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Montana State Medicaid Fraud Control Unit: 2012 Onsite Review

WHY WE DID THIS STUDY

OIG oversees all State Medicaid Fraud Control Units (MFCU or Unit) with respect to Federal grant compliance. As part of this oversight, OIG annually reviews and certifies all Units. In addition, OIG conducts onsite reviews of selected States. These reviews assess Unit performance in accordance with the 12 MFCU performance standards and monitor Unit compliance with Federal grant requirements, laws, and regulations.

HOW WE DID THIS STUDY

We analyzed data from seven sources: (1) a review of documentation, policies, and procedures related to the Unit's operations, staffing, and caseload; (2) a review of financial documentation; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit's management and selected staff; (6) an onsite review of case files; and (7) an onsite review of Unit operations.

WHAT WE FOUND

From fiscal years 2010 through 2012, the Unit reported recoveries of $9.8 million, 6 convictions, and 31 civil judgments and settlements. Ninety-five percent of Unit case files contained documentation of supervisory approval to open cases; however, 40 percent of closed case files lacked documentation of supervisory approval to close cases. In addition, 65 percent of Unit case files lacked documentation of periodic supervisory reviews. The Unit also did not refer sentenced providers to OIG for program exclusion within the appropriate timeframe. Finally, the Unit's memorandum of understanding (MOU) with Montana's State Medicaid agency-the Department of Public Health and Human Services (DPHHS)-did not reflect current law and practice as required, and the Unit did not always adhere to the MOU stipulations.

WHAT WE RECOMMEND

We recommend that the Montana Unit: (1) ensure that supervisory approval to close cases and periodic supervisory reviews are documented in Unit case files, (2) ensure that it refers providers for exclusion to OIG within the appropriate timeframe, (3) revise its MOU with DPHHS, and (4) adhere to the MOU provisions. The Unit concurred with all four of our recommendations.