Department of Health and Human Services 

OFFICE OF 

  
INSPECTOR GENERAL 

 
 
 
 
 
 
 
N Y S M
EW  ORK  TATE  EDICAID 

 
F  C U :
  
RAUD  ONTROL  NIT  
 
 2011 O R
  NSITE  EVIEW
 
   
 
Stuart Wright 
  
Deputy Inspector General for 

Evaluation and Inspections 

 
June 2012 

OEI-02-11-00440
   
EXECUTIVE SUMMARY:  NEW YORK STATE MEDICAID FRAUD CONTROL UNIT, 
2011 ONSITE REVIEW  (OEI-02-11-00040) 
 
WHY WE DID THIS STUDY 
 
The Office of Inspector General is responsible for overseeing the activities of all Medicaid Fraud 
Control Units (MFCU or Unit). As part of this oversight, the Office of Evaluation and 
Inspections conducts periodic reviews of all Units and prepares public reports based on these 
reviews. The reviews describe the Units caseloads; assess performance in accordance with the 
12 MFCU performance standards, identifying any opportunities for improvement; identify any 
instances of noncompliance with laws, regulations, or policy transmittals; and highlight any 
noteworthy practices. 
 
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) structured 
interviews with key stakeholders; (3) a survey of Unit staff; (4) structured interviews with the 
Units management; (5) an onsite review of case files; (6) an onsite review of financial 
documentation; and (7) an onsite review of Unit operations. 
 
WHAT WE FOUND 
 
From fiscal years 2008 to 2010, the New York Unit filed criminal charges against more than 
400 defendants, obtained over 400 convictions, and was awarded more than $750 million in 
recoveries. Although the number of referrals to the Unit increased during this time, the number 
of cases that the Unit opened and closed decreased.  Additionally, the Unit did not establish 
annual training plans for each of the three professional disciplinesi.e., for auditors, 
investigators, or attorneysand provided limited training opportunities to staff.  The Unit also 
lacked policies and procedures to reflect many of its current practices, and its case files lacked 
consistency and uniform supervisory reviews.  Finally, the Unit lacked a number of internal 
controls. At the same time, our review found no evidence of significant noncompliance with 
applicable laws, regulations, or policy transmittals.  Further, Unit managers, staff, and 
stakeholders cited a number of the Units noteworthy practices, including its approach to patient 
abuse and neglect cases, its list of ongoing investigations (created to avoid conflicts among 
investigating agencies), and its use of technology.   
 
WHAT WE RECOMMEND 
 
We recommend that the New York MFCU: (1) seek to expand staff sizes to reflect the number 
of staff approved in the Units budget; (2) establish annual training plans and increase the 
number of training opportunities available to staff; (3) ensure that its memorandum of 
understanding, its policies, and its procedures reflect current practices; (4) ensure that its case 
files are maintained with greater consistency and reviewed more frequently; and (5) establish 
written policies and procedures for certain internal controls.  The New York Unit concurred with 
all five of our recommendations.   
 
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

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

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

Findings........................................................................................................6 

From fiscal years 2008 to 2010, the New York Unit filed     

criminal charges against more than 400 defendants, obtained    

over 400 convictions, and was awarded more than $750 million    

in recoveries.....................................................................................6 

Although the number of referrals to the Unit increased, the 
number of cases the Unit opened and closed decreased ..................6 

The Unit did not establish annual training plans and 
provided limited training opportunities to staff ...............................8 

The Unit lacked policies and procedures to reflect many of its 
current practices...............................................................................9 

Case files lacked consistency and uniform supervisory         
reviews ...........................................................................................10 

Although no major concerns were identified in the Units    

financial oversight, the Unit lacked a number of internal      

controls...........................................................................................11 
 
Managers, staff, and stakeholders cited a number of        
noteworthy practices ......................................................................12 

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

Unit Comments.............................................................................17 

Appendixes ................................................................................................18 

A: Performance Standards for Medicaid Fraud Control Units .....18 

B: Investigations Opened and Closed by Provider Category,
     
Fiscal Years 2008 to 2010 ..............................................................22 

C: Confidence Interval Estimates Based on Case File Review  

Data................................................................................................24 
 
D: Unit Comments ........................................................................25 

Acknowledgments......................................................................................35 
  
   
OBJECTIVES 
To conduct an onsite review of the New York 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 Department of Health and Human 
Services (HHS) determines that operation of a Unit would not be 
cost-effective because minimal Medicaid fraud exists in that State and that 
the State has other adequate safeguards to protect Medicaid beneficiaries 
from abuse and neglect.2  Currently, 49 States and the District of Columbia 
have created such Units.3  In fiscal year (FY) 2011, HHS and the States 
spent a combined total of $208.6 million on these Units.  Of this amount, 
$40.5 million, or 19.4 percent of the total, was spent on the New York 
Unit.4  
Each Unit must employ sufficient staff consisting of at least an 
investigator, an auditor, and an attorney to carry out its duties and 
responsibilities in an effective and efficient manner.5   The staff review 
complaints provided by the State Medicaid agency and other sources and 
determine their potential for criminal prosecution.  Collectively, in 
FY 2011 the 50 Units obtained 1,230 convictions as well as 906 civil 
settlements or judgments.6   That year, the Units reported recoveries of 
more than $1.7 billion.7  
Units are required to have either Statewide authority to prosecute cases or 
formal procedures to refer suspected criminal violations to an office with 
 
1 
Social Security Act  1903(q). 

2 
 Social Security Act  1902(a)(61) and 1903(q)(3).  Regulations in 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.  For the purposes of this study, 

misappropriation of patient funds is combined with patient abuse and neglect. 

