Mississippi Medicaid Fraud Control Unit: 2020 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 Units and prepares public reports based on these reviews.

HOW WE DID THIS STUDY

OIG conducted the inspection of the Mississippi MFCU in August 2020 using a remote format. Our inspection covered the 3-year period of FYs 2017 through 2019. We based our inspection on an analysis of data and information from 6 sources: (1) Unit documentation; (2) financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with the Unit's managers and selected staff; (5) a review of a random sample of 100 case files from the 2,250 nonglobal case files that were open at some point during the review period; and (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.

WHAT WE FOUND

We found that reporting requirements contained in the Mississippi Vulnerable Persons Act imposed a significant workload on the Unit that led to many convictions of patient abuse or neglect but also presented challenges to Unit operations. The Unit received about 2,000 complaints of patient abuse or neglect for each year of the review period and devoted half of its investigative staff and 90 percent of its caseload to patient abuse or neglect. The Unit's chief investigator devoted more than half of his time to screening complaints and encountered difficulties conducting periodic supervisory reviews of the large caseload. We also found significant unexplained investigative delays in 18 percent of cases.

We observed the Unit's fraud caseload and numbers of fraud convictions were low, compared to those of similarly sized MFCUs. We found that the Unit took some steps to maintain an adequate volume and quality of fraud referrals, but its efforts to maintain fraud referrals from the Medicaid agency were inconsistent and the Unit received few fraud referrals. Additionally, we found that the Unit maintained limited communication and coordination with OIG and stopped working joint cases with Federal partners in 2018.

We also found that certain operational issues have persisted since OIG's prior onsite review in 2014. We found that the Unit's policies and procedures manual did not reflect all aspects of Unit operations, including for periodic supervisory reviews. We also found that the Unit did not timely report a substantial number of convictions to OIG for purposes of excluding providers from Federal health care programs, and that the Unit's timeliness declined significantly since OIG's 2014 onsite review.

WHAT WE RECOMMEND AND HOW THE UNIT RESPONDED

To address the findings about patient abuse or neglect and fraud cases, we recommend that the Unit (1) examine the Unit's intake process for complaints of patient abuse or neglect and identify improvements; (2) take steps to avoid investigation delays and ensure that delays are documented in the case files; (3) develop and implement a plan to increase fraud referrals from the Medicaid agency and other sources; and (4) improve communication and coordination with OIG investigators and other Federal partners. We also make eight additional recommendations to address other findings related to the Unit's compliance with legal requirements and adherence to MFCU performance standards. The Unit concurred with 11 of our recommendations and did not concur with 1 recommendation.