Rhode Island Medicaid Fraud Control Unit: 2022 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 an inspection of the Rhode Island MFCU in August 2022. Our inspection covered the 3-year period of fiscal years 2019-2021. 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 and other selected staff; (5) a review of a random sample of 51 criminal and nonglobal civil 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) an onsite review of Unit operations.

WHAT WE FOUND

The Rhode Island MFCU maintained strong working relationships and investigated cases jointly with OIG and the U.S. Attorney's Office. The Unit also took steps to maintain an adequate volume and quality of fraud and patient abuse or neglect referrals, including maintaining strong relationships with State partners.

However, we made three findings related to the Unit's management of case files and case information. First, we found that the Unit did not have an information management system with the functionality to manage and track case information from initiation to resolution, which posed challenges for monitoring cases and reporting case information and performance data. Further, we found that the Unit did not have adequate policies or procedures, or consistent practices, for effectively maintaining case files. We also found that 60 percent of applicable case files contained no documentation of periodic supervisory reviews and that the Unit's policies and procedures manual did not describe the procedures for or frequencies of supervisory reviews.

We made four additional findings related to other aspects of the Unit's operations. We found that some parts of the Unit's policies and procedures manual lacked adequate guidance and some parts did not describe the Unit's current practices. In addition, we found that the Supervisor of Investigations performed auditing duties and carried an investigative caseload in addition to his managerial responsibilities, which may have impeded the efficiency and effectiveness of the Unit's operations. We also found that the Unit did not consistently report convictions and adverse actions to Federal partners within the appropriate timeframes. Finally, we found that Unit supervisors did not track and verify that staff met training requirements.

WHAT WE RECOMMEND AND HOW THE UNIT RESPONDED

To address the findings, we recommend that the Unit (1) assess whether the Office of the Attorney General's case management system can be modified to fully meet the Unit's needs, and if appropriate, seek approval to implement its own case management system; (2) establish policies and/or procedures to ensure that case files are maintained in an effective manner; (3) develop a plan to ensure that case files include documentation of periodic supervisory reviews and update the Unit's policies and procedures manual to describe the Unit's current practices for periodic supervisory reviews; (4) update its policies and procedures manual to reflect current practices; (5) assess the duties of the Supervisor of Investigations, and if warranted, develop a plan to reduce his nonmanagerial duties; (6) take steps to ensure that convictions and adverse actions are reported to Federal partners within the appropriate timeframes; and (7) take steps to track and verify that Unit staff meet requirements in its training plan. The Unit concurred with all seven recommendations.