for investigating fraud in the administration of the Medicaid program. The mission of the MFCU is to protect West Virginia’s vulnerable residents and the integrity of its health care programs.

If you want to report Medicaid provider fraud or patient abuse, neglect or financial exploitation, please call 1-304-558-1858 or toll free at 1-888-FRAUD-WV (1-888-372-8398).


Nursing Home Employee Sentenced in Medicaid Fraud, Financial Exploitation of Patients

The West Virginia Department of Health and Human Resources Medicaid Fraud Control Unit announced today that Mary Jane Brown, 58, of Belington, was sentenced subsequent to conviction on multiple felony counts in Randolph County Circuit Court, including Medicaid fraud, financial exploitation and fraudulent schemes. The convictions resulted from a criminal investigation by the Medicaid Fraud Control Unit, which determined that over the course of four years, Brown, a Social Worker employed by a nursing home in Elkins, financially exploited 13 patients, stealing over $50,000. Brown also caused over $40,000 in fraudulent claims to be submitted to the Medicaid program. The total loss to all victims including the Medicaid program was $97,264.59. Brown was initially arrested in July 2014, and later indicted on one count of fraudulent schemes, six counts of financial exploitation, and two counts of Medicaid Fraud. The case was prosecuted by MFCU Attorney Michael Malone, in cooperation with the Randolph County Prosecuting Attorney’s Office.

Brown was sentenced to serve one year in jail on one count of financial exploitation, and 2 consecutive terms of 1-10 years in prison on one count each of fraudulent schemes and Medicaid Fraud. The prison sentences were suspended in favor of 7 years’ probation, to begin upon Brown’s release from jail. In addition, Brown is ordered to pay full restitution.

The Medicaid Fraud Control Unit, through DHHR’s Office of Inspector General, investigates and prosecutes or refers for prosecution allegations of healthcare fraud committed against the Medicaid program and allegations of the criminal abuse, neglect or financial exploitation of patients in Medicaid-funded facilities and residents in board and care facilities. Additionally, the MFCU is responsible for investigating fraud in the administration of the Medicaid program. The mission of the MFCU is to protect West Virginia’s vulnerable citizens and the integrity of its healthcare programs.

If you want to report Medicaid provider fraud or patient abuse, neglect or financial exploitation, please call 1-304-558-1858 or toll free at 1-888-FRAUD-WV (1-888-372-8398).

Director

Trina Crowder, MLS, CFE

Administrative Services Assistant

Jennifer Rutherford

Office Assistant

Vacant

Contact Information:

408 Leon Sullivan Way

Charleston, WV 25301

Phone: (304) 558-1858

Fax: (304) 558-3498