Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
W V S
  EST  IRGINIA  TATE 
 
M F C
E DICAID  RAUD  ONTROL 
 
U :  2013 O R
NI  T      NSITE  EVIEW 
 
Stuart Wright  
Deputy Inspector General for 
Evaluation and Inspections 
 
October 2013 
OEI-07-13-00080   
   
EXECUTIVE SUMMARY:  WEST VIRGINIA STATE MEDICAID FRAUD 
CONTROL UNIT:  2013 ONSITE REVIEW 
OEI-07-13-00080 
 
WHY WE DID THIS STUDY 
The Office of Inspector General (OIG) oversees all Medicaid Fraud Control Units 
(MFCU or Unit) with respect to Federal grant compliance.  As part of this oversight, OIG 
reviews all Units. These reviews assess Unit performance in accordance with the 
12 MFCU performance standards and monitor Unit compliance with Federal grant 
requirements.   
 
HOW WE DID THIS STUDY  
We based our review on an analysis of data from seven sources:  (1) a review of policies 
and procedures, and documentation on the Units operations, staffing, and caseload; (2) a 
review of financial documentation; (3) structured interviews with key stakeholders; (4) a 
survey of Unit staff; (5) structured interviews with the Units management; (6) an onsite 
review of case files; and (7) an onsite review of Unit operations. 
 
WHAT WE FOUND 
For Federal fiscal years 2010 through 2012, the Unit reported combined civil and 
criminal recoveries of nearly $46 million and 20 convictions.  Our review identified 
instances in which the Unit did not fully meet Federal regulations or performance 
standards, and we also identified opportunities for improvement.  For example, the time 
from the Units receipt of a referral to the opening of a case exceeded the 60-day 
investigative timeframe in 70 percent of cases, and case activities and reviews were not 
adequately documented.  Additionally, in 10 of 20 instances, the Unit sent an exclusion 
referral more than 30 days after sentencing, which could allow convicted individuals to 
inappropriately bill and be paid by Medicaid and other Federal healthcare programs.  The 
Unit did not provide OIG and other Federal agencies with timely information concerning 
significant actions in cases.  The Unit also had an inadequate case management tracking 
system, reported inaccurate recovery data in Quarterly Statistical Reports, and did not 
have complete inventory logs.  However, the Unit has made improvements to its 
operating processes over the past year. 
 
WHAT WE RECOMMEND   
Based on these findings, the Unit should work to ensure compliance with each of the 
12 performance standards.  For example, the Unit should (1) make certain that cases are 
opened within 60 days of the receipt of referral; (2) investigative activity is adequately  
documented; (3) individuals are referred for the purpose of program exclusion to OIG 
within the appropriate timeframe; (4) share cases lists with OIG as agreed; (5) develop an 
adequate case management tracking system; (6) submit accurate Quarterly Statistical 
Reports; and (7) ensure inventory logs are complete.  The West Virginia Unit concurred 
with all eight of our recommendations.  
 
   
   
TABLE OF CONTENTS 
Objective......................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................4 

Findings........................................................................................................8 

For FYs 2010 through 2012, the West  Virginia Unit reported 

combined civil and criminal recoveries of nearly $46 million  

and 20 criminal convictions .............................................................8 
 
The time from receipt of referral to the opening of the case 

exceeded 60 days for 70 percent of cases; two cases were open  

for an extended period and lacked documentation of case 

progression.......................................................................................9 

Case files lacked documentation of supervisory approval for  
key stages of investigations and periodic reviews .........................10 

The Unit made all required referrals to OIG for program 
 
exclusions; however, in 10 of 20 instances, the Unit sent the 

referral more than 30 days after sentencing ...................................10 

The Unit did not provide OIG and other Federal agencies  

with timely information concerning significant actions in cases 

pursued by the Unit........................................................................11 
 
The Units case management and tracking system was  

inadequate ......................................................................................11
  
The Unit reported inaccurate recovery data ...................................12 

The Units inventory logs did not include all property purchased  

by the Unit......................................................................................12 

Other observations: Unit improvements, managed care referrals, 

and wireless technology.................................................................13 

Conclusion and Recommendations ............................................................15 

Unit Comments and Office of Inspector General Response ......................17 

Appendixes ................................................................................................19 

A: 1994 Performance Standards ...................................................19 

B: 2012 Revised Performance Standards ......................................23 

C: Population and Sample Distribution of Case Files Open  

Any Time During Fiscal Years 2010 Through 2012 ......................30 

   
   
D: Investigations Opened and Closed By Provider Category  

for Fiscal Years 2010 Through 2012 ..............................................31 

E: Point Estimates and 95-Percent Confidence Intervals Based  

on Our Reviews of Case Files........................................................33 

F: Medicaid Fraud Control Unit Referrals by Provider Category 

for Fiscal Years 2010 Through 2012 ..............................................34 

G: Unit Comments ........................................................................35 

Acknowledgments......................................................................................42 

 
 
 
 
 
 
 
 
 
 
 
 
 
   
OBJECTIVE 
To conduct an onsite review of the West Virginia State Medicaid Fraud 
Control Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse and 
neglect under State law.1  Under the Medicaid statute, each State must 
maintain a certified Unit, unless the Secretary of Health and Human 
Services determines that operation of a Unit would not be cost effective 
because (1) minimal Medicaid fraud exists in that State; and (2) the State 
has other, adequate safeguards to protect Medicaid beneficiaries from  
abuse and neglect.2  Currently, 49 States and the District of Columbia 
(States) have created such Units.3 In Federal fiscal year (FY)4 2012, 
combined Federal and State grant expenditures for the Units totaled 
$217.3 million, and Units employed 1,901 individuals.    
To carry out its duties and responsibilities in an effective and efficient 
manner, each Unit must employ an interdisciplinary staff that consists of at 
least an investigator, an auditor, and an attorney.5  Unit staff review 
complaints provided by the State Medicaid agency and other sources and 
determine the potential for criminal prosecution.  In FY 2012, the 50 Units 
obtained 1,337 convictions and 823 civil settlements or judgments.6   That 
year, the Units reported recoveries of more than $2.9 billion.7 
The Unit must be in an office of the State Attorney Generals office, 
another State government office with statewide prosecutorial authority, or 
operate under a formal arrangement with the State Attorney Generals 
office.8  Units are required to have either Statewide authority to prosecute 
 
1 Social Security Act (SSA)  1903(q)(3). 
 
2 SSA   1902(a)(61).  Regulations at  42 CFR   1007.11(b)(1) add that the Units 

responsibilities may include reviewing complaints of misappropriation of patients 

private funds in  residential health care facilities. 

3 North Dakota  and the territories of American Samoa, Guam, the Northern Mariana 

Islands, Puerto Rico, and the U.S. Virgin  Islands have not established Units. 
4 FY references in this report are based  on the Federal FY (October  1 through 
 
September 30). 
 
5 SSA  1903(q)(6) and 42 CFR  1007.13. 
 
6 OIG, State Medicaid Fraud Control Units  Fiscal Year 2012 Grant Expenditures and 

Statistics. Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/ on 
 
March 7,  2013. 

7 Ibid. 

8 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov on March 7,  2013. 
  
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)   1   
   
cases or formal procedures to refer suspected criminal violations to an 
office with such authority.9  In 44 States, the Units are located within 
offices of State Attorneys General; in the remaining 6 States, including 
West Virginia, the Units are located in other State agencies.10 Generally, 
Units outside of the offices of State Attorneys General must refer cases to 
other offices with prosecutorial authority.   
Each Unit must be a single identifiable entity of State government, distinct 
from the State Medicaid agency, and each Unit must develop a formal 
agreementi.e., a Memorandum of Understanding (MOU)that 
describes the Units relationship with that agency.11  
Oversight of the MFCU Program 
The Secretary of Health and Human Services delegated to OIG the 
authority to both annually certify the Units and to administer grant awards 
to reimburse States for a percentage of their costs in operating certified 
Units.12   All Units are currently funded by the Federal Government on a 
75-percent matching basis, with the States contributing the remaining 
25 percent.13   To receive Federal reimbursement, each Unit must submit an 
initial application to OIG.14 OIG reviews the application and notifies the 
Unit if the application is approved and the Unit is certified.  Approval and 
certification are for a 1-year period; the Unit must be recertified each year 
thereafter.15  
Under the Medicaid statute, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.16 OIG 
developed and issued 12 performance standards to further define the 
criteria it applies in assessing whether a Unit is effectively carrying out 
statutory functions and meeting program requirements.17  Examples of 
 
9 SSA  1903(q)(1). 

10 The Units share responsibility for protecting  the integrity of the Medicaid  program with  

the section of the State Medicaid agency that functions as the Program Integrity Unit.  

