New Mexico Medicaid Fraud Control Unit: 2020 Review

WHY WE DID THIS STUDY

OIG administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies each Unit, 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 issues public reports based on these reviews. OIG conducted this review of the New Mexico MFCU to examine the Unit's operations and to identify and address factors that contributed to the Unit's low case outcomes during fiscal years (FYs) 2017 through 2019.

HOW WE DID THIS STUDY

We conducted the review of the New Mexico MFCU in September 2020 using a remote format. Our review covered the 3-year period of FYs 2017-2019. We based our review on an analysis of data and information from 7 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) review of a random sample of 76 case files from the 218 nonglobal case files that were open at any point during the review period; (5) referrals received by the Unit;

(6) 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) documentation associated with the Unit's fiscal controls.

WHAT WE FOUND

We identified several factors that contributed to the MFCU's low case outcomes during FYs 2017-2019. The Unit experienced significant turnover of management and staff, which hampered its operations and performance. The Unit did not take sufficient steps to ensure that it received quality referrals from the State Medicaid agency and other sources, and we found significant investigative delays; both factors affected the Unit's case outcomes. Further, the Unit did not maintain regular communication and worked few cases jointly with Federal partners. Unit management practices also resulted in inconsistent periodic supervisory reviews and documentation in Unit case files.

Additionally, we identified areas in which the Unit should improve its compliance with Federal regulations. We found that the Unit did not report all convictions and adverse actions to Federal partners within the appropriate timeframes. Further, the Unit's memorandum of understanding (MOU) with the State Medicaid agency lacked procedures by which the Unit would receive managed care referrals. Finally, we found that the Unit did not exclude costs associated with non-MFCU activities from its Federal reimbursement request.

WHAT WE RECOMMEND

To address the findings identified in this report and improve case outcomes, we recommend that the Unit (1) develop and implement an action plan to reduce turnover of management and staff and to ensure continuity of Unit operations should turnover occur; (2) develop and implement an action plan to ensure that the Unit receives adequate quality referrals of fraud and patient abuse or neglect; (3) ensure that investigations are completed within the appropriate timeframes and that delays are documented; (4) improve communication and seek more opportunities to investigate cases jointly with Federal partners; (5) ensure that supervisory reviews of case files are conducted periodically and documented in accordance with Unit policy; (6) ensure that all convictions and adverse actions are reported to Federal partners within the appropriate timeframes; (7) revise the Unit's MOU with the State Medicaid agency to establish procedures by which the Unit will receive referrals of potential fraud from managed care organizations; and (8) ensure that costs associated with non-MFCU activities are excluded from the Unit's Federal reimbursement request. The Unit concurred with all eight recommendations.