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Pennsylvania State Medicaid Fraud Control Unit: 2015 Onsite Review


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 the Unit's adherence to the 12 MFCU performance standards and compliance with applicable Federal statutes and regulations.


We conducted an onsite review of the Pennsylvania Unit in November 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.


For FYs 2012 through 2014, the Pennsylvania Unit reported 130 criminal convictions, 37 civil judgments and settlements, and combined criminal and civil recoveries of $80 million. We found that the Pennsylvania Unit was generally in compliance with applicable laws, regulations, and policy transmittals, with one notable exception. Although Federal regulations require the Unit to employ a Chief Investigator to supervise and direct investigative activities, no one held this position prior to February 2016. With respect to adherence to the Performance Standards, we found that the Unit does not document periodic supervisory reviews in its case files. We also found that the Unit maintained proper fiscal control of its resources. Last, we observed that legal barriers limit the Unit's ability to refer cases for civil recovery and pursue patient abuse cases.


We recommend that the Pennsylvania Unit implement policies and procedures to ensure it documents periodic supervisory reviews and explains investigative delays in the case files. The Unit concurred with our recommendation.