Sneak Preview: MFCUs Urged To Improve Case File Documentation

April 1, 2016 | By Jerry Ashworth | Post a Comment

xsass_bookshot(The following was excerpted from a recent article in the Single Audit Information Service.) The Department of Health and Human Services (HHS) Office of Inspector General (OIG) recently recommended that two state Medicaid Fraud Control Units (MFCUs) establish procedures to improve case file documentation and to inform federal officials about Medicaid provider convictions.

MFCUs investigate and prosecute Medicaid provider fraud and patient abuse and neglect under state law. In federal Fiscal Year (FY) 2014, investigations by the 50 state MFCUs resulted in 1,318 convictions and 874 civil settlements and judgments. HHS issues grants to states to help fund their MFCUs, and the HHS OIG reviews the MFCUs to assess their performance and compliance with federal grant requirements.

In recent audits of the California and Delaware MFCUs, the OIG found numerous deficiencies related to case file documentation and reporting on convictions. MFCU supervisors must approve the opening and closing of Medicaid fraud cases and periodically review case files. However, the HHS OIG found that the California MFCU case files lacked documentation such as: (1) supervisory approval to open and close cases; (2) proof of periodic reviews; and (3) relevant facts and information to explain investigative delays.

For example, 40 percent of California MFCU case files lacked documentation of supervisory approval to open the case, and 8 percent lacked documentation for approval to close the case. “The unit management reported that supervisors always approve the opening and closing of cases and conducted periodic reviews of case files in accordance with unit policy, but acknowledged that these approvals and reviews were not always documented in the case files,” the OIG added.

Federal regulations require state and federal agencies to report final adverse actions (e.g., convictions, civil judgments, Medicaid program exclusions) from investigations or prosecutions of healthcare providers to the National Practitioner Data Bank within 30 days following the action. In addition, MFCUs must report convictions of healthcare providers to the OIG within 30 days of sentencing so that the OIG can determine whether to exclude such providers from billing federal healthcare programs. The California MFCU reported 283 adverse actions and 270 convictions during FYs 2012-2014, but 224 (79 percent) of the adverse actions and 176 (65 percent) of the convictions were reported more than 90 days after sentencing.

California MFCU officials told the OIG that the delays were caused by the time needed to obtain documentation or other case information from the various courts. “Although these timeframes can potentially affect the unit’s ability to report some convictions and adverse action to OIG and the National Practitioner Data Bank within 30 days, it should not result in the unit reporting 65 percent of convictions more than 90 days after sentencing,” the OIG explained.

(The full version of this story has now been made available to all for a limited time on Thompson’s Grants Compliance Expert site.)

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