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.  For the purposes of this 

review, we refer to the District of Columbia as a State.  

4
 Office of Inspector General (OIG) analysis of Office of Management and Budget Forms 

SF-269 for FY 2011. 

5 
 Social Security Act  1903(q)(6); 42 CFR  1007.13. 

6  OIG, State Medicaid Fraud Control Units Fiscal Year 2011 Grant Expenditures and 

Statistics. Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2011.asp on June 14, 2011. 

7  Ibid. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               1  
     
   
such authority.8  In 43 States, the Units are located within Offices of State  
Attorneys General; in the remaining 7 States, the Units are located in other  
State agencies and refer cases to other offices with prosecutorial 
authority.9  Additionally, each Unit must be a single identifiable entity of 
State government, distinct from the single State Medicaid agency, and 
each Unit must develop a formal agreement, e.g., a memorandum of 
understanding (MOU), that describes the Units relationship with that 
agency.10  
Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority both to annually 
certify the Units and to administer grant awards to reimburse States for a 
percentage of their costs in operating a certified Unit.11   All States 
currently operating Units are reimbursed by the Federal Government on a 
75-percent matching basis, with the States required to contribute the 
remaining 25 percent.12  In order to receive Federal reimbursement, each 
Unit must submit an initial application to OIG.13  OIG reviews the 
application and notifies the Unit if the application is approved and the Unit 
is certified. Approval and certification is for a 1-year period; the Unit 
must be recertified each year thereafter.14    
Under the Medicaid statute, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.15   To  
clarify the criteria that OIG applies in assessing whether a Unit is 
effectively carrying out these functions and meeting program  
requirements, OIG developed and issued 12 performance standards.16   
Examples include maintaining an adequate caseload through referrals from 
several sources, maintaining an annual training plan for all three of the 
professional disciplines (i.e., for auditors, investigators, and attorneys), 
 
8 
9 Social Security Act  1903(q)(1). 
 In most States, the Unit shares 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 establish an Office of Medicaid Inspector General that conducts and 
coordinates fraud, waste, and abuse activities for the State agency.  
10
 Social Security Act  1903(q)(2); 42 CFR  1007.9(d).  
11
 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 the Federal  
Financial Participation (FFP).
12
 Social Security Act  1903(a)(6).  
13
 42 CFR  1007.15(a). 
14  42 CFR  1007.15(b) and (c). 
15  Social Security Act  1902(a)(61). 
16
 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-
control-units-mfcu/files/Performance%20Standards.pdf on November 22, 2011.  OIG revised 
these standards on June 1, 2012 (see 77 Fed. Reg. 77106).  The standards referred to 
throughout this report are those from 1994, which were in effect at the time of our review. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               2  
     
   
and establishing policy and procedure manuals to reflect the Units 
operations. See Appendix A for a complete list of these performance 
standards. 
New  York State MFCU  
The New York Unit is located within the Office of the New York State 
Attorney General and has the authority to prosecute Medicaid cases.  At 
the time of our review, it had 283 employees.  The Unit is composed of 
seven field offices located around the State.  Although most of its staff 
work on Medicaid fraud cases, the Unit also includes a Patient Protection 
Section, which focuses exclusively on the investigation and prosecution of 
patient abuse and neglect cases.  The Unit also includes a Civil 
Enforcement Division, which handles complex civil fraud investigations, 
including qui tam (whistleblower) actions.   
The Unit receives referrals of fraud, abuse, or neglect primarily from the 
State Medicaid Agency, which includes the Office of the Medicaid 
Inspector General. Other sources of referrals include law enforcement 
agencies, the State Long Term Care Ombudsman, and other State 
agencies. From FYs 2008 to 2010, the Unit received an average of 
879 referrals each year. 
When the Unit receives a referral, it makes a determination as to whether 
it should be opened as a criminal or civil case, or whether it should be 
referred to another agency.  In addition to receiving referrals, the Unit may 
generate its own cases. Once a case is opened, the Unit may close it 
through criminal prosecution, civil action, or administrative action.  The 
Unit may also close a case if there is insufficient evidence or by referring 
it to another agency.  
Previous Review  
In 2005, OIG conducted an onsite review of the New York Unit.  Based on 
the findings in that report, OIG recommended that the Unit develop 
internal policies and procedures for conducting undercover investigations, 
ensure that Unit equipment is not used by non-Unit staff to conduct 
non-Medicaid related activities, reinstitute the annual training conferences  
for its staff, and provide specialized training to investigators in its Patient 
Protection Unit.  The report also noted that the Unit should consider 
recruiting and retaining more investigative staff with medical/technical 
expertise. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               3  
     
