West Virginia State Medicaid Fraud Control Unit: 2013 Onsite Review

WHY WE DID THIS STUDY

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.

HOW WE DID THIS STUDY

We based our review on an analysis of data from seven sources: (1) a review of policies and procedures, and documentation on 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 2010 through 2012, the Unit reported combined civil and criminal recoveries of nearly $46 million and 20 convictions. Our review identified instances in which the Unit did not fully meet Federal regulations or performance standards, and we also identified opportunities for improvement. For example, the time from the Unit's receipt of a referral to the opening of a case exceeded the 60-day investigative timeframe in 70 percent of cases, and case activities and reviews were not adequately documented. Additionally, in 10 of 20 instances, the Unit sent an exclusion referral more than 30 days after sentencing, which could allow convicted individuals to inappropriately bill and be paid by Medicaid and other Federal healthcare programs. The Unit did not provide OIG and other Federal agencies with timely information concerning significant actions in cases. The Unit also had an inadequate case management tracking system, reported inaccurate recovery data in Quarterly Statistical Reports, and did not have complete inventory logs. However, the Unit has made improvements to its operating processes over the past year.

WHAT WE RECOMMEND

Based on these findings, the Unit should work to ensure compliance with each of the 12 performance standards. For example, the Unit should (1) make certain that cases are opened within 60 days of the receipt of referral; (2) investigative activity is adequately documented; (3) individuals are referred for the purpose of program exclusion to OIG within the appropriate timeframe; (4) share cases lists with OIG as agreed; (5) develop an adequate case management tracking system; (6) submit accurate Quarterly Statistical Reports; and (7) ensure inventory logs are complete. The West Virginia Unit concurred with all eight of our recommendations.

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