New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review

WHY WE DID THIS STUDY

OIG administers the MFCU 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. The primary purpose of the review was to follow up on issues that OIG had identified through its ongoing administration and oversight activities. We focused the review on five general areas: (1) case outcomes; (2) referrals; (3) staff and leadership turnover; (4) MFCU operations; and (5) fiscal controls.

HOW WE DID THIS STUDY

We conducted the onsite review of the New Hampshire MFCU in May 2017. Our review covered the 3-year period of Federal fiscal years (FYs) 2014-2016. We based our inspection on an analysis of data from six sources: (1) MFCU documentation; (2) financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with the MFCU's managers and staff; (5) a review of case files that were open at some point during the review period; and (6) observation of MFCU operations.

WHAT WE FOUND

The MFCU's case outcomes—i.e., its convictions of fraud, patient abuse, or neglect; its criminal recoveries; its civil judgments and settlements; and its civil recoveries—were low during FYs 2014-2016, both as compared to the MFCU's past performance history and as compared to similarly sized MFCUs from other States. The New Hampshire MFCU reported no fraud convictions; four patient abuse or neglect convictions; $13,923 in criminal recoveries; 25 civil judgments and settlements; and $2.6 million in civil recoveries. We found a variety of factors that contributed to the low case outcomes: (1) the MFCU received few fraud referrals from the Medicaid Program Integrity Unit and other key sources; (2) the MFCU experienced significant turnover among staff and leadership; and (3) a few cases had investigative delays, and almost half of the case files lacked documented supervisory review. We also found-as a separate operational issue-that the MFCU generally maintained proper fiscal controls, but lacked some policy guidance related to the proper allocation of vehicle costs.

WHAT WE RECOMMEND

We recommend that the New Hampshire MFCU (1) develop and implement a plan to increase referrals from the Medicaid agency and managed care organizations; (2) develop and implement a plan to reduce staff and leadership turnover; (3) implement policies and procedures to ensure that significant investigative delays are explained in the case files and that periodic supervisory reviews are documented; and (4) revise its fiscal control policies governing vehicle costs. The New Hampshire MFCU concurred with all four recommendations.