Some States also employ a Medicaid Inspector General  who conducts and coordinates the 

State agencys activities to combat fraud, waste, and abuse in this area. 

11 SSA  1903(q)(2);  42 CFR   1007.5 and 42 CFR   1007.9(d).  

12 The portion of funds reimbursed to States by the Federal  Government for its share of 
 
expenditures for the Federal  Medicaid program, including  the MFCUs, is  called Federal 
 
Financial Participation  (FFP). 

13 SSA   1903(a)(6)(B). 

14 42  CFR  1007.15(a). 
 
15 42  CFR  1007.15(b) and (c). 
 
16 SSA  1902(a)(61). 

17 59 Fed. Reg. 49080 (Sept. 26, 1994). Accessed at http://oig.hhs.gov on November 22, 

2011.  Note that the Office of Inspector General (OIG) published revised performance 

standards on June 1,  2012.  (See 77  Fed. Reg. 32645.)  The standards referred to in this 
 
report are those from 1994, which were in effect at the time of  our review.  We apply the 

2012  performance standards in the report  recommendations, where appropriate. 

West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   2 
   
   
criteria include maintaining an adequate caseload through referrals from  
several sources, maintaining an annual training plan for all professional 
disciplines, and establishing policy and procedure manuals to reflect the 
Units operations.  See Appendix A for a complete list of the 
1994 performance standards used for this review and Appendix B for a 
complete list of the 2012 performance standards.  
West Virginia State MFCU 
The West Virginia Unit is located within the Department of Health and 
Human Resources, Office of Inspector General.  The Unit is authorized to 
investigate and refer for prosecution cases of Medicaid fraud and of 
patient abuse and neglect. The Unit does not have its own prosecutorial 
authority.  Abuse and neglect prosecutions are handled by each of the 
individual county prosecuting attorneys.  According to West Virginia State 
law, Medicaid fraud cases may be prosecuted in the circuit court of 
Kanawha County, where the State capital of Charleston is located; the 
county in which the defendant conducts business; the county in which the 
offense was committed; or other venues provided by State law.18,  19 At the 
time of our review, the Units 16 employees were located in Charleston.  
For FY 2012, the West Virginia Unit was authorized $1,455,192 in Federal 
funds and expended a total of $1,043,589 in combined Federal and State 
funds. Total Medicaid expenditures in West Virginia increased from  
$2.7 billion in FY 2010 to $2.9 billion in FY 2012.  
The Unit receives referrals of fraud, abuse, or neglect from the State 
Medicaid agency, State Survey and Certification agency, contractors, 
telephone calls to the Units Tip Line, and a fraud reporting form located 
on the Units  Web site.20 For FYs 2010 through 2012, the Unit received an 
average of 245 referrals each year.   
The Unit office assistant routes the referrals to the supervisory  
investigators. The supervisors review the referrals and returns them to the 
office assistant with a notation to take one of the following actions:  
(1) enter the case into the online case-tracking system and assign it to an 
investigator; (2) if the case is not going to be assigned immediately, enter 
the case into the online case-tracking  system and return it to the submitting 
 
18  See West Virginia  Code  9-7-5A. 
 
19 The Units decision as to  where to refer a case for prosecution  depends on multiple 

factors:  the prosecutors expertise and his or  her working relationship with the Unit,
  
notoriety of the defendant(s) in the community, the number of cases in  which the 

defendant is currently a party, current resources and case loads of prosecutors, 

complexity of the case, and the availability of witnesses.  Additionally, if a case of abuse, 

neglect, or financial exploitation contains elements of Medicaid fraud, the  Unit  pursues 

the entire matter in the county in which the conduct occurred.  
  
20 Accessed at https://www.wvdhhr.org/oig/mfcu/secRepFrd/ on  April 15, 2013. 

West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   3 
   
   
supervisor; (3) enter the case into the online case-tracking system and 
close it for lack of jurisdiction; or (4) enter the case, close it, and refer the 
case to the appropriate agency.    
West Virginias Medicaid population is served primarily through managed 
care organizations (MCOs).  West Virginias Medicaid managed care 
program, Mountain Health Trust, contracts with and pays MCOs a 
monthly capitated rate for beneficiaries enrolled in each MCO.21 Each 
MCO contracts with and pays medical providers to provide services to 
those beneficiaries. West  Virginia contracts with three MCOs:  Coventry 
Health Care of West Virginia, The Health Plan of the Upper Ohio, and 
Unicare.22  Approximately 236,067 members were enrolled in 
West Virginia MCOs as of FY 2012, constituting about 55 percent of 
West Virginias Medicaid enrollees.23  
Previous Review  
In 2007, OIG conducted an onsite review of the West Virginia Unit and 
found that (1) the Unit did not submit Quarterly Statistical Reports (QSRs) 
on a timely basis, (2) the information contained in QSRs was inaccurate 
and required frequent revisions; (3) the Unit did not have an automated, 
computerized case tracking and management system; and (4) the Unit did 
not note the final disposition of cases in case files.  
In the Unit directors response to the 2007 onsite review, he responded to 
OIG that future quarterly reports would be accurate and submitted on a 
timely basis.  OIG recommended that the Unit (1) install a computerized 
case management and tracking system and (2) include a closing 
memorandum in case files to notate the final disposition of an  
investigation. 
METHODOLOGY 
Our review covered the 3-year period of FYs 2010 through 2012.  We  
based our review on an analysis of data from seven sources:  (1) a review 
of policies and procedures and of documentation of the Units operations, 
staffing, and caseload for FYs 2010 through 2012; (2) a review of 
financial documentation for FYs 2010 through 2012; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
interviews with the Units management; (6) an onsite review of case files 
 
21 West Virginia Bureau for Medical Services,  Mountain  Health Trust (Managed Care),  
accessed at http://www.dhhr.wv.gov  on February 23, 2013.  

22 After the close of FY  2011, beneficiaries in West Virginias Berkeley, Hampshire, 

Jefferson, Mineral, and Morgan counties were required to enroll in an MCO, causing the 

number  of MCO enrollees to increase from 170,000 in FY  2011 to  236,000 in FY  2012. 

23 Accessed at http://www.medicaid.gov on  February 23, 2013.  
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   4 
   
   
that were open at any time in FYs 2010 through 2012; and (7) an onsite 
review of Unit operations.  We conducted our fieldwork in February 2013.   
Although interview and survey respondents occasionally provided 
information that fell outside of our 3-year review period, we used this 
information to further explain the results of our analyses covering 
FYs 2010 through 2012. As relevant, we also included observations we 
made while onsite in February 2013. 
We analyzed data from all seven sources to describe the caseload and 
assess the performance of the Unit.  We also analyzed the data to identify 
any opportunities for improvement and any instances in which the Unit 
did not fully meet the performance standards or was not operating in 
accordance with laws, regulations, and policy transmittals.24 In addition, 
we noted practices that appeared to be beneficial to the Unit.  We based 
these observations on statements from Unit staff, data analysis, and our 
own judgment.  We did not independently verify the effectiveness of these 
practices, but included the information because it may be useful to other 
Units in their operations. 
Data Collection and Analysis 
Review of Unit Documentation. Prior to the onsite visit, we analyzed 
information from several sources regarding the Units investigation and 
referral for prosecution of Medicaid cases.  Specifically, we collected and 
analyzed information about the number of referrals the Unit received, the 
number of investigations the Unit opened and closed, the outcomes of 
those investigations, and the Units  case mix.  We also collected and 
analyzed information about the number of cases that the Unit referred for 
prosecution and the outcomes of those prosecutions.  We gathered this 
information from several sources, including the Units QSRs, annual 
reports, recertification questionnaire, policy and procedures manuals, 
MOU with the State Medicaid agency, and the 2007 report on OIGs 
onsite review.  Additionally, we confirmed with the Unit director that the 
information we had was current as of February 2013 and, as necessary, 
requested any additional data or clarification.   
Review of Fiscal Control.  We reviewed the Units control over its fiscal 
resources to identify any internal control issues or other issues involving 
use of resources. Prior to the onsite review, we reviewed the Units 
financial policies and procedures; its response to an internal control 
questionnaire; and documents (such as financial status reports) related to 
MFCU grants. During the onsite review, we reviewed a sample of the 
 
24 All relevant  regulations, statutes, and  policy transmittals are available online at  
http://oig.hhs.gov.  
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   5 
   
