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Virginia State Medicaid Fraud Control Unit: 2015 Onsite Review


The Office of Inspector General (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 onsite reviews of all Units and prepares public reports based on these reviews. The reviews assess the Units' adherence to the 12 MFCU performance standards and compliance with applicable Federal statutes and regulations.


We conducted an onsite review of the Virginia Unit in September 2015. We based our review on an analysis of data from seven sources: (1) policies, procedures, and documentation related to the Unit's operations, staffing, and caseload; (2) financial documentation for fiscal years (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) a sample of files for cases that were open in FYs 2012 through 2014; and (7) observation of Unit operations.


The Unit reported significant results and was in general compliance with applicable laws, regulations, and policy transmittals. For FYs 2012 through 2014, the Virginia Unit reported 79 criminal convictions, 46 civil judgments and settlements, and combined criminal and civil recoveries of $1.1 billion. This amounted to recovery of more than $34 for every $1 spent in the review period. The Unit also maintained proper fiscal control of its resources. We identified two practices that assisted the Unit in obtaining its results. First, the Virginia Unit's partnerships with a variety of stakeholders led to successful Medicaid fraud prosecutions and increased recoveries. Second, the Unit's use of specialty software improved its ability to process and share investigative information.

However, we identified several areas where the Unit should improve its operations. Although the Unit's active case files generally contained the required supervisory reviews, the Unit's policy did not require supervisory reviews of monitored cases. Furthermore, the Unit's policy did not define what constituted a monitored case. Also, the Unit did not report all convictions and adverse actions to Federal partners within required timeframes.


We recommend that the Virginia Unit revise its policy to define what constitutes a monitored case and indicate the appropriate level and frequency of supervisory review for such cases. Further, the Unit should formalize its processes to ensure that convictions and adverse actions are consistently reported to Federal partners within required timeframes. The Unit concurred with both recommendations.