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Report (OEI-09-13-00490)

04-16-2014
Utah State Medicaid Fraud Control Unit: 2013 Onsite Review

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Summary

WHY WE DID THIS STUDY

OIG oversees all State Medicaid Fraud Control Units (MFCUs or Units) 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 2010 through 2012, the Unit reported recoveries of $61 million, 26 convictions, and 51 civil judgments and settlements. Unit case files lacked documentation of supervisory approval to open and close cases and documentation of periodic supervisory reviews. In addition, the Unit did not refer three sentenced individuals to OIG for program exclusion. The Unit's policies and procedures manual did not reflect current Unit operations. Finally, the Unit did not report adverse actions to the National Provider Data Bank (NPDB) as required by Federal regulations.

WHAT WE RECOMMEND

We recommend that the Utah Unit (1) ensure that supervisory approval and periodic reviews are documented in Unit case files, (2) ensure that it refers individuals for exclusion to OIG, (3) revise its policies and procedures manual, and (4) ensure that adverse actions are reported to the NPDB. The Unit concurred with all four of our recommendations.

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