West Virginia Medicaid Fraud Control Unit: 2023 Inspection

Why OIG Did This Review

The Office of Inspector General (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 inspections of Units and issues public reports of its findings and observations.

What OIG Found

For the review period fiscal years (FYs) 2020-2022, the Unit reported obtaining 37 indictments, 34 convictions, 41 civil settlements, and $75.3 million in recoveries. We observed that the Unit maintained strong working relationships with stakeholders, took steps to ensure continuous case flow, and provided ample training to its staff. We identified several areas in which the Unit should improve its adherence to performance standards or program requirements:

Some of the Unit’s case files were accessible by unauthorized Unit staff.

Although the Unit’s case management system allowed managers to effectively monitor cases, it did not allow for the accurate reporting of Unit performance data to OIG.

The Unit did not report adverse actions to the National Practitioner Data Bank (NPDB) from 2017 through 2022 and did not consistently report its convictions to OIG for exclusion within the required timeframe.

Although the Unit reported that it made program recommendations to the State Medicaid agency, it did not adequately monitor the State’s response to the Unit’s program recommendations.

The Unit reported retaining certain settlement proceeds rather than working with the Medicaid agency to ensure the appropriate return of the Federal Government’s share of those recoveries.

What OIG Recommends

To address the findings, we recommend that the Unit:

1. Eliminate access to sensitive case material for unauthorized staff.
2. Take steps to ensure that its new case management system allows for the accurate reporting of performance data.
3. Take steps to report adverse actions to the NPDB within the required timeframe.
4. Take steps to report all convictions to OIG within the required timeframe.
5. Implement a method to monitor the State’s responses to the Unit’s program recommendations.
6. Work with the Bureau of Medicaid Services to ensure the return of the Federal Government’s share of all recoveries.

The Unit concurred with five recommendations and non-concurred with one recommendation.