   
Units purchase and travel transactions.  In addition, we reviewed vehicle 
records, the equipment inventory, and a sample of time and effort records.  
Interviews with key stakeholders. In December 2012, we interviewed key  
stakeholders, such as officials in the United States  Attorneys Offices, the 
West Virginia Department of Health and Human Resources and its Office of 
Inspector General, and other agencies that interacted with the Unit (i.e., the 
State Ombudsman, the Office of Health Facility Licensure and Certification, 
and the Insurance Commissioner).  We focused these interviews on the 
Units relationship and interaction with OIG and other Federal and State 
authorities, and we identified opportunities for improvement.  We used the 
information collected from these interviews to develop subsequent interview 
questions for Unit management. 
Survey of Unit staff.  In December 2012, we administered an electronic 
survey of all nonmanagerial Unit staff within each professional discipline 
(i.e., investigators, auditors, and attorneys) as well as support staff.  The 
response rate was 100 percent. Our questions focused on operations of the 
Unit, opportunities for improvement, and practices that contributed to the 
effectiveness and efficiency of Unit operations and/or performance.  The  
survey also sought information about the Units compliance with 
applicable laws and regulations. 
Onsite interviews with Unit management.   We conducted structured 
interviews with the Units management in February 2013.  We interviewed 
the Unit director, the Deputy Director (who also served as the Units lead  
attorney), and the two supervisory investigators.  We asked these 
individuals to provide additional information to better illustrate the Units  
operations, identify opportunities for improvement, identify practices that 
contributed to the effectiveness and efficiency of Unit operations and/or 
performance, and clarify information obtained from other data sources.  
Finally, we discussed with Unit management the status of their actions 
with respect to recommendations from the 2007 report; we describe these 
actions in the findings section of this report. 
Onsite review of case files and other documentation. We selected a simple 
random sample of 100 case files from the 198 cases that were open at 
some point during FYs 2010 through 2012.  We reviewed all sampled case 
files for documentation of supervisory reviews for the opening and closing 
(as appropriate) of cases, as well as to see whether supervisors conducted 
periodic case file reviews.  From these 100 case files, we selected a further 
random sample of 50 files for a more in-depth review of selected issues, 
such as the timeliness of investigations and case development.  We  
projected the results of our case file reviews to the population of Unit 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   6 
   
   
cases. See Appendix C for the distribution of case files from the 
population and sample.  
Onsite Review of Unit Operations.  During our February 2013 site visit, 
we reviewed the Units workspace and operations.  Specifically, we 
visited the Unit headquarters in the State Capital; we did not visit Unit 
staff who worked remotely in Department of Health and Human 
Resources offices.  While onsite, we observed the Units offices and 
meeting spaces, security of data and case files, location of select 
equipment, and the general functioning of the Unit. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   7 
   
   
FINDINGS 
For FYs 2010 through 2012, the West Virginia Unit 
reported combined civil and criminal recoveries of 
nearly  $46 million and 20 criminal convictions 
The Unit reported total combined criminal and civil recoveries of nearly 
$46 million for FYs 2010 through 2012.  Recoveries decreased from  
$18 million in FY 2010 to $11 million in FY 2012 as a result of reduced 
recoveries through global settlements in 2012.25   Although overall 
recoveries were less in 2012, the Unit obtained a greater percentage of 
recoveries from State investigations than in the 2 years prior. In FY 2010, 
approximately 15 percent of total recoveries were attributable to 
non-global cases; however, in FY 2012, that figure increased to 
37 percent. Refer to Table 1 for details regarding criminal and civil 
recoveries. 
Table 1: West Virginia MFCU Criminal and Civil Recoveries,  
FYs 20102012.  
Type of  Total  
FY 2010   FY 2011   FY 2012  
Recovery   Recoveries  
Criminal 
$1,074,058   $256,964   $3,490   $1,334,512  
Recoveries 
Global 
$15,635,038 $14,438,712   $7,058,873   $37,132,623  
Recoveries  
Non-Global 
$1,721,104   $1,352,301   $4,186,740   $7,260,145 
Civil Recoveries  
 Total     
$18,430,200   $16,047,977  $11,249,103  $45,727,280  
     Recoveries  
Source:  OIG review of Unit self-reported QSR and other data, FYs 20102012. 
 
 
During the review period, the Unit closed 120 investigations with 
21 individuals charged, obtained 20 criminal convictions, and obtained 
 
25 Global cases are civil false-claims actions involving the U.S. Department of Justice 
and other State MFCUs.  The National  Association of Medicaid Fraud Control Units  
facilitates the settlement of global cases. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   8 
   
   
2 dismissals.26  See Appendix D for details on investigations opened and 
closed by provider category for FYs 2010 through 2012. 
The time from receipt of referral to the opening of the 
case exceeded 60 days for 70 percent of cases; two 
cases were open for an extended period and lacked 
documentation of case progression 
According to Performance Standard 6(a), each stage of an investigation 
and prosecution should be completed in an appropriate timeframe.  The 
Units policy requires that no more than 60 days elapse between the 
receipt of a referral and the opening of a case (i.e., the preliminary 
investigation period).  Our review revealed that 70 percent of referrals 
remained in the preliminary investigation status beyond the 60-day 
timeframe.  The median time from receipt of referral to opening the case 
was 91 days.   Some referrals were received by the Unit but not opened as 
cases for several months, during which time Unit staff conducted no 
apparent investigative activity.  In other instances, the Unit conducted 
investigative activity; however, this activity was conducted after 60 days 
from receipt of referrals.  See Appendix E for information regarding the 
time from receipt of referral to the opening of cases.  Later, when those 
cases were documented in the case-tracking system as having been 
opened, we could find only limited documentation in the case opening 
memorandum accounting for investigative activity that had occurred while 
the case was in a preliminary investigation status (i.e., the period between 
receipt of referral and opening of the case).  Three cases were open for an 
extended period without any documented investigative progress; one case 
was left open for 210 days and the other two cases for over 240 days. We  
could find no evidence in the case files to support those delays.  
Case files lacked documentation of supervisory 
approval for key stages of investigations and periodic 
reviews 
According to Performance Standards 6(b) and (c), Unit supervisors must 
approve the opening and closing of investigations and conduct periodic 
supervisory reviews that are documented in the case files.  Twenty percent 
of the Units case files did not contain evidence to support supervisory 
 
26 According to  Unit staff, the number of people charged in  a given time period  will not  
equal the sum of convictions, acquittals, and dismissals for that same period.  Some of the 
20 individuals convicted during the review period were charged prior to the review  
periodfor example, one suspect was charged in September 2009, prior to the review  
period, but  was convicted in December 2009.  Additionally, some of the individuals 
charged during the review  period had not  had their cases fully adjudicated by the end of  
the review period.   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   9 
   
   
approval of opening the case, and 27 percent of cases lacked supervisory 
approval of closing the case. The Unit did not file case documents in a 
consistent order, and did not place forms and documents in the case file 
with any consistency. Additionally, the Unit did not document contact 
between Unit staff and other Federal agencies.  However, all sampled 
cases opened after April 2011 noted supervisory approval of the case 
opening; all sampled cases closed after August 2011 noted supervisory 
approval of the case closing. The Unit indicated that it had developed a 
case review form to ensure that each stage of an investigation and 
prosecution is completed in the appropriate timeframe.  
Unit policy required that abuse and neglect cases receive monthly 
supervisory review and that fraud cases receive a supervisory review at the 
end of each quarter. Seventy-three percent of abuse and neglect cases 
were missing periodic supervisory reviews and 34 percent of fraud cases 
were missing periodic supervisory reviews.  In total, 56 percent of cases 
were missing periodic supervisory reviews.27 See Appendix E for 
information regarding missing opening, closing, and periodic review 
documentation.  
The Unit did not document its participation in National Association of 
Medicaid Fraud Control Units Global cases.  Unit staff did not document 
actions taken by the Unit to assist or participate in global cases.  Also, it 
did not appear that the Unit had a system in place to account for the final 
signed settlement agreements for global cases.  These documents are 
essential should the Unit ever wish to pursue further legal action (e.g., 
defendant defaults on agreement).   
The Unit made all required referrals to OIG for 
program exclusions; however, in 10 of 20 instances, 
the Unit sent the referral more than 30 days after 
sentencing 
According to Performance Standard 8(d), for purpose of program  
exclusions under section 1128 of the Social Security Act, the Unit must 
transmit to OIG the reports of convictions and copies of Judgment and 
Sentence or other acceptable documentation within 30 days or other 
reasonable time period.  The Unit reported 20 convictions in the 3-year 
period, and made all required referrals to the OIG.  However, in 10 of 
20 cases, the Unit sent the referral to OIG for exclusion more than 30 days 
after sentencing. The amount of days between the sentencing and referral 
 
