Maine State Medicaid Fraud Control Unit: 2015 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 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 of the Maine Unit in April 2015. We based our review on analysis of data from seven sources: (1) a review of policies, procedures, and documentation related to the Unit's operations, staffing, and caseload for fiscal years (FYs) 2012 through 2014; (2) a review of financial documentation for FYs 2012 through 2014; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit's management; (6) an onsite review of files for cases that were open in FYs 2012 through 2014; and (7) an onsite observation of Unit operations. We also determined whether the Unit had established policies and procedures as recommended in a previous OIG onsite review report.

WHAT WE FOUND

For FYs 2012 through 2014, the Maine Unit reported 19 criminal convictions, 28 civil judgments and settlements, and combined criminal and civil recoveries of $32 million. Our review of the Unit's performance identified opportunities for improvement. Specifically, we found that over two-thirds of the case files open longer than 90 days lacked documentation of periodic supervisory reviews. We also found that a few cases had unexplained investigation delays of a year or more. Additionally, we found that the Unit reported convictions to OIG for program exclusion timely, but could improve its reporting of adverse actions to the National Provider Data Bank (NPDB). Further, the Unit did not conduct physical inventories of its property. Finally, we noted that only a small portion of Unit fraud referrals-less than 2 percent-came from the State Medicaid agency's Program Integrity Unit.

WHAT WE RECOMMEND

We recommend that the Maine Unit (1) implement policies and procedures to ensure that case files include documentation of supervisory approval for opening and closing cases and periodic supervisory review, (2) implement policies and procedures to document unexplained investigation delays, (3) implement processes to ensure that the Unit reports all adverse actions to the NPDB and within the required timeframe, and (4) establish policies and procedures for conducting physical inventories of its property. The Unit concurred with all four recommendations.

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