Missouri Medicaid Fraud Control Unit: 2018 Onsite Inspection

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.

HOW WE DID THIS STUDY

We conducted the onsite review of the Missouri MFCU in November 2018. Our review period covered Federal fiscal years 2016 -18. We based our inspection on an analysis of data and information from 7 sources: (1) Unit documentation; (2) financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with the Unit's managers; (5) a review of a simple random sample of 86 case files that were open at some point during the review period; (6) a review of all convictions submitted to OIG for program exclusion and all adverse actions submitted to the National Practitioner Data Bank during the review period; and (7) observation of Unit operations.

WHAT WE FOUND

During fiscal years 2016-18, the Missouri Unit generally complied with applicable laws, regulations, policy transmittals, and the MFCU performance standards. However, from the data we reviewed, we made four findings involving the Unit's adherence to the MFCU performance standards, one of which also involved compliance with Federal regulations: (1) Unit case files did not include all relevant facts, information, and significant documents; (2) the Unit lacked a policy requiring a specific frequency for periodic supervisory reviews; (3) the Unit did not report all convictions and adverse actions to Federal partners; and (4) the Unit's training plan did not include an annual minimum number of training hours for Unit investigators.

WHAT WE RECOMMEND

We recommend that the Missouri Unit (1) ensure that Unit case files include all relevant facts, information, and significant documents; (2) revise the Unit's policies and procedures manual to include a specific frequency for conducting periodic supervisory review of Unit case files, and take steps to ensure that case files include documentation of periodic supervisory reviews; (3) ensure that the Unit consistently reports convictions and adverse actions to Federal partners; and (4) establish training-hour requirements for Unit investigators and ensure that all investigators receive annual training. The Unit concurred with all four recommendations.