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Behavioral health compliance through deterrence

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The problems facing our country regarding access to and obtaining mental and behavioral health has grown over recent years. As part of the expanding need for these types of services, there has also been a rise in fraud against the Medicaid system involving behavioral health providers. Medicaid will do its best to identify fraud and administratively handle most issues that involve fraud, waste, and abuse. However, when the fraudulent conduct is egregious, the Medicaid Fraud Control Unit (MFCU) can step in and handle these providers either through criminal prosecution or civil settlements.[1] The cases in which MFCU works and the messages sent to the provider community can be essential in ensuring compliance by deterring fraudulent providers and keeping necessary Medicaid funds for recipients needing these behavioral health services.

The Nevada MFCU is part of the Office of Attorney General—as are most MFCUs found throughout the country.[2] The unit has two primary objectives: combating fraud and abuse against the Medicaid system by medical services and supplies providers, and protecting elderly and vulnerable adults in medical facilities from abuse and neglect.

The Nevada MFCU is a complaint-driven unit. Citizens and agencies provide complaints regarding fraudulent practices by providers and patient harm. Complaints originate from (i) recipients themselves who complain about the amount/type of services provided; (ii) employees of providers who have witnessed acts of fraud or have been asked to participate in fraudulent acts; (iii) state/federal agencies, including Nevada Medicaid, Managed Care Organizations (MCOs), the Office of the Inspector General (OIG); (iv) law enforcement; and (v) industry contacts.[3]

During the past 10 years, the Nevada MFCU has seen a dramatic rise in the number of complaints/referrals received in the behavioral health arena. To date, most complaints received and criminal cases opened by the Nevada MFCU involve behavioral health providers.[4]

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