27 For the purposes of this report, supervisory approval to  open and close a case does not  
constitute a case file review.  Periodic supervisory review indicates that a supervisor 
reviewed a case more than once between the opening and closing of the case. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   10 
   
   
in these cases ranged from 38 to 385 days. During our onsite interview, 
the Unit director attributed this delay to the Units lack of prosecution 
authority and prosecutors not reporting back to the Unit regarding the 
disposition of cases. As a result, the Unit inquires with county prosecutors 
as to when defendants are sentenced but does not always receive a 
response. The Unit plans to employ a paralegal to make regular inquiries 
in the future.  
The Unit did not provide OIG and other Federal 
agencies with timely  information concerning 
significant actions in cases pursued by the Unit 
According to revised Performance Standard 8(b), a unit should cooperate 
and, as appropriate, coordinate with OIGs Office of Investigations (OI) 
and other Federal agencies on cases being pursued jointly, cases involving 
the same suspects or allegations, and cases that have been referred to the 
Unit by OIG or another Federal agency.  OIG and other Federal agencies 
reported that the Unit has not routinely shared information about targets of 
investigations in a timely manner unless the agencies specifically request  
such information. In June 2012, the Unit director met with the Special 
Agent in Charge for OIs Region 3 to discuss shared cases and general 
information about how the offices can best work together to maximize 
resources. The Unit director stated that the two offices have developed a 
plan to share caseload lists. In May 2013, the Unit began informing OIG 
of the cases that the Unit is pursuing, so as to avoid potential conflicts.   
In the past, the Unit as well as the Northern and Southern Assistant United 
States Attorneys (AUSAs) jointly worked on the detection, development, 
and prosecution of Medicaid cases from the opening of the cases until 
their final dispositions, and the Unit provided six recent Department of 
Justice press releases giving credit to the Unit in several investigations.  
However, both the Northern and Southern Offices of United States 
Attorneys reported that they are no longer involved in the Units 
investigations or prosecutions. Although the AUSAs in these offices 
receive the information they request  from the Unit, they report that 
investigations are no longer a collaborative effort.   
The Units case management and tracking system was 
inadequate 
According to Performance Standard 3(b), a unit should have an adequate, 
computerized case management and tracking system in place.  However, 
Unit staff reported that the their computerized case management and 
tracking system regularly lost data and merged case file information from 
unrelated cases. The Unit created parallel spreadsheets to compensate for 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   11 
   
   
the systems inadequacies.  One respondent to the staff survey reported:  
The case-tracking system is a huge hindrance; it is old, slow and doesnt 
work half the time.  Another staff member reported that the case-tracking 
system is not always accessible and that logging in is difficult.  The Unit 
has selected a new case management system that should be operational in 
the summer of 2014.  The problems that our 2007 onsite review found 
with the case management and tracking system remain unresolved. 
The Unit reported inaccurate recovery data 
According to Performance Standard 7, a unit should have a process for 
monitoring the outcome of cases, including the amount of fines and 
restitution ordered as well as the amount of civil recoveries.  In 
December 2006, representatives of OIG conducted a conference call with 
the Unit director, the chief investigator, and an administrative services 
assistant to educate them  on preparing the QSRs and ensuring that the 
reports were correct. The individual serving as the Unit director at that 
time stated that the Unit would work diligently to ensure that all future 
QSRs would be accurate and submitted to OIG on a timely basis.   
During the course of our review, we identified numerous errors in the 
recovery statistics reported by the Unit.  For example, we identified a 
$500,000 discrepancy for FY 2010 after reviewing the Units QSR and the 
data we collected directly from the Unit at the outset of our review.  The 
QSR reflected that total criminal case outcomes for FY 2010 totaled 
$529,000; however, after our inquiries, the Unit revised the total to 
indicate that total criminal case outcomes for FY 2010 totaled nearly 
$1.1 million.  Additionally, the Units QSR showed that total criminal 
recoveries for FY 2011 were $33,367; however, the Unit later provided 
information indicating that the total criminal recoveries for FY 2011 were 
$257,000. These errors required the Unit to revise QSRs for FYs 2010, 
2011, and 2012. 
The Unit had to develop multiple spreadsheets in an attempt to adequately  
capture all recovery data because the current case-tracking system was 
inadequate. 
The problems that our 2007 onsite review found with the reporting of 
inaccurate recovery data remain unresolved.  
The Units inventory logs did not include all property 
purchased by the Unit 
According to the 2012 version of Performance Standard 11(b), a unit 
should maintain an equipment inventory that is updated regularly to reflect 
all property under the Units control.  To determine compliance with 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   12 
   
   
applicable laws and regulations, as well as to determine the need for 
additional internal controls, we performed a limited review of financial 
documents from the Unit and of the Units equipment inventory and 
purchase records. During our onsite review, we observed that the 
following items were not included in the inventory report:  a customized 
office chair, two printers, a paper shredder, and an identification card 
system.  Additionally, we identified an equipment storage room that 
housed various other property purchased by the Unit, and the items located 
in this room were not included in the inventory logs.  However, the items  
we selected for review were included in the appropriate log.  
Units must take appropriate measures to ensure that they are able to 
maintain effective control and accountability for property purchased.  
According to Unit staff, physical inventories of property occur annually.  
The Units logistics manager told us that although physical inventories 
were conducted during his tenure, the results of those inventories were not 
reconciled with equipment records.  However, inventory is reconciled to a 
system maintained by the Department of Health and Human Resources.  
The logistics manager stated that he had no projected timeframe as to 
when this task will be completed.   
Other observations:  Unit improvements, managed 
care referrals, and wireless technology  
Unit improvements 
During 2012, the Unit made many improvements to its operating 
processes. In September 2012, two individuals in the Unit passed 
examinations to become certified fraud examiners so as to assist the Unit 
with analyzing fraud cases. Another individual obtained certification as a 
Certified Coding Professional. Unit investigators performed outreach at 
nursing homes, such as distributing brochures and Unit contact 
information. 
In January 2011, the State Medicaid agency began using a Medicaid Fraud 
Referral Form developed to streamline the referral of cases from the State  
Medicaid agency to the Unit.28  The Unit modified this form to include all 
information necessary for the Unit to proceed with an investigation after 
receiving the initial referral.  Additionally, Unit staff reported that the Unit 
 
28 Accessed at  http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/WVfy13.pdf on April 16, 2013.  According 
to CMS, West Virginias Medicaid Fraud Referral Form incorporates all of the criteria in 
CMS September 2008 guidance document  Performance Standard for Referrals of 
Suspected Fraud from  a Single State Agency to  a Medicaid Fraud Control Unit. The  
guidance was adopted in  Federal regulations at 42 CFR  455.436 effective March 25, 
2011. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   13 
   
   
has increased its interaction and improved its communication with the 
State Medicaid agency.  For example, Unit staff met with the State 
Medicaid Agency staff each month to discuss referrals.   
Managed care referrals 
According to the 2012 version of Performance Standard 4(a), the Unit 
should take stepssuch as the development of operational protocolsto 
ensure that the State Medicaid agency, managed care organizations, and 
other agencies refer to the Unit all cases of suspected provider fraud.  In 
West Virginia, 55 percent of Medicaid enrollees receive their health care 
services through MCOs.29 However, in FYs 2010 through 2012, QSRs 
reflected that the Unit opened only one MCO case during our review 
period. The Unit director reported that as MCO enrollment grows, the 
Unit has begun meeting with MCO administrators to obtain referrals.30   
See Appendix F for information on referrals by provider category. 
Wireless technology 
Unit management reported that it is unable to obtain wireless technology 
for investigative staff.  The Unit investigates cases Statewide, and staff  
may be on the road for days at a time but still have a need to stay in touch 
with the office, their colleagues, and other law enforcement personnel.  
Unit management reported that there have been instances in which the 
lack of availability of information in the field has been detrimental to Unit 
investigators.  These instances include an inability to scan documentary 
evidence, communicate through email or text messaging (e.g., while 
executing a search warrant or during other activities at a suspects 
location), and access applications (e.g., flashlight, notepad, camera, 
audio/video, calculator, GPS, Emergency Alert System, and a translator in  
the event the investigators have to interview someone who does not speak 
English). 
 
