Puerto Rico Medicaid Fraud Control Unit: 2024 Onsite Review

Why OIG Did This Review

OIG administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies each Unit, and oversees the Units’ performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic reviews of Units and issues public reports of its findings. This was the first onsite inspection of the Puerto Rico MFCU since it was certified to operate in FY 2019.

What OIG Found

The Puerto Rico MFCU reported 24 indictments; 11 convictions; 9 civil settlements and judgments; and nearly $4.6 million in recoveries during our review period of FYs 2021–2023. The MFCU undertook several efforts to build strong relationships with Federal partners and other agencies; increase awareness of its mission in the community; and improve its operations. However, the Unit did not always adhere to the MFCU performance standards or comply with applicable requirements.

• The Unit made several efforts to increase fraud referrals from managed care organizations (MCOs), including conducting outreach with partner agencies and requesting updates to the MCO contract, yet it received few MCO referrals during our review period.
• Despite the Unit implementing an electronic case management system in FY 2023, limitations of the system hindered efficient access to case information and case outcome data, causing the Unit to rely on other case repositories.
• Half of the Unit’s case files lacked documentation of any supervisory reviews, and the Unit’s policies and procedures manual did not specify a frequency for conducting and documenting such reviews.
• The Unit did not submit its convictions to OIG within the required timeframe due to delays in translating court documents from Spanish to English, and, during part of our review period, it was not registered with the National Practitioner Data Bank.

What OIG Recommends

To address the findings, we recommend that the MFCU:

1. Build upon its efforts to increase referrals from MCOs;
2. Update its electronic case management system to address the system’s limitations and provide further training on the system to Unit staff;
3. Implement a process to ensure that periodic supervisory case file reviews are conducted and documented on a consistent basis; and
4. Take steps to ensure that it reports all convictions and adverse actions to Federal partners within the appropriate timeframes.

The MFCU concurred with all four recommendations.