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Iowa Medicaid Fraud Control Unit: 2021 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 Iowa MFCU in November 2021. Our inspection covered the 3-year period of fiscal years (FYs) 2019-2021. We based the 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 managers and selected staff; (5) a review of a random sample of 84 case files from the 372 nonglobal 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) onsite review of Unit operations.

WHAT WE FOUND

The Iowa MFCU reported exceptionally strong case outcomes for FYs 2019-2021, as compared to similarly sized MFCUs. From the data we reviewed, we found that the Unit generally operated in accordance with applicable laws, regulations, and policy transmittals and the MFCU performance standards. However, we found that although the Unit operated effectively and achieved high case outcomes, the Unit did not maintain staffing levels in accordance with its approved budget, maintained low staffing levels in relation to State Medicaid expenditures, and experienced significant turnover of investigators and high caseloads. We also made observations regarding Unit operations and practices, including that the Unit (1) took steps to maintain an adequate volume and quality of referrals, although referrals from key sources generally decreased during the review period; (2) took steps to maintain a continuous case flow and to complete cases within appropriate timeframes; and (3) maintained a positive working relationship with Federal law enforcement partners, including the Office of Inspector General and U.S. Attorney's Offices.

WHAT WE RECOMMEND AND HOW THE UNIT RESPONDED

To address the finding, we recommend that the Unit assess the adequacy of existing staffing levels, and if warranted, develop a plan to expand the size of the Unit. The Unit concurred with our recommendation.