Oregon State Medicaid Fraud Control Unit: 2016 Onsite Review

WHY WE DID THIS STUDY

OIG administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units' performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic reviews of all Units and prepares public reports based on these reviews. These reviews assess the Unit's adherence to the 12 MFCU performance standards and compliance with applicable Federal statutes and regulations.

HOW WE DID THIS STUDY

We conducted an onsite review of the Oregon Unit in May 2016. We based our review on an analysis of data from seven sources: (1) policies, procedures, and documentation related to the Unit's operations, staffing, and caseload; (2) financial documentation for fiscal years (FYs) 2013 through 2015; (3) structured interviews with key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit's management; (6) a sample of files for cases that were open in FYs 2013 through 2015; and (7) observation of Unit operations.

WHAT WE FOUND

For FYs 2013 through 2015, the Oregon Unit reported obtaining 92 criminal convictions, 34 civil judgments and settlements, and combined criminal and civil recoveries of nearly $33 million. We found that the Oregon Unit was generally in compliance with applicable laws, regulations, and policy transmittals; however, we identified three areas where the Unit should improve its adherence to performance standards and its compliance with applicable Federal requirements. Specifically, the Unit did not fully secure its case files, part of the Unit's memorandum of understanding with two of its State partners was inconsistent with the Federal regulation governing Medicaid payment suspensions, and the Unit did not report some convictions and adverse actions to Federal partners within the appropriate timeframes.

WHAT WE RECOMMEND

We recommend that the Oregon Unit: 1) implement procedures for securing case files, 2) revise its memorandum of understanding with State partners to be consistent with Federal regulation, and 3) implement processes to ensure it reports convictions and adverse actions to Federal partners within the appropriate timeframes. The Unit concurred with all three recommendations.

---