Vermont Medicaid Fraud Control Unit: 2013 Onsite Review

WHY WE DID THIS STUDY

OIG oversees all Medicaid Fraud Control Units (MFCUs or Units) with respect to Federal grant compliance. As part of this oversight, OIG reviews all Units. 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 based our review on an analysis of data from six sources: (1) a review of policies, procedures, and documentation related to the Unit's operations, staffing, and caseload; (2) a review of financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with the Unit's management and staff; (5) an onsite review of case files; and (6) an onsite review of Unit operations.

WHAT WE FOUND

From fiscal year (FY) 2010 through FY 2012, the Unit reported combined civil and criminal recoveries of $15 million, 18 convictions, and 36 civil settlements and judgments. Although most case files indicated supervisory approval to open and close cases, almost all lacked documentation of periodic supervisory reviews. The Director and staff reported that such reviews occur on a regular basis but are not generally documented in the case files. Also, the Unit did not refer all convictions to OIG appropriately. In addition, large caseloads hinder the Unit's ability to investigate and prosecute fraud and abuse in a timely manner. Lastly, we identified as beneficial (1) the Unit's creation of Provider Focus Teams to collaborate on existing cases with the Program Integrity Unit in the Department of Vermont Health Access; and (2) the development of the Elder Justice Working Group, which has initiated an effort to reduce the use of antipsychotics in nursing homes in Vermont.

WHAT WE RECOMMEND

We recommend that the Unit (1) ensure that case files contain documentation of supervisory reviews; (2) ensure that all convicted individuals are appropriately referred to OIG for program exclusion; and (3) assess the adequacy of existing staffing levels and take appropriate action based on that assessment. The Unit concurred with all three of our recommendations.

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