   
METHODOLOGY 
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) structured interviews with key 
stakeholders; (3) a survey of Unit staff; (4) structured interviews with the 
Units management; (5) an onsite review of case files; (6) an onsite review 
of financial documentation; and (7) an onsite review of Unit operations.  
We analyzed data from all seven sources to describe the caseload and 
assess the performance of the Unit, identifying any opportunities for 
improvement.  We also analyzed the data to identify any instances in 
which the Unit did not fully meet the performance standards or was not 
operating in accordance with laws, regulations, or policy transmittals.17   
Lastly, we identified the  Units noteworthy practices. 
Data Collection and Analysis 
Review of Unit documentation.  We requested and reviewed policies and 
procedures and documentation on the Units operations, staffing, and 
caseload, including its annual reports, quarterly statistical reports, and 
responses to recertification questionnaires.  We also requested and 
reviewed the Units data describing how it detects, investigates, and 
prosecutes Medicaid cases. Data collected included information such as 
the number of referrals received by the Unit and the number of 
investigations opened and closed. We requested and reviewed these data 
for the 3-year period of FYs 2008 to 2010.  
Interviews with key stakeholders. We conducted structured interviews 
with key stakeholders who were familiar with the operations of the Unit.  
Specifically, we interviewed the Deputy Medicaid Inspector General in the 
State Medicaid Agency, an official in the U.S. Attorneys office, and the 
Special Agent in Charge for OIGs New York region. 
Survey of Unit staff.  We conducted an electronic survey of nonmanagerial 
Unit staff. In total, we sent the survey to a simple random sample of 80 of 
266 nonmanagerial staff.  We received responses from 76 of them, a 
95 percent response rate.18  Our questions focused on opportunities for 
improvement and noteworthy practices of the Unit.  The survey also 
sought information about the Units compliance with applicable laws and 
regulations. 
 
17
 All relevant regulations, statutes, and policy transmittals are available online at 

http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.

18
 At the time of our review, there were 283 staff; we sent surveys to 80 nonmanagerial staff. 

 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               4  
     
   
Interviews with Unit management. We conducted onsite and 
videoconference interviews with 17 Unit managers, including the Director 
and Deputy Director of the Unit, the Regional Office Directors, and the 
supervisors of the three professional disciplines.19  We asked these 
managers to provide us with additional information needed to better 
understand the Units operations, as well as to identify opportunities for 
improvement and noteworthy practices.  We used the information obtained 
from stakeholders and nonmanagerial staff to develop questions for the 
onsite interviews with Unit management. 
Onsite review of case files.  We selected a simple random sample of 
94 case files from the Units 1,887 cases that were open at some point 
during FYs 2008 to 2010.  We reviewed the 94 sampled case files and the 
Units processes for monitoring the status and outcomes of cases.   
Onsite review of financial documentation. We reviewed certain financial 
documents from the Unit, such as the Units equipment inventory and 
purchase records, to determine compliance with applicable laws and 
regulations, as well as to determine whether additional internal controls 
were needed. 
Onsite review of Unit operations.  While onsite, we reviewed the Units 
operations, including its process for receiving referrals, its electronic case 
management system, its method for case file storage and security, and its 
general operations. 
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.  
 
19 
 We interviewed all 11 of the Units managerial staff and 6 of the Units 24 supervisors.  
These 17 Unit managers and supervisors will hereinafter be referred to as managers. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               5  
     
   
FINDINGS 
From FYs 2008 to 2010, the New York Unit filed 
criminal charges against more than 400 defendants, 
obtained over 400 convictions, and was awarded more 
than $750 million in recoveries 
From FYs 2008 to 2010, the Unit filed criminal charges against 
452 defendants, of which 332 were charged with provider fraud and 
120 were charged with patient abuse and neglect.  The Unit also obtained 
423 convictions during this 3-year period.20  Further, it obtained monetary 
settlements and court orders requiring the payment of $753.9 million, 
including $29.5 million in criminal restitution.   
Additionally, as part of its efforts against patient abuse and neglect, the 
Unit used hidden cameras to uncover and deter the criminal abuse and 
neglect of nursing home residents.  In 2010, for example, the Unit reported 
that 22 health care workers from 2 nursing homes were charged using 
evidence from hidden camera investigations and 10 convictions were 
obtained in these and prior hidden camera cases. 
Although the number of referrals to the Unit increased, 
the number of cases the Unit opened and closed 
decreased 
According to the performance standards, the Unit should maintain an 
adequate workload through referrals from the single State agency and 
other sources. The Unit should also have a continuous case flow.  As 
noted earlier, the Unit receives referrals from the State Medicaid Agency 
which includes the Office of Medicaid Inspector General as well as a 
variety of other sources, such as law enforcement agencies, the State Long  
Term Care Ombudsman, and other State agencies.  From FYs 2008 to 
2010, the number of referrals received by the Unit increased by 
22 percentfrom 770 to 940.  (See Table 1.) 
 
20
 These 423 convictions are not necessarily derived from the 452 charges of criminal fraud 
filed during the same period.  Some of these convictions  may have derived from criminal 
charges that occurred prior to the 3-year period.  Similarly, not all of the criminal charges 
from this 3-year period may have resulted in convictions during this period.  
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               6  
     
   
 
Table 1: Unit Referrals from FYs 2008 to 2010, by  Type  
Type of Investigation   FY 2008   FY 2009   FY 2010  
Fraud  352  446  470 
Patient Abuse and Neglect  418  481  470 
Total    770  927  940 
 
. 
Source:  OIG analysis of New York MFCU data, 2011 
 
When a referral is received, the Unit makes a determination as to whether  
it should be opened as a criminal or civil case, or whether it should be 
referred to another agency.21  Over the past 3 years, the number of cases 
the Unit opened decreased by 25 percent. In FY 2008, the Unit opened 
421 cases, compared to 316 in FY 2010.  (See Table 2.) 
 
