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Georgia State Medicaid Fraud Control Unit: 2015 Onsite Review

WHY WE DID THIS STUDY

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. These reviews assess Unit performance in accordance with the 12 MFCU performance standards and its compliance with applicable Federal requirements.

HOW WE DID THIS STUDY

We conducted an onsite review of the Georgia Unit in March 2015. We based our review on 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 the Unit's management; (6) an onsite review of a sample of files for cases that were open in FYs 2012 through 2014; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

For FYs 2012 through 2014, the Georgia Unit reported 34 criminal convictions, 58 civil judgments and settlements, and combined criminal and civil recoveries of $179 million. We identified areas where the Unit could improve its functioning. Specifically, nearly a third of case files lacked documentation of supervisory approval to open cases and nearly half of the Unit's case files open longer than 90 days lacked documentation of periodic supervisory reviews. Additionally, the Unit did not report all convictions and adverse actions to Federal partners within required timeframes. We also found that the Unit did not always exercise proper fiscal control of its resources. Specifically, the Unit did not comply with special terms added to its grant in one year; and did not have fiscal controls necessary to ensure accurate and timely fiscal reporting.

WHAT WE RECOMMEND

We recommend that the Georgia Unit: (1) implement processes to ensure that case files include documentation of supervisory approval for opening and closing cases and periodic supervisory review; (2) implement processes to ensure that convictions and adverse actions are reported to Federal partners within required timeframes; (3) work with OIG to repay the $47,550 offset that should have been made in FY 2012; and (4) implement additional controls to ensure that the Unit's expenditures are accounted for timely, accurately, and in compliance with the terms of the grant. The Unit concurred with all four 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