 
29 Medicaid.gov, West Virginia  Medicaid  Statistics, accessed at 
http://www.medicaid.gov/ on February  20, 2013. 

30 After the close of FY  2011, beneficiaries in West Virginias Berkeley, Hampshire, 

Jefferson, Mineral, and Morgan counties were required to enroll in an MCO, causing the 

number  of MCO enrollees to increase from 170,000 in FY  2011 to  236,000 in FY  2012. 

West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   14 
   
   
CONCLUSION AND RECOMMENDATIONS 
For FYs 2010 through 2012, the Unit reported combined civil and criminal 
recoveries of nearly $46 million.  During the review period, the Unit 
closed 120 investigations with 21 individuals charged, obtained 
20 criminal convictions, and obtained 2 dismissals.  In January 2011, the 
Unit adopted a standardized referral form that helps to ensure that all 
pertinent information is now included in referrals.  Other agencies have 
reported that in the past year, the Units interactions and communication 
with them have markedly improved. 
However, our review identified instances in which the Unit did not fully  
meet performance standards and identified opportunities for improvement.  
Specifically, in 70 percent of cases, the time from the Units receipt of a 
referral to the opening of the case exceeded the 60-day investigative 
timeframe established by the Unit.  Fifty-six percent of case files lacked 
evidence of supervisory review and approval for key stages of 
investigations. The Unit made all required referrals to OIG for program  
exclusion, but in 10 of 20 instances, the Unit sent the referral more than 
30 days after sentencing. 
Although 55 percent of West Virginias Medicaid enrollees are enrolled in 
managed care, the Unit received no managed-care referrals during our 
review period.  Additionally, the Unit did not provide OIG with timely 
information concerning significant actions in cases pursued by the Unit, 
and both the Northern and Southern Offices of United States Attorneys 
reported that they are no longer included in the Units investigations or 
prosecutions. The Units staff reported that the case management and 
tracking system is inadequate.  The Units inventory logs did not include 
many of the items purchased by the Unit, and physical inventory results 
had not been reconciled with equipment records.  
We recommend that the West Virginia Unit: 
Open cases referred to the Unit within 60 days of the receipt of 
referral and document all investigative activity 
The Unit should make certain that complaints referred to the Unit are 
investigated and opened, if appropriate, within the 60-day timeframe 
established in the Units policy.   Additionally, the Unit should account for 
all investigative activity that occurs while cases are in the preliminary 
investigation status. 
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   15 
   
   
Ensure that all case files contain documented supervisory  
approvals of opening and closing cases and documentation of 
periodic supervisory reviews  
The Unit should ensure that supervisors are approving the opening and 
closing of investigations and that documentation thereof is contained in all 
case files.  Additionally, the Unit should ensure that supervisory reviews 
are conducted periodically and are also noted in each case file.  
Refer individuals to OIG for exclusion within the appropriate 
timeframe  
The Unit should make certain that individuals convicted of fraud, abuse, 
and/or neglect are reported within 30 days of their sentencing, in 
accordance with performance standard 8(f) of the revised MFCU 
performance standards.  
The Unit should continue sharing case lists with OIG, as 
agreed between the Unit and OIG 
The Unit should re-establish collaborative efforts with the 
Northern and Southern Offices of United States Attorneys 
Upgrade the Units case management and tracking system 
The Unit should implement a new case management and tracking system  
that is not vulnerable to data discrepancies and inaccuracies. The new 
system should also ensure that accurate QSR data is submitted to OIG. 
The Unit should ensure accurate reporting of recovery data 
The Unit should ensure that all items purchased by the Unit 
are documented in the inventory log  
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   16 
   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The West Virginia Unit concurred with all eight of our recommendations.  
However, for two of the recommendations, the Unit disagreed with the 
associated finding but stated that it agreed with the recommendation. 
Regarding our first recommendation, involving opening cases timely and 
documenting all investigative activity, the Unit concurred.  The Unit was 
aware of this issue and initiated action to correct this deficiency prior to 
the onsite review.  Supervisors are conducting formal, monthly meetings 
with each investigator and reviewing case documentation to ensure 
appropriate progression in referrals and cases.  The Unit will implement a 
new case management system in June 2014. 
Regarding our second recommendation, involving the Units efforts to 
ensure that case files contained required documentation, the Unit 
concurred. Unit supervisors now formally meet each month to ensure that 
every case is being reviewed and that these reviews are documented.  
Effective February 2013, case opening and closing approvals are part of 
the case files. 
Regarding our third recommendation, involving referring individuals for 
exclusion to OIG within the appropriate timeframe, the Unit concurred.  
The Unit is currently monitoring all cases that have been referred for 
prosecution and will contact the prosecutors on a monthly basis to monitor  
the progress of each case. Effective May 2013, the Unit began submitting 
exclusion referrals to OIG within the 30-day timeframe. 
Regarding our fourth recommendation, involving the Units sharing case 
lists with OIG, the Unit concurred with the recommendation to continue 
sharing cases lists with OIG.  However, the Unit disagreed with the 
finding that the Unit did not provide OIG and other Federal agencies with  
timely information about cases.  In response to the recommendation, the 
Unit stated that it began sharing its entire caseload list with OIG in 
May 2013 and will continue to do so.  
Regarding our fifth recommendation, involving re-establishing 
collaborative efforts with the Northern and Southern Office of United 
States Attorneys, the Unit concurred with the recommendation.  However,  
the Unit disagreed with the finding related to this recommendation and 
asserts that it cooperates fully and coordinates with Federal partners.  The 
Unit stated that it currently collaborates with the Southern District and has 
reached out to the Northern District to improve communications, 
collaboration, and relationships. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   17 
   
   
Regarding our sixth recommendation, involving upgrading the case 
management and tracking system, the Unit concurred.  A new system  
should be fully implemented by the end of June 2014. 
Regarding our seventh recommendation, involving accurate reporting of 
recovery data, the Unit concurred. The Unit has taken a number of steps 
to ensure accurate reporting of recovery data and is working to correct the 
report function of the current case-tracking software so that all data will be  
captured and reported accurately.  
Regarding our eighth recommendation, involving inventory logs, the Unit 
concurred. The Unit director asserted that, by February 2013, the Unit 
addressed all inventory deficiencies identified in the review, and, effective 
July 2013, the Unit implemented an employee equipment log to track 
inventory items issued to each employee. 
We did not make changes to the report based on the Units comments.  The 
full text of the Units comments is provided in Appendix G.   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   18 
   
   
APPENDIX A 
1994 Performance Standards31   
1. 	A Unit will be in conformance with all applicable statutes, 
regulations and policy transmittals.  In meeting this standard, the 
Unit must meet, but is not limited to, the following requirements:  
a. 	  The Unit professional staff must consist of permanent employees 
working full-time on Medicaid fraud and patient abuse matters. 
b. 	  The Unit must be separate and distinct from the State Medicaid 
agency.  
c. 	  The Unit must have prosecutorial authority or an approved formal 
procedure for referring cases to a prosecutor. 
d. 	  The Unit must submit annual reports, with appropriate 

certifications, on a timely basis. 
 
e. 	  The Unit must submit quarterly reports on a timely basis. 
f. 	  The Unit must comply with the Americans with Disabilities Act, 
the Equal Employment opportunity requirements, the Drug Free 
workplace requirements, Federal lobbying restrictions, and other 
such rules that are made conditions of the grant. 
2. 	A Unit should maintain staff levels in accordance with staffing 
allocations approved in its budget. In meeting this standard, the 
following performance indicators will be considered: 
a. 	  Does the Unit employ the number of staff that was included in the 
Unit's budget as approved by the OIG? 
b. 	  Does the Unit employ the number of attorneys, auditors, and 
investigators that were approved in the Unit's budget? 
c. 	  Does the Unit employ a reasonable size of professional staff in 
relation to the State's total Medicaid program expenditures?   
d. 	  Are the Unit office locations established on a rational basis and are 
such locations appropriately staffed? 
3. 	A Unit should establish policies and procedures for its operations, 
and maintain appropriate systems for case management and case 
tracking.  In meeting this standard, the following performance 
indicators will be considered: 
a. 	  Does the Unit have policy and procedure manuals? 
 