Table 2: Cases Opened from FYs 2008 to 2010, by  Type*  
Type of Investigation   FY 2008   FY 2009   FY 2010  
Fraud  376  342  279 
Patient Abuse and Neglect  45  63  37 
Total    421  405  316 
*Includes only new cases opened during the FY.   
. 
 Source:  OIG analysis of New York MFCU data, 2011 
 
Once a case is opened, the Unit may close it through criminal prosecution, 
civil action, or administrative action.  The Unit may also close a case if 
there is insufficient evidence or by referring it to another agency.  Since 
FY 2008, the number of cases closed by the Unit decreased by 20 percent.  
In FY 2008, the Unit closed 364 cases, compared to 291 in FY 2010.  (See 
Table 3.) See Appendix B for information about the Units cases by 
provider category. 
 
Table 3: Cases Closed from FYs 2008 to 2010, by  Type  
Type of Investigation   FY 2008   FY 2009   FY 2010  
Fraud  311  288  244 
Patient Abuse and Neglect  53  49  47 
Total    364  337  291 
 
. 
 Source:  OIG analysis of New York MFCU data, 2011 
 
21 
 When the Unit encounters an issue outside of its regulated activities, it makes referrals to 
other agencies.  The Unit most commonly sent referrals to the State Medicaid Agency, other 
State agencies, or private health insurers.  
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               7  
     
   
Several managers and staff attributed the decreases in their overall 
caseload to a decrease in the Units staff and funding during this 3-year 
period. According to the performance standards, the Unit should maintain 
staff levels in accordance with staffing allocations approved in its budget.  
As a part of its oversight role, OIG approves the number of staff requested 
by the Unit in its annual budget.22  At the time of our review, the Unit 
employed 283 staff membersa 16 percent decline from FY 2008 when  
the Unit employed 336 staff members.  Additionally, the Units staff 
levels were significantly below the number of staff that the Unit requested  
and OIG approved. For example, in FY 2010, the Unit employed 306 staff 
members, even though the Unit requested and OIG approved funding for 
380 positions. 
Several managers attributed the decline in staff levels to State budget 
constraints and acknowledged the effect this has had on the Unit.  
According to one manager, There are cases we probably should do but 
cant because we dont have the manpower; we have to refer them back.  
In addition to the decline in the Units staffing, the Unit has also seen a 
decline in its funding from the State, which has affected the Units total 
annual expenditures. For example, from FYs 2009 to 2010, the Units 
expenditures fell by18 percent, dropping from $49.6 million to  
$40.5 million.   
The Unit did not establish annual training plans and 
provided limited training opportunities to staff 
According to the performance standards, the Unit should establish annual 
training plans for each of the three professional disciplines.  The training 
provided under these plans should aid the mission of the Unit.  Managers 
acknowledged that the Unit did not have annual training plans for any of 
these disciplines; however, several noted that doing so would be useful for 
the Unit.23   As one manager noted, No question it would be helpful...  It 
would be good to expand [staff] knowledge. 
Several managers also stated that few training opportunities have been 
available for staff in recent years.  Almost half of the Units staff surveyed 
reported that there was a need for additional training to improve the 
 
22
 The Units are reimbursed by the Federal Government at a 75-percent matching rate.  
23
  Although we reviewed training records, we did not evaluate the staffs professional 
qualifications.  Rather, we applied the performance standards to evaluate whether the Unit 
maintained a formal training plan for each professional discipline, as well as training 
opportunities specific to MFCU operations.  We recognize that attorneys, investigators, and 
auditors receive professional and law enforcement training, and that the lack of an annual 
training plan does not necessarily mean that professional staff are unqualified. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               8  
     
   
overall management, operations, or performance of the Unit.  For 
example, prior to 2008, the Unit held separate training conferences for 
each of the three disciplines; however, over the last 4 years, the Unit has 
not held such trainings. Additionally, prior to 2003, the Unit held regular 
multidisciplinary training conferences, which brought together staff of all 
disciplines from across the State.  Unit managers attributed the lack of 
such training to State budget restrictions, rather than a lack of interest by 
the Unit.  
Many staff and managers called for the reinstatement of annual training 
conferences and other training opportunities.  As one manager noted, We 
have experienced staff, but we are also consistently confronted with new 
and novel areas. Several managers and numerous staff stated that the 
lack of training from FYs 2008 to 2010 presented a significant morale 
problem for staff and also contributed to difficulties in retaining staff.  
Managers anticipated that additional training will be offered in the 
upcoming years; one manager noted that training is a priority for the 
present State Attorney Generals Office. 
The Unit lacked policies and procedures to reflect 
many of its current practices 
According to the performance standards, the Unit should establish policies 
and procedures for its operations. These policies and procedures should 
reflect current practices within the Unit.  At the time of our review, the 
Unit did not have an MOU with the State Medicaid Agency that reflected 
key legislative changes, including the June 2006 establishment of the 
Office of the Medicaid Inspector General.  The Unit also lacked updated 
procedures manuals that clearly describe staff roles and responsibilities for 
each of the three professional disciplines.  In addition, it had no policies 
governing the maintenance of case files. 
MOU.  According to the performance standards, the Unit should 
periodically review its MOU with the State agency and seek amendments 
as necessary to ensure it reflects current law and practice.  However, the 
Units MOU was last updated in 2005 and did not include any reference to 
the Office of the Medicaid Inspector General, nor did it reflect the 
enactment of the States false claims act.  Although the Unit and the State 
Medicaid Agency have worked on amending the MOU, one manager 
stated that they have not been able to complete negotiations because of 
leadership changesin the Unit, the Attorney Generals Office, and the 
State Medicaid Agency, including the Office of the Medicaid Inspector 
Generalthat occurred during the period of review.  
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               9  
     
