Utah Medicaid Fraud Control Unit: 2018 onsite review
Utah Medicaid Fraud Control Unit: 2018 onsite review
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Report in brief
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections, issuing body.
- Publication:
- [Washington, D.C.] : U.S. Department of Health and Human Services, Office of Inspector General, August 2019
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Fraud -- prevention & control
Fraud -- statistics & numerical data
Medicaid
Forecasting
Fraud -- trends
Government Regulation
State Government
Violence -- prevention & control
Humans
United States
Utah - Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. The primary purpose of this onsite review was to identify and address factors that contributed to the MFCU's low number of fraud convictions during FYs 2015–2017 and declining amounts of nonglobal civil settlements, judgments, and recoveries in FY 2017. The Office of Inspector General (OIG) administers MFCU grant awards, annually recertifies each MFCU, and oversees MFCU performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic onsite reviews of MFCUs and prepares public reports. These onsite reviews supplement OIG's annual recertifications of the MFCUs. What OIG Found. During Federal fiscal years (FYs) 2015–2017, the number of criminal fraud convictions that the Utah Medicaid Fraud Control Unit (MFCU) obtained—four convictions—fell below the level that the MFCU had achieved in the preceding years. This decrease in fraud convictions came at the same time as a decrease in fraud referrals to the MFCU from the Utah Inspector General for Medicaid Services (Utah MIG) and from Medicaid managed care organizations, which Utah's Medicaid program refers to as “accountable care organizations” (ACOs). We note that, subsequent to our period of review, the MFCU obtained seven fraud convictions for FY 2018. The MFCU increased the number of convictions that it obtained for patient abuse or neglect during FYs 2015–2017, compared to previous years. Several factors contributed to the MFCU's declining nonglobal civil settlements, judgments, and recoveries in FY 2017. MFCU management reported a decline in civil cases involving pharmaceutical manufacturers, as well as a change in State law that limited the MFCU's ability to follow its historical approach for litigating nonglobal civil cases. We also found two instances of nonadherence with MFCU performance standards--one related to the MFCU's practices for storing and maintaining case information, and the other regarding a lack of documentation of supervisory review of case files. What OIG Recommends and How the Unit Responded. We recommend that the MFCU take steps to address the factors contributing to its decreased case outcomes. Specifically, we recommend that the MFCU: (1) develop and implement a plan to increase Medicaid fraud referrals from the Utah MIG and ACOs; and (2) further develop its approach to litigating nonglobal civil cases in-house or refer them to other appropriate agencies for litigation. To address the instances of nonadherence with MFCU performance standards, we recommend that the MFCU: (1) develop and implement written procedures for storing, maintaining, and efficiently accessing case information; and (2) establish a process to ensure that case files contain appropriate documentation. The MFCU concurred with all four recommendations.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (29 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101757638 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101757638