31 59 Fed. Reg. 49080, Sept. 26, 1994. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   19 
   
   
b. 	  Is an adequate, computerized case management and tracking 
system in place? 
4. 	A Unit should take steps to ensure that it maintains an adequate 
workload through referrals from the State Medicaid agency and 
other sources. In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit work with the State Medicaid agency to ensure 
adequate fraud referrals? 
b. 	  Does the Unit work with other agencies to encourage fraud 
referrals? 
c. 	  Does the Unit generate any of its own fraud cases? 
d. 	  Does the Unit ensure that adequate referrals of patient abuse 
complaints are received from all sources? 
5. 	A Units case mix, when possibl e, should cover all significant 
provider types. In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit seek to have a mix of cases among all types of 
providers in the State? 
b. 	  Does the Unit seek to have a mix of Medicaid fraud and Medicaid 
patient abuse cases? 
c. 	  Does the Unit seek to have a mix of cases that reflect the 
proportion of Medicaid expenditures for particular provider 
groups? 
d.	   Are there any special Unit initiatives targeting specific provider 
types that affect case mix? 
e. 	  Does the Unit consider civil and administrative remedies when  
appropriate? 
6. 	A Unit should have a continuous case flow, and cases should be 
completed in a reasonable time. In meeting this standard, the 
following performance indicators will be considered:  
a. 	  Is each stage of an investigation and prosecution completed in an 
appropriate time frame?  
b.	   Are supervisors approving the opening and closing of 

investigations?
   
c. 	  Are supervisory reviews conducted periodically and noted in the 
case file? 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   20 
   
   
7. A Unit should have a process for monitoring the outcome of cases.  
In meeting this standard, the following performance indicators will be 
considered:  
a. 	  The number, age, and type of cases in inventory. 
b. 	  The number of referrals to other agencies for prosecution. 
c. 	  The number of arrests and indictments. 
d. 	  The number of convictions. 
e. 	  The amount of overpayments identified. 
f. 	  The amount of fines and restitution ordered. 
g. 	  The amount of civil recoveries. 
h. 	  The numbers of administrative sanctions imposed. 
8. 	A Unit will cooperate with the OIG and other Federal agencies, 
whenever appropriate and consistent with its mission, in the 
investigation and prosecution of health care fraud.  In meeting this 
standard, the following performance indicators will be considered: 
a. 	  Does the Unit communicate effectively with the OIG and other 
Federal agencies in investigating or prosecuting health care fraud 
in their State? 
b. 	  Does the Unit provide OIG regional management, and other 
Federal agencies, where appropriate, with timely information 
concerning significant actions in all cases being pursued by the 
Unit? 
c. 	  Does the Unit have an effective procedure for referring cases,  
when appropriate, to Federal agencies for investigation and other 
action?  
d. 	  Does the Unit transmit to the OIG, for purposes of program  
exclusions under section 1128 of the Social Security Act, reports 
of convictions, and copies of Judgment and Sentence or other 
acceptable documentation within 30 days or other reasonable time 
period? 
9. 	A Unit should make statutor y or programmatic recommendations, 
when necessary, to the State government. In meeting this standard, 
the following performance indicators will be considered:  
a. 	  Does the Unit recommend amendments to the enforcement 
provisions of the State's statutes when necessary and appropriate to 
do so? 
b. 	  Does the Unit provide program recommendations to State 

Medicaid agency when appropriate? 

West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   21 
   
   
c. 	  Does the Unit monitor actions taken by State legislature or State 
Medicaid agency in response to recommendations? 
10. 	A Unit should periodica lly review its memorandum of 
understanding (MOU) with the State Medicaid agency and seek 
amendments, as necessary, to ensure it reflects current law and 
practice. In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Is the MOU more than 5 years old? 
b.	   Does the MOU meet Federal legal requirements? 
c. 	  Does the MOU address cross-training with the fraud detection staff  
of the State Medicaid agency? 
d.	   Does the MOU address the Units responsibility to make program  
recommendations to the Medicaid agency and monitor actions  
taken by the Medicaid agency concerning those recommendations? 
11. 	The Unit director should exercise proper fiscal control over the 
Unit resources.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit director receive on a timely basis copies of all fiscal 
and administrative reports concerning Unit expenditures from the 
State parent agency? 
b.	   Does the Unit maintain an equipment inventory?  
c. 	  Does the Unit apply generally accepted accounting principles in its 
control of Unit funding? 
12. 	A Unit should maintain an annual training plan for all 
professional disciplines.  In meeting this standard, the following 
performance indicators will be considered:  
a. 	  Does the Unit have a training plan in place and funds available to 
fully implement the plan? 
b.	   Does the Unit have a minimum number of hours training 
requirement for each professional discipline, and does the staff 
comply with the requirement? 
c. 	  Are continuing education standards met for professional staff? 
d.	   Does the training undertaken by staff add to the mission of the 
Unit? 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   22 
   
   
APPENDIX B 
2012 Revised Performance Standards32   
1. 	A unit conforms with all applicable statutes, regulations, and 
policy directives, including:  
a. 	  Section 1903(q) of the Social Security Act, containing the basic 
requirements for operation of a MFCU; 
b.	   Regulations for operation of a MFCU contained in 42 CFR part 
1007; 
c. 	  Grant administration requirements at 45 CFR part 92 and Federal 
cost principles at 2 CFR part 225; 
d.	   OIG policy transmittals as maintained on the OIG Web site; and  
e. 	  Terms and conditions of the notice of the grant award. 
2. 	A Unit maintains reasonable staff levels and office locations in 
relation to the States Medicaid program expenditures and in 
accordance with staffing allocations approved in its budget.  
a. 	  The Unit employs the number of staff that is included in the Units 
budget estimate as approved by OIG. 
b. 	  The Unit employs a total number of professional staff that is 
commensurate with the States total Medicaid program  
expenditures and that enables the Unit to effectively investigate  
and prosecute (or refer for prosecution) an appropriate volume of 
case referrals and workload for both Medicaid fraud and patient 
abuse and neglect. 
c. 	  The Unit employs an appropriate mix and number of attorneys, 
auditors, investigators, and other professional staff that is both 
commensurate with the States total Medicaid program  
expenditures and that allows the Unit to effectively investigate and 
prosecute (or refer for prosecution) an appropriate volume of case 
referrals and workload for both Medicaid fraud and patient abuse 
and neglect. 
d. 	  The Unit employs a number of support staff in relation to its 
overall size that allows the Unit to operate effectively.  
e. 	  To the extent that a Unit maintains multiple office locations, such 
locations are distributed throughout the State, and are adequately 
 
32 77 Fed. Reg. 32645, June  1, 2012. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   23 
   
   
staffed, commensurate with the volume of case referrals and 
workload for each location. 
3. 	A Unit establishes written policies and procedures for its 
operations and ensures that staff are familiar with, and adhere to, 
policies and procedures.  
a. 	  The Unit has written guidelines or manuals that contain current 
policies and procedures, consistent with these performance 
standards, for the investigation and (for those Units with 
prosecutorial authority) prosecution of Medicaid fraud and patient 
abuse and neglect. 
b. 	  The Unit adheres to current policies and procedures in its 

operations. 

c. 	  Procedures include a process for referring cases, when appropriate, 
to Federal and State agencies. Referrals to State agencies, 
including the State Medicaid agency, should identify whether 
further investigation or other administrative action is warranted, 
such as the collection of overpayments or suspension of payments. 
d. 	  Written guidelines and manuals are readily available to all Unit 
staff, either online or in hard copy. 
e. 	  Policies and procedures address training standards for Unit 

employees. 

4. 	A Unit takes steps to maintain an adequate volume and quality of 
referrals from the State Medicaid agency and other sources. 
a. 	  The Unit takes steps, such as the development of operational 
protocols, to ensure that the State Medicaid agency, managed care 
organizations, and other agencies refer to the Unit all suspected 
provider fraud cases. Consistent with 42 CFR 1007.9(g), the Unit 
provides timely written notice to the State Medicaid agency when 
referred cases are accepted or declined for investigation.  
b. 	  The Unit provides periodic feedback to the State Medicaid agency 
and other referral sources on the adequacy of both the volume and 
quality of its referrals.  
c. 	  The Unit provides timely information to the State Medicaid or 
other agency when the Medicaid or other agency requests 
information on the status of MFCU investigations, including when 
the Medicaid agency requests quarterly certification pursuant to 
42 CFR 455.23(d)(3)(ii). 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   24 
   