   
Procedures Manuals.  The performance standards state that the Unit 
should establish policies and procedures for its operations.  However, the 
Unit did not have a procedure manual for its auditors and its manuals for 
attorneys and investigators were out of date; investigator manuals were 
more than 7 years old and attorney manuals were more than 10 years old.  
Because of their age, these manuals lacked information about key changes 
to the Units operations, such as the Units increased reliance on electronic 
data management.  Managers cited the lack of updated manuals and 
acknowledged the need to update them. 
Several managers emphasized the importance of having current policies 
and procedure manuals and noted their value when experienced managers 
or staff retire or leave the Unit. In addition, one staff member expressed 
what it was like to be a new employee: I know that I felt absolutely 
clueless about any policy and procedures for quite some time, and still run 
into situations where I [am] expected to know something but have not 
been told the way things normally work. 
Case File Policies.  The Unit did not have written policies governing the 
maintenance of case files.  Several staff acknowledged the need for written  
policies or guidelines governing case files.  As discussed below, variation 
in how the Unit maintains its case files further demonstrates the need for 
such policies. 
Case files lacked consistency and uniform 
supervisory reviews  
According to the performance standards, the Unit should complete cases 
within a reasonable timeframe.  As a part of this effort, supervisors should 
approve the opening and closing of cases and note any supervisory case 
reviews in the case file. The Units case files, however, had inconsistent 
documentation of both the opening and closing of cases and supervisory 
reviews. 
Most notably, case files did not always contain documentation on the 
opening or closing of the case. Specifically, 10 percent of all case files 
were missing any form of an opening memorandum, and 7 percent of the 
closed case files did not include a closing memorandum detailing the case 
closure. In addition, supervisory reviews were not consistently noted in 
the case files.  In fact, almost half of the case files (48 percent) did not 
include any documentation indicating at least one supervisory review 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               10  
     
   
between the opening and closing of the case.24  See Appendix C for 
confidence intervals. 
When asked how to improve the Units overall management, operations, 
and performance, a number of staff called for increased case reviews or 
improved case management.  One staff member noted that having case 
reviews more frequently would help keep all parties involved in a case on 
the same track and informed.  [A] case that isnt moving quickly can be 
forgotten and these reviews get the parties thinking about it again. 
Managers indicated that although they periodically review cases, no 
policies or guidelines currently exist governing their review.  Managers 
acknowledged that the frequency of such reviews has historically been left 
to the discretion of relevant managers, and that this is an area warranting 
formal policy. 
Finally, our review of the Units case files uncovered one instance of the 
Unit pursuing a case that did not involve allegations of fraud in the 
administration of the Medicaid program, in the provision of Medicaid 
services, or in the activities of Medicaid providers.  To receive Federal 
funding, fraud investigations must involve one of these three activities.25   
The Unit is working with OIG to repay the grant for the time spent on the 
case. 
Although no major concerns were identified in the 
Units financial oversight, the Unit lacked a number of
internal controls 
According to the performance standards, the Unit should exercise proper 
fiscal control over its resources.  Although we identified no major 
concerns, our review of the Units financial systems identified a lack of  
internal controls over purchase cards, reconciliation of accounting records, 
and vehicle sale and transfer.  Within each of these areas, the Unit lacked 
certain policies and procedures necessary to mitigate the risk of error or 
fraud.  
Notably, the Unit lacked internal controls over the authorization and 
payment of purchase cards.  The same staff member was responsible for 
authorizing purchase card accounts, approving purchase card 
expenditures, directly receiving purchase card statements, and making 
 
