Washington State Medicaid Fraud Control Unit: 2016 Onsite Review

WHY WE DID THIS STUDY

OIG oversees 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. 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 Washington Unit in January 2016. We analyzed data from seven sources: (1) a review of any documentation related to the Unit's policies and procedures, operations, staffing, and caseload, (2) a review of financial documentation for FYs 2013-2015; (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 associated with cases that were open at any point during FYs 2013-2015; and (7) an onsite review of Unit operations.

WHAT WE FOUND

During FYs 2013-2015, the Unit generated 39 convictions, 46 civil judgments and settlements, and total recoveries of more than $48 million. Our review of the Unit found that it was generally in compliance with applicable laws, regulations, and policy transmittals, and that it exercised proper fiscal control of its resources. However, we identified two aspects of Unit operations that should be improved. The Unit did not fully secure some case files, and the Unit's case management system posed challenges to locating and retrieving case information. We noted two practices that the Unit reported were beneficial to its operations: (1) the Unit took steps to ensure it received fraud referrals from managed care organizations, and (2) the Unit made programmatic recommendations to State agencies on its case closing forms and tracked these recommendations in a database.

WHAT WE RECOMMEND

We recommend that the Washington Unit: 1) take steps to ensure that all case files are fully secured, and 2) revise its case file management policies and procedures to enable Unit staff to more efficiently locate and retrieve case information. The Unit concurred with both recommendations.

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