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Massachusetts State Medicaid Fraud Control Unit: 2015 Onsite Review

WHY WE DID THIS STUDY

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 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 its compliance with applicable Federal statutes and regulations.

HOW WE DID THIS STUDY

We conducted an onsite review of the Massachusetts Unit in October 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.

WHAT WE FOUND

The Unit was generally in compliance with applicable laws, regulations, and policy transmittals. For FYs 2012 through 2014, the Massachusetts Unit reported 49 criminal convictions, 72 civil judgments and settlements, and combined criminal and civil recoveries of $182 million. We noted that the Massachusetts Unit has developed successful partnerships with other agencies and clinical experts to investigate and prosecute pharmacy cases, and streamlined a number of administrative processes using a customized intranet.

We identified two areas where the Unit should improve its performance. Specifically, the Unit should better ensure that all case files contain documentation of periodic supervisory reviews, and report all convictions and adverse actions to Federal partners within required timeframes.

WHAT WE RECOMMEND

We recommend that the Massachusetts Unit monitor the implementation of its new policies and processes for (1) documenting periodic supervisory reviews results, and (2) ensuring that all convictions and adverse actions are reported to Federal partners within required timeframes. The Unit concurred with both of our 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