New Mexico 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 an onsite review in April 2014. We analyzed data from seven sources: (1) a review of documentation, policies, and procedures related to 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 and selected staff; (6) an onsite review of a sample of case files from FYs 2011 through 2013; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

From fiscal years 2011 through 2013, the Unit reported recoveries of $9 million, 25 convictions, and 71 civil judgments and settlements. A Unit supervisor approved the opening and closing of almost all case files; however, 42 percent of case files lacked documentation of periodic supervisory reviews. In addition, 32 percent of case files had unexplained investigation delays of a year or more. The Unit also did not refer 28 percent of sentenced individuals to OIG for program exclusion within an appropriate timeframe, and it did not report 56 percent of adverse actions to the National Practitioner Data Bank (NPDB) within an appropriate timeframe. The Unit's MOU with the New Mexico Human Services Department had not been updated, and the Unit's policies and procedures manual was incomplete. Finally, the Unit incorrectly reported its program income and inappropriately claimed expenditures for indirect costs.

WHAT WE RECOMMEND

We recommend that the New Mexico Unit (1) ensure that periodic supervisory reviews are documented in Unit case files, (2) ensure that any investigation delays are limited to situations imposed by resource constraints or other exigencies, (3) ensure that it reports all relevant information to OIG and the NPDB within an appropriate timeframe, and (4) revise its policies and procedures manual to reflect current operations. The Unit concurred with all four of our recommendations.

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