Missouri State Medicaid Fraud Control Unit: 2011 Onsite Review

WHY WE DID THIS STUDY

The Office of Inspector General (OIG) oversees all Medicaid Fraud Control Units (MFCU or Unit) with respect to Federal grant compliance. As part of this oversight, OIG reviews all Units. These reviews assess Unit performance in accordance with the 12 MFCU performance standards and monitor Unit compliance with Federal grant requirements. This is a review of the Missouri Unit.

HOW WE DID THIS STUDY

We based our review on an analysis of data from seven sources: (1) a review of policies, procedures, and documentation of the Unit's operations, staffing, and caseload; (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 case files; and (7) an onsite review of Unit operations.

WHAT WE FOUND

For Federal fiscal years (FY) 2008 through 2010, the Missouri Unit reported recoveries of $135 million, 13 convictions, and 36 civil settlements. The Unit exercised proper fiscal controls over its resources. The Unit expanded its definition of referrals and changed its process for closing older cases during FYs 2008 through 2010. It did not establish annual training plans for its professional disciplines. One-third of case files lacked documentation of supervisory approval for key stages of the investigation, and nearly all lacked documentation of periodic supervisory reviews. Finally, the Unit lacked safeguards to secure case files. At the same time, our review found no evidence of significant noncompliance with applicable laws, regulations, or policy transmittals.

WHAT WE RECOMMEND

Based on these findings, the Missouri Unit should: (1) establish annual training plans for professional disciplines, (2) ensure that case files contain documented supervisory approval and periodic supervisory reviews, and (3) ensure that case files are not vulnerable to unauthorized access. The Missouri Unit concurred with all of our recommendations.

---