Delaware 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. The reviews assess the Units' performance in accordance with the 12 MFCU performance standards and their compliance with applicable Federal requirements.

HOW WE DID THIS STUDY

We conducted an onsite review of the Delaware Unit in June 2015. We based our review on an analysis of data from seven sources: (1) policies, procedures, and documentation related to the Unit's operations, staffing, and caseload for fiscal years (FYs) 2012 through 2014; (2) financial documentation for FYs 2012 through 2014; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with Unit management; (6) a sample of files for cases that were open at any time in FYs 2012 through 2014; and (7) observation of Unit operations.

WHAT WE FOUND

For FYs 2012 through 2014, the Delaware Unit reported 28 convictions, 47 civil judgments and settlements, and combined criminal and civil recoveries of $5 million. We identified areas where the Unit should improve its operations. Specifically, the absence of final written policies and procedures may have contributed to the lack of adherence to certain performance standards and noncompliance with certain Federal regulations. The Unit did not report any sentenced individuals to OIG within required timeframes and did not report any adverse actions to the National Practitioner Data Bank (NPDB). Forty-four percent of case files open longer than 90 days lacked documentation of supervisory reviews. The Unit investigated two sampled cases that were not eligible for Federal funding. The Unit stored some case files in a location accessible to non-Unit staff. Only a small portion of Unit fraud referrals came from the State Medicaid agency; however, the Unit worked to increase the number and quality of referrals. Finally, the Unit's memorandum of understanding (MOU) with the State Medicaid agency did not reflect current practice.

WHAT WE RECOMMEND

We recommend that the Delaware Unit: (1) ensure that it reports convictions to OIG within 30 days of sentencing; (2) ensure that it reports adverse actions to the NPDB; (3) ensure that it conducts and documents supervisory reviews of case files open longer than 90 days; (4) repay Federal matching funds spent on cases ineligible for Federal funding; (5) secure its case files; and (6) revise its MOU with the State Medicaid agency to reflect current practice. The Unit concurred with all six recommendations.

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