Hawaii State Medicaid Fraud Control Unit: 2014 Onsite Review

WHY WE DID THIS STUDY

The Office of Inspector General (OIG) oversees all State Medicaid Fraud Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. The 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 conducted a review of the Hawaii Unit in October 2014. We analyzed data from seven sources: (1) a review of any documentation related to the Unit's operations, staffing, and caseload; (2) a review of financial documentation for fiscal years (FYs) 2011 through 2013; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit's management and selected staff; (6) an onsite review of a sample of files for cases that were open at any point during FYs 2011 through 2013; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

During the FY 2011 through FY 2013 review period, the Unit expended $3.9 million and generated 18 patient abuse and neglect convictions, 6 fraud convictions, $330,000 in criminal fraud recoveries, and $7,000 of civil recoveries from fraud cases investigated directly by the Unit. We found that the Unit had a number of operational deficiencies. Among other findings, only two of the Unit's seven investigators were hired as long-term employees (as required), the Unit did not have an auditor, it did not have written policies and procedures for its operations, and it did not have a required training plan for its professional employees. Furthermore, the Unit did not regularly communicate with Federal law enforcement agencies, it worked cases outside of its grant authority, and it did not exercise adequate fiscal control of its resources.

WHAT WE RECOMMEND

On the basis of our findings, OIG is concerned about the Unit's ability to carry out its statutory functions and meet program requirements. In addition to reimbursing OIG for Federal financial participation claimed for costs related to investigations of ineligible cases, to misplaced equipment, and to unallowable costs for equipment, the Unit should develop and implement a corrective action plan to address the deficiencies described in this report. That plan should address-among other things-modifying the Unit's hiring practices, including hiring an auditor; establishing written policies and procedures for the Unit's operations; establishing a training plan for the Unit's professional employees; establishing regular communication with Federal agencies; establishing procedures ensuring that Unit staff investigate cases solely within the Unit's grant authority; and establishing fiscal control of the Unit's resources. OIG will take appropriate action to ensure that these deficiencies are addressed; this action may include imposing special conditions on and/or restricting the MFCU grant and conducting a follow-up review to monitor implementation of the plan. The Unit concurred with one of the report's recommendations, concurred in part with four recommendations, and did not indicate whether it concurred with the other recommendation. The Unit's comments included a plan to address all six recommendations.

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