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Wyoming 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 Units' 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 Wyoming Unit in October 2016. We based our review on an analysis of data from six 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) structured interviews with Unit staff; (5) files for all cases that were open in FYs 2013 through 2015; and (6) observation of Unit operations.

WHAT WE FOUND

For FYs 2013 through 2015, the Wyoming Unit reported obtaining 11 criminal convictions; 25 global civil judgments and settlements; and total recoveries of over $3 million. We found that the Wyoming Unit was generally in compliance with applicable laws, regulations, and policy transmittals, and the Unit overcame training barriers by working with another MFCU to train its newly hired investigator. However, we identified three areas of concern: (1) the Unit did not pursue civil fraud cases other than "global" civil fraud cases (i.e., cases that involve the National Association of Medicaid Fraud Control Units and typically involve a group of MFCUs) during the review period; (2) although the Unit referred cases to its Federal and State agency partners, its written procedures for such referrals were incomplete; and (3) the Unit did not employ any investigators for a period of approximately 6 months, which appeared to have negative consequences for Unit investigations.

WHAT WE RECOMMEND

We recommend that the Wyoming Unit (1) develop and implement a plan to improve its ability to pursue nonglobal fraud cases as civil matters; (2) incorporate procedures for referring cases to Federal partners and other State agencies into its written policies and procedures manual; and (3) take steps to ensure that it does not lack an investigator for a significant period of time. The Unit concurred with all three 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