Colorado 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 Colorado Unit in October 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; (6) a sample of files for cases that were open in FYs 2013 through 2015; and (7) observation of Unit operations.

WHAT WE FOUND

Our review found that the Colorado Unit was generally in compliance with applicable laws, regulations, and policy transmittals. For FYs 2013 through 2015, the Unit reported 32 criminal convictions, 106 civil judgments and settlements, and combined criminal and civil recoveries of over $22 million. However, we found four areas in which the Unit should improve. First, the Unit investigated few patient abuse or neglect cases. Second, the Unit did not report all convictions or adverse actions to Federal partners within the required timeframes. Third, 46 percent of the Unit's case files lacked documentation of periodic supervisory reviews, although supervisors documented the opening and closing of all cases. Finally, the Unit did not retain documentation for a recurring grant expenditure, as required by Federal regulation.

WHAT WE RECOMMEND

We recommend that the Colorado Unit: (1) take steps to increase the number of investigations of patient abuse or neglect; (2) ensure that it consistently reports convictions and adverse actions to Federal partners within the required timeframes; (3) ensure that supervisory reviews of Unit case files are conducted and documented according to the Unit's policies and procedures; and (4) ensure that it retains expenditure documentation for the time period required by regulation. The Unit concurred with our recommendations.

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