Hawaii Medicaid Fraud Control Unit: 2019 Onsite Review

WHY WE DID THIS REVIEW

The purpose of this review was to identify and address factors that contributed to the Hawaii Medicaid Fraud Control Unit's (MFCU's or Unit's) low case outcomes during federal fiscal years (FYs) 2016-18 and to assess Unit operations. In 2015, OIG issued a report from its 2014 onsite review of the MFCU that raised concerns about the Unit's ability to carry out its statutory functions and meet program requirements. To address the deficiencies identified during OIG's previous onsite review, the MFCU developed and implemented a corrective action plan. Despite this effort, we found that the Hawaii MFCU's case outcomes were low during FYs 2016-18, compared to other similarly sized MFCUs.

HOW WE DID THIS REVIEW

We conducted the onsite review of the Hawaii MFCU in March 2019. Our review period covered FYs 2016-18. We based our review on an analysis of data from seven sources: (1) Unit documentation, such as policies and procedures; (2) structured interviews with key stakeholders; (3) structured interviews with Unit managers and selected staff; (4) a review of a random sample of case files open at some point during the review period; (5) referrals received by the Unit; (6) observation of Unit operations; and (7) documentation associated with the Unit's fiscal controls.

WHAT WE FOUND

We identified several contributing factors in three areas that affected the Hawaii MFCU's low case outcomes during FYs 2016-18. We found that the MFCU received few fraud referrals from the Medicaid Program Integrity Unit and other stakeholders, which limited the number of cases available for the Unit to investigate and prosecute. The Unit also experienced significant turnover of investigators and lacked sufficient Medicaid fraud cases to adequately train new and inexperienced investigators. Additionally, we found that the MFCU's agreement with Adult Protective and Community Services Branch (referred to as Adult Protective Services) for processing patient abuse and neglect complaints was structured in such a way that it led to the Unit screening thousands of complaints unsuitable for investigation, which diverted the Unit's time and resources from working viable cases with substantial potential for criminal prosecution.

WHAT WE RECOMMEND AND HOW THE UNIT RESPONDED

To address the issues identified in this report and improve case outcomes, we recommend that the Unit (1) develop and implement a plan to increase Medicaid fraud referrals from the Medicaid agency and other stakeholders; (2) develop and expedite an in-house Medicaid fraud training program for Unit investigators; and (3) revise the Unit's agreement with Adult Protective Services to establish minimum criteria for a complaint to be sent to the MFCU. The Unit concurred with all three recommendations.