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Montana Medicaid Fraud Control Unit: 2019 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 their grants. 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

OIG conducted the onsite inspection of the Montana MFCU in April 2019. Our review covered the 3-year period of fiscal years 2016 through 2018. 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 selected staff; (5) a review of a random sample of 56 case files from the 96 nonglobal case files that were open at some point during the review period; (6) a review of all convictions submitted to OIG so that convicted individuals could be excluded from Federal health care programs and all adverse actions submitted to the National Practitioner Data Bank during the review period; and (7) observation of Unit operations.

WHAT WE FOUND

Based on the information we reviewed, we found that the Unit operated in accordance with applicable laws, regulations, and policy transmittals. However, we made two findings involving the Unit's adherence to Performance Standard 7. We found that the Unit lacked a central repository for case information, making access to case data and pertinent case documents inefficient. We also found that the Unit's practices for conducting periodic supervisory review were not fully reflected in its policies and procedures manual.

WHAT WE RECOMMEND AND HOW THE UNIT RESPONDED

We recommend that, to address the two findings, the Montana Unit: (1) implement a comprehensive case management system that allows for efficient access to case documents and information; and (2) revise its policies and procedures manual to address the frequency of its periodic supervisory reviews. The Unit concurred with both recommendations.