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Report (OEI-09-12-00450)

10-22-2013
Nevada State Medicaid Fraud Control Unit: 2012 Onsite Review

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Summary

WHY WE DID THIS STUDY

OIG oversees all State Medicaid Fraud Control Units (MFCU or Unit) with respect to Federal grant compliance. As part of this oversight, OIG annually reviews and certifies all Units. In addition, OIG conducts onsite reviews of selected States. These reviews assess Unit performance in accordance with the 12 MFCU performance standards and monitor Unit compliance with Federal grant requirements, laws, and regulations.

HOW WE DID THIS STUDY

We analyzed data from seven sources: (1) a review of documentation, 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 and selected staff; (6) an onsite review of case files; and (7) an onsite review of Unit operations.

WHAT WE FOUND

From fiscal years 2009 through 2011, the Unit reported recoveries of $13.4 million, Unit convictions increased, and the Unit opened 262 cases. All reviewed case files contained documentation indicating supervisory approval to open and close cases and almost all case files contained documentation indicating periodic supervisory reviews. Unit professional staff occasionally performed non-Unit duties, however. In addition, the Unit's policies and procedures manual and memorandum of understanding (MOU) with Nevada's State Medicaid agency-the Division of Health Care Financing and Policy (DHCFP)-were not updated, and the Unit did not always comply with the MOU provisions. The Unit maintained proper fiscal control of its resources, but incorrectly claimed indirect costs. Except for the use of Unit professional staff for non-Unit duties, an MOU stipulation that the Unit agreed to assist DHCFP in obtaining funding for data requests, and the overclaiming of indirect costs, we found no evidence of noncompliance with applicable laws, regulations, and policy transmittals.

WHAT WE RECOMMEND

We recommend that the Nevada Unit: (1) ensure that Unit professional staff exclusively perform Unit duties, (2) revise its policies and procedures manual, (3) revise its MOU with DHCFP, (4) comply with the MOU provisions, and (5) ensure that it correctly claims indirect costs. In its written comments to our draft report, the Unit did not indicate whether it concurred with each of the recommendations. However, the Unit, in its comments, described actions that the Unit stated that it has taken, or plans to take, to address each of the recommendations.

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

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