New Hampshire Medicaid Fraud Control Unit: 2012 Onsite Review

WHY WE DID THIS STUDY

The Office of Inspector General is responsible for overseeing the activities of all Medicaid Fraud Control Units (MFCU or Unit). As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. The reviews describe the Units' caseloads; assess performance in accordance with the 12 MFCU performance standards; identify any opportunities for improvement; and identify any instances of noncompliance with laws, regulations, or policy transmittals.

HOW WE DID THIS STUDY

We based our review on an analysis of data from six sources: (1) a review of policies and procedures and documentation on the Unit's operations, staffing, and caseload; (2) structured interviews with key stakeholders; (3) structured interviews with Unit staff; (4) a review of financial documentation; (5) an onsite review of case files; and (6) an onsite review of Unit operations.

WHAT WE FOUND

From fiscal years (FY) 2009 to 2011, the New Hampshire Unit reported recoveries of $14 million, filed criminal charges against 25 defendants, and obtained 15 convictions. Although the number of fraud cases opened and closed by the Unit increased during this time, the overall number of cases opened and closed by the Unit decreased. This was due to a decrease in patient abuse and neglect cases. The Unit attributed the overall decrease primarily to staffing limitations; for all 3 years, the Unit's staff levels were below the number of staff that the Unit requested and OIG approved. Additionally, although the Unit reported that its best source of fraud referrals was the State's Surveillance and Utilization Review Subsystem (SURS), the Unit also noted that the number of referrals from SURS was low. Our review also found that the Unit's case files lacked documentation of periodic supervisory review, and the Unit lacked annual training plans for each of the three professional disciplines (i.e., for auditors, investigators, or attorneys). At the same time, our review found no evidence of significant noncompliance with applicable laws, regulations, or policy transmittals. The Unit identified as a noteworthy practice its sending a letter to nursing facilities and assisted living facilities explaining that drug diversion is a form of patient abuse and neglect; this letter resulted in facilities making drug diversion-related referrals to the Unit. (Drug diversion is when facility staff members or other individuals divert residents' prescription drugs for their own use or for sale.)

WHAT WE RECOMMEND

We recommend that the New Hampshire Unit: (1) seek to expand staff sizes to reflect the number of staff approved in the Unit's budget, (2) ensure that it maintains an adequate workload through referrals from SURS, (3) ensure that case files contain documented supervisory reviews, and (4) establish annual training plans for each professional discipline. The New Hampshire Unit concurred with all four of our recommendations.

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