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District of Columbia Medicaid Fraud Control Unit: 2015 Onsite Review

WHY WE DID THIS STUDY

The OIG administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units' performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. The reviews assess the Units' performance in accordance with the 12 MFCU performance standards its compliance with applicable Federal requirements.

HOW WE DID THIS STUDY

We conducted an onsite review of the District of Columbia (D.C.) Unit in January 2015. 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 for fiscal years (FYs) 2012 through 2014; (2) a review of financial documentation for FYs 2012 through 2014; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with Unit management; (6) an onsite review of a sample of files for cases that were open at any time in FYs 2012 through 2014; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

Our review of the D.C. Unit identified several findings that may undermine Unit efficiency and effectiveness. We identified delays in case progress that may have been explained by Unit management practices that we observed, including a lack of documented supervisory reviews intended to ensure cases progress at a reasonable pace as well as a lengthy clearance process for documents. We also found that the Unit did not use its case management system to allow efficient access to case information, and that it investigated seven cases that were outside of the Unit's authority. Until July 2015, the Unit's MOU with D.C.'s Medicaid agency was out of date. Formal communication between the Unit and the Medicaid agency was infrequent, and the Unit did not report all relevant information to Federal partners within required timeframes.

WHAT WE RECOMMEND

We recommend that the Unit implement effective management practices that ensure cases progress at a reasonable pace, and that supervisory reviews of Unit case files are conducted and documented. The Unit should use its case management system in a way that allows for efficient access to case information, and the Unit should repay Federal matching funds spent on the cases that were not eligible for Federal funding. The Unit should communicate regularly with the D.C. Medicaid agency. Finally, we recommend that the Unit report all relevant information to the OIG and the National Practitioner Data Bank within the required timeframe. The Unit concurred with all six recommendations.

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

Download the complete report.

Office of Inspector General, U.S. Department of Health and Human Services | 330 Independence Avenue, SW, Washington, DC 20201