MFCU
Erica J. Bailey, A.A.G.
Chief of Civil Investigations
Overview
• Methods for investigating civil Medicaid fraud
cases involving pharmaceutical manufacturers
• Coordination with other Medicaid Fraud
Control Units (MFCU)
• Coordination with the Federal government
Investigation Methods
•Qui Tam Relators
•CID/Subpoena
•Data Analysis
Investigation Methods – Qui
Tam Relator
• Review pre-filing disclosure documents and exhibits
provided by the relator in support of the fraud allegations.
• Determine the credibility and strength of the relator’s
allegations based on the interview.
•Identify other witnesses that may have relevant
information in support of the fraud allegations.
•Identify other relevant documents that may support the
fraud allegations.
Investigation Methods –
CID/Subpoena
• Civil Investigative Demand (CID) – Virginia Fraud Against
Taxpayers Act, Va. Code Ann. § 8.01-216.10:
•Produce such documentary material for inspection and
copying,
•Answer in writing written interrogatories with respect to
such documentary material or information,
•Give oral testimony concerning such documentary
material or information,
•Furnish any combination of such material, answers, or
testimony.
Investigation Methods –
CID/Subpoena
• Medicaid Fraud Subpoena – Virginia Fraud Against
Taxpayers Act, Va. Code Ann. § 32.1-320:
•Conduct audits and investigations,
•Issue subpoenas,
•Take depositions,
•Compel the production of pertinent books, payrolls,
accounts, papers, records, documents and testimony
relevant to such investigation.
Methods – Relevant Information
Obtained by CID/Subpoena
• Call notes
• Training materials
• Sales and marketing documents
• Organizational charts
• Studies sponsored by the company
• Emails or internal correspondence
• Witnesses interview reports
• Deposition transcripts
Methods – Data Analysis
• Determine the total Medicaid utilization (total dollars
spent, as well as total number of claims) for the target drug,
• Determine whether the patient was diagnosed with a
condition the drug was approved to treat,
• Determine whether the patient was switched from another
drug to the target drug,
• Determine physician prescribing trends, and
• Determine the age of the patient at the time the drug was
prescribed
Coordination with Other
State MFCUs
•National Association of Medicaid Fraud Control
Units (NAMFCU)
•Intake Teams
•Investigation Teams
•Global Case Teams
•Litigation Teams
Coordination with the
Federal Government
• Includes joint investigation, settlement, and litigation
with the Department of Justice and United States
Attorney’s Offices.
• 42 C.F.R. § 1007.11 (e) provides, that “the unit will
make available to Federal investigators or prosecutors
all information in its possession concerning fraud in the
provision or administration of medical assistance under
the State plan and will cooperate with such officials in
coordinating any Federal and State investigations or
prosecutions involving the same suspects or
allegations.”
QUESTIONS?
Erica J. Bailey, A.A.G.
Medicaid Fraud Control Unit
Virginia Attorney General’s Office
900 East Main Street
Richmond, VA 23219
804-225-3192