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New Jersey Medicaid Fraud Control Unit: 2013 Onsite Review


OIG oversees all Medicaid Fraud Control Units (MFCUs or Units) 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, laws, and regulations.


We based our review on an analysis of data from seven sources: (1) a review of policies, procedures, and documentation 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 staff; (6) an onsite review of case files; and (7) an onsite review of Unit operations.


From fiscal year (FY) 2010 through FY 2012, the Unit's recoveries increased but felony charges and convictions decreased. The Unit also investigated fewer cases of patient abuse and neglect in FY 2012 than in FY 2010. Although most case files included opening and closing documents, half lacked documentation of supervisory review. Further, the Unit did not refer 94 percent of convictions to OIG appropriately. The Unit also did not meet the requirements of its training plan in FY 2012. In addition, the Unit Director does not supervise the majority of Unit staff and does not oversee part of the Unit's caseload. Lastly, the Unit identified as beneficial a case management tool that tracks tasks and deadlines and includes descriptions of investigative and legal issues that arise.


We recommend that the Unit: (1) take steps to ensure that its case mix includes more cases of patient abuse and neglect; (2) ensure that case files contain supervisory reviews; (3) appropriately refer individuals to OIG for program exclusion; (4) ensure that staff receive at least the minimum training required in the Unit's training plan; and (5) change its supervisory structure to provide the Unit Director with supervision of all of the Unit's staff and oversight of all of its caseload. The Unit concurred with our first four recommendations and described plans to implement each. In response to the fifth recommendation, the Unit did not specifically state whether it concurred.