24
 Unit managers stated that a lack of documentation of supervisory  review in case files does 
not necessarily indicate that the review did not take place.  According to these managers, all 
major events in a case are subject to supervisory approval.  They considered the lack of 
documentation to be an issue of case file management. 
25
 Social Security Act  1903(q)(3); 42 CFR  1007.11(a). 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               11  
     
   
purchase card payments.  The Unit did not have any policies and 
procedures to segregate the authorization, custody, and recordkeeping 
functions for purchase cards. 
Additionally, the Unit lacked written policies and procedures to formalize 
its accounting process.  Due to limitations in the States accounting 
software, the Units financial staff must manually enter data into a 
separate accounting subsystem.26  This accounting subsystem is used to 
track Federal funds and to report expenditures on OIGs Financial Status 
Report. At the time of our onsite review, staff were unable to provide 
sufficient documentation for several expenditures in the accounting 
subsystem.  
Finally, prior to our onsite review, the Unit identified and alerted OIG to a  
lack of internal controls over the sale and transfer of vehicles.  During the 
period under review, Unit vehicles that were no longer needed were 
transferred to the New York State Department of General Services for 
auction or transfer to another State agency, and the Unit did not receive the 
proceeds of the sale or transfer.27   The Unit lacked written policies and 
procedures for determining and documenting the value of vehicles and for 
appropriately accounting for their sale or transfer to ensure that the 
Federal Government was reimbursed accordingly.  Since identifying the 
issue, the Unit has worked with OIG to develop an adequate model for 
determining the value of vehicles and has reimbursed the Federal 
Government accordingly.  
Managers, staff, and stakeholders cited a number of
noteworthy practices  
Managers, staff, and stakeholders familiar with the Units operations 
highlighted a number of noteworthy practices.  These practices include its 
approach to patient abuse and neglect cases, its list of ongoing 
investigations (created to avoid conflicts among investigating agencies), 
and its use of technology. 
The Units approach to patient abuse and neglect cases.  Virtually all of  
the Units stakeholders and numerous managers and staff cited the Units 
approach to patient abuse and neglect cases as a noteworthy practice.  
Managers, staff, and stakeholders highlighted the establishment of a 
 
26 
 We learned during our discussions with Unit accounting staff that the State of New York is 
developing new accounting software that may address some of our concerns. 
27
 Prior to our review, the Unit was decommissioning vehicles without determining the fair 
market value, which is necessary to ensure that any Federal reimbursement is identified and 
returned. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               12  
     
   
separate Patient Protection Unit as important to the Units success in this 
area. One Unit manager noted that when the Unit separated patient abuse 
and neglect cases into a distinct unit, staff no longer felt pressured into 
prioritizing multimillion-dollar fraud cases over these cases.  This resulted 
in additional resources and expertise being devoted to patient abuse and 
neglect cases. 
Multiple parties cited other practices related to patient abuse and neglect 
cases, including the use of hidden cameras in nursing homes and the use of 
nurse analysts employed by the Unit.  Many staff surveyed mentioned the 
use of hidden cameras, which the Unit installs in nursing home residents 
rooms with the consent of the residents families.  Specifically, one staff  
member noted, I believe that we are one of the first Units to implement 
the use of hidden cameras in nursing facilities.  This has proven very 
effective in attempts to curtail neglect, abuse, and mistreatment of  
residents. One manager agreed, attributing a drop in neglect cases to a 
real change in the behavior of some  of the nursing homes [as a result of 
the hidden camera cases].  Unit managers also cited the use of nurse 
analysts as important to the success of such cases.  In the Unit, nurse 
analysts provide medical expertise to the case, including reviewing hidden 
camera data.  According to one manager, All of our medical analysts are 
nurses and worked with nursing homes before they came here.  Having 
that knowledge in-house is key. 
The Units list of ongoing investigations.  To avoid conflicts among 
investigating agencies, the Unit created a list of names associated with 
ongoing investigations. The Unit shares this list with the Office of the 
Medicaid Inspector General and helps facilitate communication about 
ongoing investigations. As part of its investigations, the Office of the 
Medicaid Inspector General checks this list and contacts the Unit to obtain 
information about investigation status.  Unit managers believe that the list 
reduces the likelihood that an ongoing  investigation will be compromised 
by another investigation.  One manager also noted that this list will be  
helpful in instituting the new payment suspension rules mandated by the 
Affordable Care Act, which permit the State Medicaid agency to suspend  
payment in cases of suspected fraud identified by the Unit or by the Office 
of the Medicaid Inspector General.28  
The Units use of technology.  Many managers, staff, and stakeholders also 
highlighted the Units innovative use of technology.  Specifically, the Unit 
established a group of staff called the Electronic Investigative Support 
 
28
 The Patient Protection and Affordable Care Act, P. L. 111-148,  6402(h)(2), amending 
Social Security Act  1903(i)(2) and implemented in 42 CFR  455.23. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               13  
     
   
Group that is dedicated to providing technical assistance throughout a 
case. As one staff member noted, The Unit added specialists, including 
electronic data [and] systems technicians, computer forensic specialists, 
and clinical specialists.  This team approach is essential to the success of 
the Unit. Another added, [The Electronic Investigative Support Group] 
created a discovery team along with procedures that our attorneys follow 
when collecting electronically stored information.  It has worked very well 
and has saved our unit a lot of time and money.  Others highlighted the 
groups expertise in assisting in undercover operations, such as the Units 
hidden camera cases, discussed above.  
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               14  
     
