District of Columbia Medicaid Fraud Control Unit: 2022 Onsite 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 of its findings. The primary purpose of this review was to examine two areas of concern that we identified during our ongoing administration and oversight of the District of Columbia MFCU: (1) the Unit's law enforcement authority and (2) fraud referrals from managed care organizations (MCOs). As part of this review, we also examined the Unit's performance and operations.

HOW WE DID THIS STUDY

OIG conducted the review of the District of Columbia MFCU in September 2022. Our review covered the 3-year period of fiscal years (FYs) 2019-2021. We based the review on an analysis of data and information from seven sources: (1) a review of Unit documentation; (2) a review of financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with Unit management and selected staff; (5) a review of a random sample of case files that were open at any point during the review period; (6) a review of convictions submitted to OIG for program exclusion and adverse actions submitted to the National Practitioner Data Bank during the review period; and (7) observation of Unit operations.

WHAT WE FOUND

We made two findings based on our review of areas of concern identified during our ongoing administration and oversight activities: the Unit's law enforcement authority and fraud referrals from managed care organizations (MCOs). We found that the Unit's limited law enforcement authority and the lack of adequate policies and procedures to address its limited authorities posed challenges during our review period of FYs 2019-2021. A few months after our onsite review, the District of Columbia OIG succeeded in obtaining a legislative amendment from the District of Columbia Council. The legislation, which was enacted in January 2023 as the Inspector General Enhancement Amendment Act of 2022, provides Unit investigators with enhanced law enforcement authorities. Despite the challenges associated with its limited law enforcement authority, we observed that the Unit maintained strong working relationships with Federal and District partners, including the U.S. Department of Health and Human Services OIG, the Federal Bureau of Investigation, the U.S. Attorney's Office, and the District's Department of Healthcare Finance's Division of Program Integrity. Further, we found that the Unit received few fraud referrals from MCOs during our review period but has begun to take steps to increase these referrals. We also made two findings related to other aspects of the Unit's operations. We found that, for cases open longer than 90 days, 41 percent lacked documentation of periodic supervisory reviews consistent with Unit policy. We also found that the Unit did not always report convictions or adverse actions to Federal partners within the appropriate timeframes. These operational issues have persisted since our previous onsite review in 2015; however, we found that the Unit has improved in both areas since that time.

WHAT WE RECOMMEND

To address the findings, we recommend that the Unit (1) develop policies and procedures to implement the District of Columbia OIG's expanded law enforcement authority and ensure that Unit investigators receive training on the new authorities; (2) build upon its efforts with the District's Medicaid agency to increase fraud referrals from the MCOs; (3) ensure that supervisory reviews of case files are conducted and documented in accordance with Unit policy; and (4) ensure that all convictions and adverse actions are reported to Federal partners within the appropriate timeframes. The Unit concurred with all four recommendations.