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Report (OEI-07-13-00540)

09-30-2014
Connecticut State Medicaid Fraud Control Unit: 2013 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 October 2013. 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 Director and supervisors; (6) an onsite review of case files; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

For fiscal years 2010 through 2012, the Connecticut Unit reported combined civil and criminal recoveries of nearly $84 million and 20 criminal convictions. Our review identified instances in which the Unit did not fully meet Federal regulations or performance standards. Specifically, the Unit did not always maintain case files in an effective manner. The Unit also lacked policies and procedures sufficient to ensure timely completion of cases. Further, the Unit did not provide OIG with adequate information to initiate exclusion of convicted individuals. Additionally, the Unit worked on a case not related to Medicaid. The Unit's vehicle expenditures were not properly allocated, but the Unit otherwise maintained proper fiscal control of its resources. Lastly, during the period we reviewed, the Unit did not regularly communicate and coordinate with OIG to investigate and prosecute health care fraud.

WHAT WE RECOMMEND

The Unit should work with OIG's MFCU oversight division to ensure compliance with the 12 performance standards and adhere to Federal regulations. The Unit concurred with all six of our recommendations.

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Exclusions Database Report Fraud

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