Mississippi State Medicaid Fraud Control Unit: 2014 Onsite Review

WHY WE DID THIS STUDY

OIG oversees the activities of all State Medicaid Fraud Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. The reviews assess Unit performance in accordance with the 12 MFCU performance standards and monitor Unit compliance with Federal grant requirements.

HOW WE DID THIS STUDY

We conducted an onsite review in January 2014. We based our review on an analysis of data from seven sources: (1) a review of policies, procedures, and documentation on the Unit's operations, staffing, and caseload for fiscal years (FYs) 2011 through 2013; (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 a sample of case files that were open in FYs 2011 through 2013; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

From FYs 2011 through 2013, the Unit reported recoveries of $52 million, 174 convictions, and 37 civil judgments and settlements. A Unit supervisor approved the opening and closing of most case files; however, 44 percent of case files lacked documentation of periodic supervisory reviews. In addition, the Unit did not adequately safeguard some of its case files. The Unit did not investigate 5 percent of cases before the statute of limitations expired, and may not have enough investigators assigned to patient abuse and neglect cases. The Unit also did not refer 11 sentenced individuals to OIG for program exclusion within an appropriate timeframe. Finally, the Unit's policies and procedures manual did not reflect current Unit operations.

WHAT WE RECOMMEND

We recommend that the Mississippi Unit (1) ensure that supervisors approve the opening and closing of cases and that periodic supervisory reviews are conducted and documented in Unit case files; (2) ensure that case files are secure; (3) ensure that all cases are investigated or closed, as appropriate, before the statute of limitations expires; (4) assess the allocation of existing staff levels; (5) ensure that it refers all sentenced individuals for exclusion to OIG within an appropriate timeframe; and (6) revise its policies and procedures manual to reflect current operations. The Unit concurred with all six of our recommendations.

---