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Alaska State Medicaid Fraud Control Unit: 2016 Onsite Review

WHY WE DID THIS STUDY

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.

HOW WE DID THIS STUDY

We conducted an onsite review of the Alaska Unit in August 2016. 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) 2013 through 2015; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit's management and forensic accountant; (6) a sample of files for cases that were open in FYs 2013 through 2015; and (7) observation of Unit operations.

WHAT WE FOUND

For FYs 2013 through 2015, the Alaska Unit obtained 80 criminal convictions; 36 civil judgments and settlements; and combined criminal and civil recoveries totaling $10.4 million, and it increased its combined criminal and non-"global" civil recoveries each year. We found that the Unit was generally in compliance with applicable laws, regulations, and policy transmittals. In addition, the Unit improved its collaboration with stakeholders. Further, the Unit combated fraud in personal care services (PCS) through investigations of large PCS agencies, effective collaboration with stakeholders, and recommendations to Alaska's Medicaid agency.

However, we found two operational areas in which the Unit should improve its adherence to performance standards: the Unit's case files lacked documentation of periodic supervisory reviews, and its training plan did not specify the minimum number of training hours that Unit staff were required to complete. We also found two areas in which the Unit should improve its compliance with Federal requirements: it did not fully secure its paper case files, and it did not appropriately remove costs associated with non Unit activities from its Federal reimbursement request. After our review, the Unit worked with OIG to return these funds.

WHAT WE RECOMMEND

We recommend that the Alaska Unit (1) develop and implement procedures to ensure that all case files include documentation of periodic supervisory reviews, (2) revise its training plan to specify the minimum number of training hours that Unit staff are required to complete, (3) revise its policies and procedures manual to include procedures for securing paper case files, and (4) develop and implement internal controls to ensure that costs associated with non Unit activities are removed from Federal reimbursement requests. The Unit concurred with all four 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