   
CONCLUSION AND RECOMMENDATIONS 
From FYs 2008 to 2010, the Unit filed criminal charges against more 
than 400 defendants, obtained over 400 convictions, and was awarded 
more than $750 million in recoveries.  Although the number of referrals to 
the Unit increased during this time, the number of cases that the Unit 
opened and closed decreased. Additionally, the Unit did not establish 
annual training plans for each of the three professional disciplines and 
provided limited training opportunities to staff.  The Unit also lacked an 
up-to-date MOU with the State Medicaid agency, as well as policies and 
procedures to reflect many of its current practices.  Further, its case files 
lacked consistency and uniform supervisory reviews.  Finally, the Unit 
lacked certain internal controls with respect to purchase cards, 
reconciliation of accounting records, and vehicle sale and transfer.  At the 
same time, our review found no evidence of significant noncompliance 
with applicable laws, regulations, or policy transmittals.  In addition, Unit 
managers, staff, and stakeholders cited a number of the Units noteworthy 
practices, including its approach to patient abuse and neglect cases, its list 
of ongoing investigations (created to avoid conflicts among investigating 
agencies), and its use of technology.    
Based on these findings, we recommend that the New York MFCU: 
Seek to expand staff sizes to reflect the number of staff 
approved in the Units budget 
The Unit should seek to maintain staff  levels in accordance with staffing 
allocations requested by the Unit and approved by OIG.   
Establish annual training plans and increase the number of 
training opportunities available to staff 
The Unit should develop formal training plans that indicate the type and  
duration of training expected each year for employees in each professional 
discipline. The Unit should also provide additional training opportunities 
and consider reinstituting the annual training conferences.  
Ensure that the MOU, policies, and procedures of the Unit 
reflect current practices 
The Unit should update its MOU with the State agency so that it addresses 
recent changes, such as the establishment of the Medicaid Inspector 
General and the State false claims act.  The Unit should also develop 
up-to-date policies and procedures manuals for each professional 
discipline and for the maintenance of case files.   
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               15  
     
   
Ensure greater consistency in how case files are maintained 
and increase the frequency and documentation of supervisory  
reviews  
Unit supervisors should periodically review case files to ensure they 
include all necessary documentation.  Additionally, supervisors should 
include notation of such reviews in the case files, to ensure timely 
investigation, prosecution, and closure of cases. 
Establish written policies and procedures for controls over 
(1) purchase cards, (2) reconciliation of accounting records, 
and (3) the sale and transfer of vehicles 
The Unit should develop and disseminate written policies and procedures 
for purchase cards to ensure that staff responsible for acquiring cards are 
not the same staff responsible for paying them.  The Unit should also 
develop an electronic means of maintaining accounting records.  Finally, 
the Unit should develop policies and procedures for decommissioning its 
vehicles in accordance with Federal regulations. 
 
 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               16  
     
   
UNIT COMMENTS 
The New York State Unit concurred with all five of our recommendations 
and provided a detailed plan for how it will implement each of them.   
The Unit concurred with our recommendation to expand its staff to reflect 
the number approved in the Units budget.  The Unit reported that it has 
already hired additional staff members and that vigorous recruitment 
efforts are continuing.   
The Unit also agreed with our recommendation to establish annual training 
plans and to increase the number of training opportunities available to 
staff.  The Unit has implemented annual training plans based on a 
credit-hour model to give it more flexibility in uncertain budget times 
and has established training committees for each of the professional 
disciplines.  
The Unit agreed with our recommendation to ensure that the MOU, 
policies, and procedures of the Unit reflect current practices.  The Unit 
expects that an updated MOU with the State agency and the States Office 
of the Medicaid Inspector General will be in place by July 2012; the Unit 
also reports that it is revamping its approach to maintaining its policy 
statements, and anticipates that an easily accessible and updateable 
electronic system will be completed by August 2012. 
The Unit concurred with our recommendation to ensure greater 
consistency in how case files are maintained and to increase the frequency 
and documentation of supervisory reviews.  The Unit states that it has 
created several new approaches to electronic files that will be integrated 
with its software used for investigative work. 
Finally, the Unit concurred with our recommendation to establish written 
policies and procedures for controls over (1) purchase cards, 
(2) reconciliation of accounting records, and (3) the sale and transfer of 
vehicles. The Unit noted that it is revising the handling of purchase cards  
and that it has already adopted a solution to the vehicle disposition issue.  
Also, now that a new Statewide accounting platform has been launched, 
the Unit has plans for a records-maintenance system.   
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               17  
     
   
APPENDIX A 
Performance Standards for Medicaid Fraud Control Units  
[59 Fed. Reg. 49080, Sept. 26, 1994] 
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 single 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 Units budget 
as approved by [the Office of Inspector General (OIG)]? 
b. 	  Does the Unit employ the number of attorneys, auditors, and investigators that 
were approved in the Units budget? 
c. 	  Does the Unit employ a reasonable size of professional staff in relation to the 
States 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 pr ocedures 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? 
b. 	  Is an adequate, computerized case management and tracking system in place? 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               18  
     
   
4. A Unit should take steps to ensure that it maintains an adequate workload 
through referrals from the single State agency and other sources.  In meeting this  
standard, the following performance indicators will be considered:  
a. 	  Does the Unit work with the single 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 possible, 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? 
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. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               19  
     
   
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 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 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 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 statutory  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 
States statutes when necessary and appropriate to do so? 
b. 	  Does the Unit provide program recommendations to single State agency when 
appropriate? 
c. 	  Does the Unit monitor actions taken by State legislature or State Medicaid agency 
in response to recommendations? 
10. 	A Unit should periodically review its memorandum of understanding (MOU) 
with the single 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? 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               20  
     