   
d. 	  For those States in which the Unit has original jurisdiction to 
investigate or prosecute patient abuse and neglect cases, the Unit 
takes steps, such as the development of operational protocols, to 
ensure that pertinent agencies refer such cases to the Unit, 
consistent with patient confidentiality and consent.  Pertinent 
agencies vary by State but may include licensing and certification 
agencies, the State Long Term Care Ombudsman, and adult 
protective services offices. 
e. 	  The Unit provides timely information, when requested, to those 
agencies identified in (D) above regarding the status of referrals. 
f. 	  The Unit takes steps, through public outreach or other means, to 
encourage the public to refer cases to the Unit.  
5. 	A Unit takes steps to maintain a continuous case flow and to 
complete cases in an appropriate timeframe based on the 
complexity of the cases.  
a. 	  Each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
b. 	  Supervisors approve the opening and closing of all investigations 
and review the progress of cases and take action as necessary to 
ensure that each stage of an investigation and prosecution is 
completed in an appropriate timeframe. 
c. 	  Delays to investigations and prosecutions are limited to situations 
imposed by resource constraints or other exigencies. 
6. 	A Units case mix, as practicabl e, covers all significant provider 
types and includes a balance of fraud and, where appropriate, 
patient abuse and neglect cases.  
a. 	  The Unit seeks to have a mix of cases from all significant provider 
types in the State.  
b. 	  For those States that rely substantially on managed care entities for 
the provision of Medicaid services, the Unit includes a 
commensurate number of managed care cases in its mix of cases. 
c. 	  The Unit seeks to allocate resources among provider types based 
on levels of Medicaid expenditures or other risk factors.  Special 
Unit initiatives may focus on specific provider types. 
d. 	  As part of its case mix, the Unit maintains a balance of fraud and 
patient abuse and neglect cases for those States in which the Unit 
has original jurisdiction to investigate or prosecute patient abuse 
and neglect cases.  
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   25 
   
   
e. 	  As part of its case mix, the Unit seeks to maintain, consistent with 
its legal authorities, a balance of criminal and civil fraud cases. 
7. 	A Unit maintains case files in an effective manner and develops a 
case management system that allows efficient access to case 
information and other performance data. 
a. 	  Reviews by supervisors are conducted periodically, consistent with 
MFCU policies and procedures, and are noted in the case file.  
b. 	  Case files include all relevant facts and information and justify the 
opening and closing of the cases. 
c. 	  Significant documents, such as charging documents and settlement 
agreements, are included in the file.  
d. 	  Interview summaries are written promptly, as defined by the Units 
policies and procedures. 
e. 	  The Unit has an information management system that manages and 
tracks case information from initiation to resolution. 
f. 	  The Unit has an information management system that allows for 
the monitoring and reporting of case information, including the 
following: 
1. 	  The number of cases opened and closed and the reason that  
cases are closed. 
2. 	  The length of time taken to determine whether to open a 
case referred by the State Medicaid agency or other 
referring source. 
3. 	  The number, age, and types of cases in the Units 
inventory/docket. 
4. 	  The number of referrals received by the Unit and the 
number of referrals by the Unit to other agencies. 
5. 	  The dollar amount of overpayments identified. 
6. 	  The number of cases criminally prosecuted by the Unit or 
referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending 
prosecutions. 
7. 	  The number of criminal convictions and the number of civil 
judgments. 
8. 	  The dollar amount of fines, penalties, and restitution 
ordered in a criminal case and the dollar amount of 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   26 
   
   
recoveries and the types of relief obtained through civil 
judgments or prefiling settlements. 
8. 	A Unit cooperates with OIG and other Federal agencies in the 
investigation and prosecution of Medicaid and other health care 
fraud.  
a. 	  The Unit communicates on a regular basis with OIG and other 
Federal agencies investigating or prosecuting health care fraud in 
the State.  
b.	   The Unit cooperates and, as appropriate, coordinates with OIGs 
Office of Investigations and other Federal agencies on cases being 
pursued jointly, cases involving the same suspects or allegations, 
and cases that have been referred to the Unit by OIG or another 
Federal agency. 
c. 	  The Unit makes available, to the extent authorized by law and 
upon request by Federal investigators and prosecutors, all 
information in its possession concerning provider fraud or fraud in 
the administration of the Medicaid program. 
d.	   For cases that require the granting of extended jurisdiction to 
investigate Medicare or other Federal health care fraud, the Unit 
seeks permission from OIG or other relevant agencies under 
procedures as set by those agencies.  
e. 	  For cases that have civil fraud potential, the Unit investigates and 
prosecutes such cases under State authority or refers such cases to 
OIG or the U.S. Department of Justice. 
f. 	  The Unit transmits to OIG, for purposes of program exclusions 
under section 1128 of the Social Security Act, all pertinent 
information on MFCU convictions within 30 days of sentencing, 
including charging documents, plea agreements, and sentencing 
orders. 
g. 	  The Unit reports qualifying cases to the Healthcare Integrity & 
Protection Databank, the National Practitioner Data Bank, or 
successor data bases.  
9. 	 A Unit makes statutory or programmatic recommendations, when 
warranted, to the State government. 
a. 	  The Unit, when warranted and appropriate, makes statutory 
recommendations to the State legislature to improve the operation 
of the Unit, including amendments to the enforcement provisions 
of the State code. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   27 
   
   
b. 	  The Unit, when warranted and appropriate, makes other regulatory 
or administrative recommendations regarding program integrity 
issues to the State Medicaid agency and to other agencies 
responsible for Medicaid operations or funding.  The Unit monitors 
actions taken by the State legislature and the State Medicaid or 
other agencies in response to recommendations. 
10. 	A Unit periodically reviews  its Memorandum of Understanding 
(MOU) with the State Medicaid agency to ensure that it reflects 
current practice, policy, and legal requirements. 
a. 	  The MFCU documents that it has reviewed the MOU at least every 
5 years, and has renegotiated the MOU as necessary, to ensure that 
it reflects current practice, policy, and legal requirements. 
b. 	  The MOU meets current Federal legal requirements as contained in 
law or regulation, including 42 CFR 455.21, Cooperation with 
State Medicaid fraud control units, and 42 CFR 455.23, 
Suspension of payments in cases of fraud. 
c. 	  The MOU is consistent with current Federal and State policy, 
including any policies issued by OIG or the Centers for Medicare 
& Medicaid Services (CMS). 
d. 	  Consistent with Performance Standard 4, the MOU establishes a 
process to ensure the receipt of an adequate volume and quality of  
referrals to the Unit from the State Medicaid agency. 
e. 	  The MOU incorporates by reference the CMS Performance 
Standard for Referrals of Suspected Fraud from a State Agency to 
a Medicaid Fraud Control Unit. 
11. 	A Unit exercises proper fiscal  control over Unit resources.  
a. 	  The Unit promptly submits to OIG its preliminary budget 
estimates, proposed budget, and Federal financial expenditure 
reports. 
b.	   The Unit maintains an equipment inventory that is updated 

regularly to reflect all property under the Units control. 

c. 	  The Unit maintains an effective time and attendance system and 
personnel activity records. 
d.	   The Unit applies generally accepted accounting principles in its 
control of Unit funding. 
e. 	  The Unit employs a financial system in compliance with the 
standards for financial management systems contained in 
45 CFR 92.20. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   28 
   
   
12. 	A Unit conducts training that  aids in the mission of the Unit. 
a. 	  The Unit maintains a training plan for each professional discipline 
that includes an annual minimum number of training hours and that 
is at least as stringent as required for professional certification. 
b. 	  The Unit ensures that professional staff comply with their training 
plans and maintain records of their staffs compliance.  
c. 	  Professional certifications are maintained for all staff, including  
those that fulfill continuing education requirements.  
d. 	  The Unit participates in MFCU related training, including training 
offered by OIG and other MFCUs, as such training is available and 
as funding permits. 
e. 	  The Unit participates in cross training with the fraud detection staff  
of the State Medicaid agency. As part of such training, Unit staff 
provide training on the elements of successful fraud referrals and 
receive training on the role and responsibilities of the State 
Medicaid agency. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   29 
   
   
APPENDIX C 
Population and Sample Distribution of Case Files Open at Any  
Time During Fiscal Years (FY) 2010 Through 2012 
Population  Population of Case  Sample Case  Sample Case Files 
Data Element Description  
of Case Files   Files (Percentage)   Files   (Percentage)  
FraudCivil (Open)   6  3  3  3 
FraudCivil (Closed)   47  23.7  20  20 
FraudCriminal (Open)   39  19.7  18  18 
FraudCriminal (Closed)   32  16.2  14  14 
AbuseCivil (Open)   0  0  0  0 
AbuseCivil (Closed)   0  0  0  0 
AbuseCriminal (Open)   28  14.1  17  17 
AbuseCriminal (Closed)   29  14.6  17  17 
Patient Funds- Civil (Open)   0  0  0  0 
Patient Funds Civil (Closed)  0  0  0  0 
Patient Funds-Criminal (Open)   7  3.5  5  5 
Patient FundsCriminal (Closed)  10  5.1  6  6 
Total   198  100  100  100 
Source:  Office of  Inspector General analysis of  West Virginias Medicaid Fraud Control Unit Quarterly Statistical  Reports, 
FYs 20102012. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   30 
   
