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Report (OEI-09-12-00010)

12-28-2012
Louisiana State Medicaid Fraud Control Unit: 2012 Onsite Review

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Summary

WHY WE DID THIS STUDY

OIG oversees all Medicaid Fraud Control Units (MFCU or Unit) with respect to Federal grant compliance. As part of this oversight, OIG reviews all Units. These 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 reviewed data from seven sources: (1) a review of documents, policies, and procedures related to the Unit's operations, staffing, and caseload; (2) a review of financial documentation; (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 case files; and (7) an onsite review of Unit operations.

WHAT WE FOUND

From fiscal year (FY) 2009 through FY 2011 (our period of review), the Unit reported recoveries of $95 million, obtained 192 convictions and 86 civil judgments or settlements, and received 1,043 referrals. Provider fraud referrals to the Unit increased and the Unit received patient abuse and neglect referrals from a variety of sources. All reviewed Unit case files contained documentation indicating supervisory approval to open cases, and 94 percent of closed case files contained documentation indicating supervisory approval to close cases. Twenty-two percent of the Unit case files lacked documentation indicating at least one supervisory review and 28 percent lacked documentation indicating additional, periodic supervisory review. The Unit did not refer 14 percent of sentenced providers to OIG for program exclusion within the appropriate timeframe. The Unit had not updated its memorandum of understanding (MOU) with the Louisiana Department of Health and Hospitals (DHH) to reflect current law and practice. The Unit maintained proper fiscal control of its resources; however, it did not report program income properly in FYs 2010 and 2011. Except for not reporting all of its program income, we found no evidence of Unit noncompliance with applicable laws, regulations, and policy transmittals.

WHAT WE RECOMMEND

We recommend that the Louisiana Unit: (1) revise its policies and procedures to ensure that periodic supervisory reviews are documented in Unit case files, (2) ensure that letters referring providers for exclusion are submitted to OIG within the appropriate timeframe, (3) revise its MOU with DHH to reflect current law and practice, and (4) ensure that all program income is reported properly on its Federal Financial Status Reports. The Unit concurred with all but the first of our four recommendations. However, the Unit is nevertheless implementing new procedures to ensure that case files include documentation of all future supervisory reviews.

Copies can also be obtained by contacting the Office of Public Affairs at Public.Affairs@oig.hhs.gov.

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