Illinois Medicaid Fraud Control Unit: 2019 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 Unit's 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. In 2012, OIG found that the Illinois MFCU's organizational structure conflicted with Federal requirements. This onsite review examined this previously identified area of concern and the MFCU's performance and operations.

HOW WE DID THIS STUDY

We conducted the onsite review of the Illinois MFCU in November 2019. Our review period covered Federal fiscal years 2017-2019. We based our review on an analysis of data from eight sources: (1) Unit documentation, such as policies and procedures; (2) financial documentation; (3) interviews with key stakeholders; (4) interviews with Unit management; (5) survey of Unit staff; (6) review of a random sample of case files that were open at some point during the review period; (7) 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 (8) observation of Unit operations.

WHAT WE FOUND

We found that the Illinois MFCU generally operated in accordance with applicable laws, regulations, and policy transmittals. However, we made six findings regarding the Unit's adherence to MFCU performance standards: (1) the Unit's organizational structure created several staffing challenges, raising concerns about its operational efficiencies; (2) the Unit's process for receiving referrals of patient abuse and neglect led to the Unit's screening of thousands of referrals that were unsuitable for investigation, diverting time and resources from viable cases; (3) the Unit did not always coordinate on or actively participate in cases with Federal partners, missing opportunities for sharing resources and training; (4) the Unit did not always report convictions or adverse actions to Federal partners within the appropriate timeframes; (5) newly hired Unit investigators did not always complete new employee trainings, which could affect the Unit's overall effectiveness; and (6) although the Unit documented its periodic supervisory reviews in most of its case files, the Unit had difficulty adhering to its policies of conducting the reviews monthly.

WHAT WE RECOMMEND AND HOW THE UNIT RESPONDED

To address these findings and further improve Unit operations, we recommend that the Unit (1) develop and implement a plan to address the challenges presented by the Unit's organizational structure (i.e., its location within the Illinois State Police, rather than within a State Attorney General's office like most other MFCUs); (2) establish minimum criteria for referrals of patient abuse and neglect to be sent to the MFCU; (3) establish a process to coordinate on cases and improve collaboration with Federal partners; (4) take steps to ensure that Unit staff report all convictions and adverse actions to Federal partners within the appropriate timeframes; (5) take steps to ensure that newly hired investigators complete new employee trainings; and (6) take steps to ensure that supervisory reviews of case files are conducted and documented in accordance with Unit policy. The Unit concurred with all six recommendations.