   
APPENDIX D 
Investigations Opened and Closed By Provider Category for 
Fiscal Years (FY) 2010 Through 2012 
Table D-1: Fraud Investigations  
Provider Category   FY 2010   FY 2011   FY 2012  
Facilities   Opened  Closed  Opened  Closed  Opened   Closed 
 Hospitals  0  1  0  0  0  0 
     Nursing Facilities   0  0  3  1  0  1 
     Other Long-Term Care   
0  0  1  0  1  1 
     Facilities  
     Substance Abuse Treatment     
0  0  0  0  0  0 
Centers  
     Other   2  0  2  1  0  1 
   Subtotal   2  1  6  2  1  3 
Practitioners   Opened  Closed  Opened  Closed  Opened   Closed 
     Doctors of Medicine or  
1  6  4  1  5  3 
     Osteopathy  
Dentists  1  0  0  0  1  1 
Podiatrists  0  0  0  1  0  0 
     Optometrists/Opticians  0  1  0  0  0  0 
     Counselors/Psychologists  0  0  0  0  0  0 
Chiropractors  0  0  0  0  0  0 
     Other   0  0  0  0  0  0 
   Subtotal   2  7  4  2  6  4 
Medical Support  Opened   Closed   Opened   Closed   Opened   Closed 
 Pharmacies  0  0  0  1  1  1 
Pharmaceutical 
10  10  18  15  7  10 
     Manufacturers  
     Durable Medical Equipment  
0  2  0  0  1  1 
     and/or Supplies 
     Laboratories  0  0  1  0  1  1 
     Transportation Services  1  0  0  1  1  4 
     Home Health Care Agencies   0  2  3  2  3  1 
     Home Health Care Aides   4  0  3  1  11  3 
     Nurses, Physician Assistants,  
Nurse Practitioners, Certified   1  1  0  0  0  1 
Nurse Aides 
Radiologists  0  0  0  0  0  0 
     Medical SupportOther   1  0  0  0  0  1 
   Subtotal   17  15  25  20  25  22 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   31 
   
   
 
 Table D-1 (Continued):  Fraud Investigations  
Program  Related   Opened  Closed  Opened  Closed  Opened   Closed 
     Managed Care    1  1  0  0  0  0 
Medicaid Program  
0  0  0  0  0  0 
Administration 
Billing Company   0  0  0  0  0  0 
     Other  0  0  0  0  0  0 
   Subtotal   1  1  0  0  0  0 
   Total Provider Categories   22  24  35  24  32  30 
Source:  Office of  Inspector General (OIG) analysis of Unit Annual Reports, FYs 20102012.  
Table D-2: Patient Abuse and Neglect Investigations  
Provider Category   FY 2010   FY 2011   FY 2012  
  Opened  Closed  Opened  Closed  Opened   Closed 
     Nursing Facility   2  0  1  1  1  1 
     Other Long-Term Care   1  0  0  0  1  0 
     Nurses/Physicians  
Assistant/Nurse  0  0  1  1  1  0 
Practitioner/  
     Certified Nurse Aides  0  0  1  0  0  1 
     Home Health Aides  7  4  3  11  7  7 
     Other  4  3  0  1  0  0 
   Total   14  7  6  14  10  9 
Source: OIG analysis of Unit Annual Reports, FYs 2010-2012. 
Table D-3: Patient Funds Investigations  
Provider Category   FY 2010   FY 2011   FY 2012  
  Opened  Closed  Opened  Closed  Opened   Closed 
     Non-Direct Care   0  0  1  2  0  0 
     Nurses/Physicians  
Assistant/Nurse  0  0  0  0  0  0 
Practitioner/  
     Certified Nurse Aides  0  0  0  0  0  0 
     Other  2  5  2  4  4  1 
Total   2   5   3   6   4   1  
Source: OIG analysis of Unit Annual Reports, FYs 2010-2012. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   32 
   
   
APPENDIX E 
Point Estimates and 95-Percent Confidence Intervals Based on  
Our Reviews of Case Files 
We calculated confidence intervals for key data points for the case file 
reviews. The sample sizes, point estimates, and 95-percent confidence 
intervals are given for the each of the following:  
Table E-1:  Confidence Intervals for Case File Review  Data  
Sample 
Data Element Description   Point Estimate   95-Percent Confidence Interval  
Size 
Cases opened more than 60 days of 
76  69.7%   61.9%76.6%  
receiving the respective referrals 
Case files missing supervisory approval 
81  19.8%   14.3%26.7%  
for the opening of investigations 
Case files missing documented 
supervisory approval for the closing of  52  26.9%   19.2%36.4%  
investigations 
Abuse and neglect case files missing 
documented periodic supervisory  reviews   44  72.7%   62.4%81.1%  
(30-day case review)  
Fraud case files missing documented 
periodic supervisory  reviews   35  34.3%   24.0%46.2%  
(90-day case review)  
Case files missing documented periodic 
79  55.7%   47.8%63.3%  
supervisory reviews (any case)  
Source:  Office of  Inspector General analysis of  West Virginias Medicaid Fraud Control Unit case files, 2013. 
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   33 
   
   
APPENDIX F 
Medicaid Fraud Control Unit Referrals by Provider Category  
for Fiscal Years (FY) 2010 Through 2012 
FY 2010   FY 2011   FY 2012  
Abuse &   Patient  Abuse &   Patient  Abuse &   Patient 
Referral Source   Fraud   Fraud   Fraud  
Neglect   Funds   Neglect   Funds   Neglect   Funds  
Medicaid Agency  
(Bureau for Medical 
Services, Office of 
1  1  0  10  3  4  33  10  21 
Quality and 
Program Integrity)   
PI/SURS1  
Medicaid Agency  
20  4  2  18  12  7  4  0  2 
Other  
State Survey & 
4  93  9  3  92  8  6  52  13 
Certification 
Other State 
11  8  3  10  2  3  0  0  0 
Agencies 
Licensing Board  1  0  0  0  0  0  1  0  0 
Law Enforcement  0  0  1  1  1  1  1  1  0 
Office of Inspector 
2  0  0  1  0  0  3  1  0 
General 
Prosecutors  0  0  0  0  0  0  0  0  0 
Providers  2  0  0  6  1  0  12  4  2 
Provider 
0  0  0  0  0  0  0  0  0 
Associations  
Private Health 
0  0  0  0  0  0  0  0  0 
Insurer 
Long Term Care 
0  0  0  0  0  0  0  0  0 
Ombudsman  
Adult Protective 
0  5  0  3  10  6  0  5  0 
Services  
Private Citizens  19  4  4  15  5  1  22  1  2 
MFCU Hotline  0  0  1  0  0  0  0  1  0 
Other   24  12  1  29  10  3  29  10  1 
   Total   84  127  21  96  136  33  111  85  21 
   Annual Total  232  265  237 
1 "PI" = "program integrity"; "SURS" = "Surveillance and Utilization Review Subsystem." 

Source:  Office of  Inspector General analysis of  West Virginias Medicaid Fraud Control Unit Quarterly Statistical  Reports, FYs 2010-2012. 

West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   34 
   
   
APPENDIX G 
Unit Comments   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   35 
   
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   36 
   
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   37 
   
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   38 
   
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   39 
   
   
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   40 
  The West Virginia Medicaid Fraud Control  Unit is dedicated to protecting West Virginia's 
vulnerable citizens and the integrity of its healthcare programs, and is committed to continuous 
improvement and exceeding the established Perf01mance  Standards. We look forward to the 
challenges ahead. Please let us know if you require further inf=ation or have any additional 
questions. 
Sincerely, 
Trina C. Crowder, Director 
West Virginia Medicaid Fraud Control Unit 
Office of Inspector General 
West Virginia Department of Health and Human Resources 
7 
West Virginia State Medicaid Fraud Control Unit; 2013 Onsite Review (OEI-07-13-00080)  41   
   
ACKNOWLEDGEMENTS 
This report was prepared under the direction of Brian T. Pattison, Regional 
Inspector General for Evaluation and Inspections in the Kansas City 
regional office.   
Brian T.  Whitley served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff who conducted the study include 
Thomas Brannon, Michael J. Brown, and Jordan R. Clementi.  Office of 
Investigations staff who conducted the study include Shawn McAleer.  
Central office staff who contributed include Christine Moritz and 
Sherri Weinstein.  
West Virginia State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00080)                                   42 
   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.