Rhode Island State Medicaid Fraud Control Unit: 2014 Onsite Review

WHY WE DID THIS STUDY

OIG oversees the activities of all 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 December 2014. We based our review on an analysis 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; (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 a sample of case files; and (7) onsite observation of Unit operations.

WHAT WE FOUND

From FYs 2012 through 2014, the Rhode Island Unit reported 28 criminal convictions, 14 civil judgments and settlements, and combined civil and criminal recoveries of $8 million. During the same period, however, the overall number of referrals to the Unit decreased significantly. Additionally, our review of the Unit's performance according to OIG standards found that the Unit did not refer convictions to OIG for program exclusion in a timely manner and that it did not report adverse actions to the National Practitioner Data Bank (NPDB). Also, the Unit's internal controls over grant expenditures did not include segregation of duties involving its purchase card. However, we also found that almost all case files contained documentation of supervisory approval to open and close cases as well as of periodic supervisory review. Finally, we noted that the Unit benefits from its relationship with the New England State Police Information Network, which provides support such as surveillance technology to the Unit.

WHAT WE RECOMMEND

We recommend that the Rhode Island Unit (1) work with the State Medicaid agency to increase referrals, (2) refer providers for exclusion to OIG within an appropriate timeframe, (3) report adverse actions to the NPDB, and (4) improve controls over purchase card duties and document purchase requests from Unit staff. The Unit concurred with three of our recommendations and concurred in part with the fourth.

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