The expansive Medicaid program spent approximately $909 billion in fiscal year 2024.
To help cover health care costs for eligible low-income individuals, the federal government contributes the majority of this funding, while state governments supply the remaining portion.
Large government programs often face a significant challenge: fraud. Even so, overall civil settlements, judgments, and recoveries related to Medicaid fraud have trended downward since 2016. Civil fraud cases commonly involve schemes to bill the government for services not provided, to charge for more expensive services than a patient actually received, to submit duplicate claims, or to otherwise obtain improper Medicaid payments.
In most instances, the government initiates Medicaid fraud investigations after receiving information from an external source, such as a whistleblower, although internal data analysis can also trigger cases. Investigation and prosecution are handled by Medicaid Fraud Control Units (MFCUs), which operate in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands.
Keller Grover whistleblower attorney Kate Scanlan recently moderated a Federal Bar Association panel discussion focused on Medicaid Fraud Control Units, with particular attention to California, the largest state, and Rhode Island, the smallest. While procedures vary by jurisdiction, oversight of multistate matters continues to evolve based on state and federal enforcement priorities.
Overall, MFCUs recovered $3.46 for every $1 spent in fiscal year 2024, according to the latest report from the Department of Health and Human Services Office of the Inspector General. Medicaid fraud cases may be criminal or civil in nature. Keller Grover focuses on civil actions, which result in civil settlements, judgments, and recoveries that may lead to whistleblower awards.
During fiscal year 2024, MFCUs reported 493 civil settlements and judgments, producing $407 million in recoveries. The largest number of civil settlements and judgments involved pharmaceutical manufacturers. The highest dollar recoveries resulted from cases involving hospitals and pharmacists.
Although civil Medicaid fraud cases have declined in recent years, this trend does not mean fraud is disappearing. Federal and state governments, as well as taxpayers, continue to rely on whistleblowers to expose fraudulent conduct that drives up health care costs.
If you suspect fraud or other misconduct, reporting it can help protect public funds and the individuals those funds are intended to serve. Whistleblowers may also be eligible for substantial rewards, typically ranging from 10 to 30 percent of recoveries.
Keller Grover offers free and confidential consultations and can advise you on your situation and potential next steps. With more than 30 years of combined experience litigating fraud cases and billions of dollars recovered for clients, our attorneys are well positioned to represent whistleblowers.