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Report (OEI-07-14-00060)

06-13-2014
Nebraska State Medicaid Fraud Control Unit: 2014 Onsite Review

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Summary

WHY WE DID THIS STUDY

OIG oversees the activities of all Medicaid Fraud Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. The reviews assess Unit performance in accordance with the 12 MFCU performance standards and monitor Unit compliance with Federal grant requirements.

HOW WE DID THIS STUDY

We conducted an onsite review in February 2014. We analyzed data from seven sources: (1) a review of policies, procedures, and documentation related to the Unit's operations, staffing, and caseload for fiscal years (FYs) 2011 through 2013; (2) a review of financial documentation for FYs 2011 through 2013; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit's management; (6) an onsite review of a sample of case files that were open in FYs 2011 through 2013; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

For FYs 2011 through 2013, the Unit reported combined civil and criminal recoveries of nearly $33 million and 22 criminal convictions. Our review identified that 91 percent of cases files contained documentation of periodic supervisory reviews and nearly all case files contained documentation of supervisory approval for opening and closing. However, the Unit did not transmit reports of nine convictions to OIG for the purpose of program exclusion, and conviction information for two cases was not transmitted in a timely manner. Additionally, the Unit's Memorandum of Understanding with the State Medicaid agency did not reflect current Federal legal requirements. Lastly, although 85 percent of Nebraska Medicaid enrollees received health care through managed care, the Unit received only 3 managed care referrals during the review period.

WHAT WE RECOMMEND

The Unit should work with OIG's MFCU oversight division to ensure compliance with the 12 performance standards. The Nebraska Unit concurred with all four of our recommendations.

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