Oklahoma State Medicaid Fraud Control Unit: 2014 Onsite Review

WHY WE DID THIS STUDY

The Office of Inspector General (OIG) oversees the activities of all 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 compliance with Federal grant requirements.

HOW WE DID THIS STUDY

We conducted an onsite review of the Oklahoma Unit in December 2014. We based our review on an analysis of data from seven sources: (1) a review of policies, procedures, and documentation related to the Unit's operations, staffing, and caseload for fiscal years (FYs) 2012 through 2014; (2) a review of financial documentation for FYs 2012 through 2014; (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 FYs 2012 through 2014 ; and (7) an onsite observation of Unit operations.

WHAT WE FOUND

For FYs 2012 through 2014, the Oklahoma Unit reported 56 criminal convictions, 51 civil judgments and settlements, and recoveries of nearly $66 million. During the same period, the State Medicaid agency's Program Integrity Unit (PIU) sent few fraud referrals to the Unit in FYs 2013 and 2014, despite Unit efforts to increase referrals. We identified opportunities for improvement in adhering to the MFCU performance standards. Specifically, we found that 42 percent of Unit case files for cases that had been open longer than 90 days lacked documentation of periodic supervisory review. Additionally, the Unit did not report all convictions and adverse actions to Federal partners within required timeframes. The Unit also claimed unallowable expenditures. We further identified two instances in which the Unit did not adhere to Federal policy or requirements. Specifically, the Unit retained monies for investigative costs associated with criminal judgments and sentencing and claimed Federal financial participation (FFP) for costs associated with two non-MFCU activities.

WHAT WE RECOMMEND

We recommend that the Oklahoma Unit (1) continue efforts to receive an adequate number of referrals from the PIU; (2) ensure that supervisors conduct and document periodic reviews of case files; (3) implement processes to ensure that the Unit reports all convictions and adverse actions to Federal partners within required timeframes; (4) work with OIG to repay the Federal government for FFP claimed for unallowable expenditures; (5) work with the State Medicaid Agency to ensure that the Federal share of identified investigative cost recoveries related to criminal judgments and sentencing is returned to the Federal government; and (6) claim FFP only for MFCU-related activities and work with OIG to determine the portion of employee salaries corresponding to non MFCU activities and to return the Federal share of that portion to the Federal government. The Unit concurred with all six recommendations.

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