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Wisconsin State Medicaid Fraud Control Unit: 2016 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 reviews of all Units and prepares public reports based on these reviews. These reviews assess Units' adherence to the 12 MFCU performance standards and compliance with applicable Federal statutes and regulations.


We conducted an onsite review of the Wisconsin Unit in June 2016. We based our review on 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) 2013 through 2015; (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 2013 through 2015; and (7) observation of Unit operations.


For FYs 2013 through 2015, the Wisconsin Unit reported significant results including 24 convictions, 24 civil judgments and settlements, and combined criminal and civil recoveries of approximately $137 million. This amounted to recovery of more than $32 for every $1 spent in the review period. However, we identified several operational deficiencies and found a lack of current and comprehensive written policies and procedures, which may have contributed to the Unit's noncompliance with Federal regulations and nonadherence to certain performance standards. Specifically, of the 41 Unit case files that we reviewed, 28 lacked documentation of supervisory approval to open the cases, and 24 lacked documentation of periodic supervisory reviews. The Unit did not report half of its convictions and one adverse action to Federal partners and reported others outside of required timeframes. Furthermore, the Unit lacked a written training plan for its professional employees and investigated five cases outside of its grant authority. Finally, the Unit did not always maintain adequate internal controls related to personnel and accounting.


In addition to reimbursing OIG for Federal financial participation claimed for investigations of ineligible cases and unallowable expenditures for salary, fringe, and associated indirect costs, we recommend that the Wisconsin Unit: (1) ensure that it documents supervisory approval to open cases and supervisory reviews of Unit case files; (2) ensure that convictions and adverse actions are consistently reported to Federal partners within required timeframes; (3) establish written training plans for the Unit's professional disciplines; and (4) improve internal controls related to personnel and accounting. The Unit concurred with all six of our recommendations.