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Report (OEI-02-11-00440)

06-22-2012
New York State Medicaid Fraud Control Unit: 2011 Onsite Review

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Summary

WHY WE DID THIS STUDY

OIG is responsible for overseeing the activities of all Medicaid Fraud Control Units (MFCU or Unit). As part of this oversight, the Office of Evaluation and Inspections conducts periodic reviews of all Units and prepares public reports based on those reviews. The reviews describe the Units' caseloads; assess performance in accordance with the 12 MFCU performance standards, identifying any opportunities for improvement; identify any instances of noncompliance with laws, regulations, or policy transmittals; and highlight any noteworthy practices.

HOW WE DID THIS STUDY

We based our review on an analysis of data from seven sources: (1) a review of policies and procedures and documentation on the Unit's operations, staffing, and caseload; (2) structured interviews with key stakeholders; (3) a survey of Unit staff; (4) structured interviews with the Unit's management; (5) an onsite review of case files; (6) an onsite review of financial documentation; and (7) an onsite review of Unit operations.

WHAT WE FOUND

From fiscal years 2008 to 2010, the New York Unit filed criminal charges against more than 400 defendants, obtained over 400 convictions, and was awarded more than $750 million in recoveries. Although the number of referrals to the Unit increased during this time, the number of cases that the Unit opened and closed decreased. Additionally, the Unit did not establish annual training plans for each of the three professional disciplines-i.e., for auditors, investigators, or attorneys-and provided limited training opportunities to staff. The Unit also lacked policies and procedures to reflect many of its current practices, and its case files lacked consistency and uniform supervisory reviews. Finally, the Unit lacked a number of internal controls.

At the same time, our review found no evidence of significant noncompliance with applicable laws, regulations, or policy transmittals. Further, Unit managers, staff, and stakeholders cited a number of the Unit's noteworthy practices, including its approach to patient abuse and neglect cases, its list of ongoing investigations (created to avoid conflicts among investigating agencies), and its use of technology.

WHAT WE RECOMMEND

We recommend that the New York MFCU: (1) seek to expand staff sizes to reflect the number of staff approved in the Unit's budget; (2) establish annual training plans and increase the number of training opportunities available to staff; (3) ensure that its memorandum of understanding, policies, and procedures reflect current practices; (4) ensure that its case files are maintained with greater consistency and reviewed more frequently; and (5) establish written policies and procedures for certain internal controls.

The New York Unit concurred with all five of our recommendations.

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