   
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 aid to the mission of the Unit?   
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               21  
     
   
APPENDIX B 
Fraud Investigations Opened and Closed by Provider Category, Fiscal Years 2008 to 2010  
Fiscal Year (FY)  
Provider Category   FY 2009   FY 2010  
2008  
Facilities  Opened  Closed  Opened  Closed  Opened  Closed  
Hospitals  62  39  30  45  23  24 
Nursing facilities   48  67  38  48  16  19 
Other long-term care facilities   2  1  2  1  2  2 
Substance abuse treatment centers   2  6  0  2  4  4 
Other  6  33  7  6  16  10 
Practitioners  Opened  Closed  Opened  Closed  Opened  Closed  
Doctors of medicine or osteopathy   13  29  11  18  12  8 
Dentists  3  6  8  6  5  7 
Counselors/psychologists  3  2  5  4  5  3 
Other   1  2  3  0  1  1 
Medical Support  Opened  Closed  Opened  Closed  Opened  Closed  
Pharmacies  22  28  22  13  18  15 
Pharmaceutical manufacturers  59  5  39  6  73  35 
Durable medical equipment and/or suppliers  25  26  5  5  17  5 
Laboratories  3  0  2  1  10  3 
Transportation services  12  9  17  4  7  15 
Home health care agencies  30  25  44  22  21  24 
Home health care aides  6  2  22  5  15  13 
Nurses, physician assistants, nurse practitioners, 
26  12  28  37  16  27 
certified nurse aides 
Radiologist  0  0  3  0  3  1 
Medical supportother   37  11  37  50  2  13 
Program Related  Opened  Closed  Opened  Closed  Opened  Closed  
Managed care   5  2  1  1  2  4 
Billing company  1  0  0  2  0  0 
Other  10  6  18  12  11  11 
Total  All Provider Categories   376  311  342  288  279  244 
Source: New York Medicaid Fraud Control Unit, 2011. 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               22  
     
   
Patient Abuse and Neglect Investigations Opened and Closed by Provider Category,  
FYs 2008 to 2010  
Provider Category   FY 2008   FY 2009   FY 2010 
  Opened  Closed  Opened  Closed  Opened  Closed  
Nursing facility   2  4  5  0  3  2 
Nondirect care   1  1  4  2  3  2 
Other long-term care  1  0  1  0  1  1 
Nurses, physician assistants, nurse 
35  45  50  39  29  40 
practitioners, certified nurse aides 
Home health care aides  0  0  0  0  0  0 
Other   6  3  3  8  1  2 
Total   45  53  63  49  37  47 
    
Source: New York Medicaid Fraud Control Unit, 2011. 
 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               23  
     
   
APPENDIX C 
Confidence Interval Estimates Based on Case File Review  
We estimated the following 3 population values for all 1,887 case files from the results of 
our review of the 94 case files selected in our simple random sample.  The table below 
includes the estimate descriptions, sample sizes, point estimates, and 95-percent 
confidence intervals for these 3 estimates. 
 
Confidence Intervals for Key Case File Review  Data  
Estimate  95-Percent Confidence 
Data   Point Estimate  
Description   Interval  
Case files missing an opening 
94  9.6%   4.5%17.4%  
memorandum  
Case files missing a closing 
57*  7.0%   1.9%17.0%  
memorandum  
Case files missing documentation 
indicating at least one supervisory   94  47.9%   37.5%58.4%  
review 
 
* Of the 94  cases reviewed, 57 were closed between fiscal years 2008 and 2010.      
 
Source: Office of Inspector General analysis of Medicaid  Fraud Control Unit  case files, 2011. 
 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               24  
     
   
APPENDIX D 
Unit Comments 
 
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)               25  
     
   
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                26  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                27  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                28  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                29  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                30  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                31  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                32  
   
   
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                33  
  Conduslon 
The New York MFCU appreciates the efforts of HRS-OIG and the Insight provided by 
the Onsite Review.  We appreciate and concur with the recommendations. which will be 
implemented to the extent not already accomplished as we recover from the budgetary impact of 
the fmancial  crisis.  As the statistics demonstrated. MFCU achieved unprecedented results 
despite such obstacles.  New York MFCU remains committed to meeting and exceeding the 
standards for Medicaid Fraud Control Units. 
Respectfully submitted, 
Monica 1. Hickey-Martin 
Special Deputy Attorney General 
Director, New York MFCU 
10 
New York State Medicaid Fraud Control Unit 2011 Onsite Review (OEI-02-11-00440)  34   
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New  York regional 
office, and Meridith Seife, Deputy Regional Inspector General.   
Vince Greiber served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the New York regional office who 
conducted the study include Hailey Davis.  Central office staff who 
provided support include Thomas Brannon and Christine Moritz.  
Michael Henry of the San Francisco regional office also contributed to the 
report. Office of Audit Services staff who contributed to the report include 
Eileen Bechkes and Ryan Moul.  Office of Investigations staff who 
contributed to the report include LaTonya Coates, Michael Mahabir, and 
Jason Weinstock.   
 
New  York State Medicaid Fraud Control Unit:  2011 Onsite Review  (OEI-02-11-00440)                35  
   
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.