Erica J. Bailey, A.A.G.Chief of Civil Investigations

MFCU

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 Office900 East Main Street

Richmond, VA 23219804-225-3192