Utah Medicaid Fraud Control Unit: 2018 Onsite Review

WHY WE DID THIS STUDY

OIG administers Medicaid Fraud Control Unit (MFCU) grant awards, annually recertifies each MFCU, and oversees MFCU performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic reviews of MFCUs and prepares public reports. These onsite reviews supplement OIG's annual recertifications of the MFCUs. The primary purpose of this onsite review was to identify and address factors that contributed to the Utah MFCU's low number of fraud convictions during fiscal years (FYs) 2015-2017 and declining amounts of nonglobal* civil settlements, judgments, and recoveries in FY 2017.

HOW WE DID THIS STUDY

We conducted the onsite review of the Utah MFCU in April 2018. Our review covered the 3 year period of FYs 2015-2017. We based our inspection on an analysis of data from six sources: (1) general 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

During FYs 2015-2017, the Utah MFCU had a low number of fraud convictions in comparison to its past performance history. This decrease in fraud convictions came at the same time as a decrease in fraud referrals to the MFCU from the Utah Inspector General for Medicaid Services (Utah MIG) and from Medicaid managed care organizations, which Utah's Medicaid program refers to as "accountable care organizations" (ACOs). We note that, subsequent to our period of review, the MFCU obtained seven fraud convictions for FY 2018. The MFCU increased the number of convictions that it obtained for patient abuse or neglect during FYs 2015-2017, compared to previous years.

Several factors contributed to the MFCU's declining nonglobal civil case outcomes in FY 2017. MFCU management reported a decline in civil cases involving pharmaceutical manufacturers, as well as a change in State law that limited the MFCU's ability to follow its historical approach for litigating nonglobal civil cases.

We also found two instances of nonadherence with MFCU performance standards-one related to the MFCU's practices for storing and maintaining case information, and the other regarding a lack of documentation of supervisory review of case files.

WHAT WE RECOMMEND

We recommend that the Utah MFCU (1) develop and implement a plan to increase Medicaid fraud referrals from the Utah MIG and ACOs; (2) further develop its approach to litigating nonglobal civil cases or refer them to other appropriate agencies for litigation; (3) develop and implement written procedures for storing, maintaining, and efficiently accessing case information; and (4) establish a process to ensure that case files contain appropriate documentation. The MFCU concurred with all four recommendations.

* Nonglobal cases involve primarily State rather than Federal litigation; are pursued separately by individual MFCUs or with other law enforcement partners; and are not coordinated by the National Association of Medicaid Fraud Control Units.