Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
U   S M F
TAH  TATE  EDICAID  RAUD 
 
C U :  
  ONTROL  NIT  
 
2013 O R  
  NSITE  EVIEW 
 
 
 
 
 
 
 
Brian P. Ritchie  
Acting Deputy Inspector General for  
Evaluation and Inspections 
 
April 2014 
OEI-09-13-00490   
   
EXECUTIVE SUMMARY  UTAH STATE MEDICAID FRAUD CONTROL UNIT:  
2013 ONSITE REVIEW 
OEI-09-13-00490 
 
WHY WE DID THIS STUDY 
 
The Office of Inspector General (OIG) oversees all State Medicaid Fraud Control Units 
(MFCUs or Units) with respect to Federal grant compliance.  As part of this oversight, 
OIG annually reviews and certifies all Units.  In addition, OIG conducts onsite reviews of 
selected States. These reviews assess Unit performance in accordance with the 12 MFCU 
performance standards and monitor Unit compliance with Federal grant requirements,  
laws, and regulations. 
 
HOW WE DID THIS STUDY  
 
We analyzed data from seven sources:  (1) a review of documentation, policies, and 
procedures related to 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 and selected staff; (6) an 
onsite review of case files; and (7) an onsite review of Unit operations. 
 
WHAT WE FOUND 
 
From fiscal years 2010 through 2012, the Unit reported recoveries of $61 million, 
26 convictions, and 51 civil judgments and settlements.  Unit case files lacked 
documentation of supervisory approval to open and close cases and documentation of 
periodic supervisory reviews. In addition, the Unit did not refer three sentenced 
individuals to OIG for program exclusion.  The Units policies and procedures manual 
did not reflect current Unit operations.  Finally, the Unit did not report adverse actions to 
the National Provider Data Bank (NPDB) as required by Federal regulations. 
 
WHAT WE RECOMMEND 
 
We recommend that the Utah Unit (1) ensure that supervisory approval and periodic 
reviews are documented in Unit case files, (2) ensure that it refers individuals for 
exclusion to OIG, (3) revise its policies and procedures manual, and (4) ensure that 
adverse actions are reported to the NPDB. The Unit concurred with all four of our 
recommendations.  
 
 
 
 
 
 
 
 
   
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

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

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

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

From FY 2010 through FY 2012, the Unit reported recoveries      

of $61 million, 26 convictions, and 51 civil judgments and 

settlements........................................................................................8 

Unit case files did not consistently contain documentation of 

supervisory approval to open and close cases, and 60 percent        

of case files lacked documentation of periodic supervisory   

reviews .............................................................................................9 

The Unit did not refer three sentenced individuals to OIG for 
program exclusion ..........................................................................10 

The Units policies and procedures manual did not reflect     

current Unit operations ..................................................................10 

The Unit did not report adverse actions to the NPDB ...................11
  
Other Observations: Certified Fraud Examiner training, 

investigator workload tracking, and managed care referrals .........11 
 
Conclusion and Recommendations ............................................................13 

Unit Comments and Office of Inspector General Response ..........14 

Appendixes ................................................................................................15 

A: Performance Standards for MFCUs (Units) ............................15 

B: Revised 2012 Performance Standards for MFCUs (Units) ......19 

C: Referrals of Provider Fraud and Patient Abuse and Neglect     

to the Utah MFCU by Source, FYs 2010 Through 2012 ...............26 

D: Investigations Opened and Closed by the Utah MFCU by 

Provider Category and Case Type, FYs 2010 Through 2012 ........27 

E: Case File Review Population, Sample Size Counts, and 

Confidence Interval Estimates .......................................................29 

F: Unit Comments.........................................................................31 

Acknowledgments......................................................................................33 

   
   
OBJECTIVE 
To conduct an onsite review of the Utah 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, 2  Pursuant to Title XIX of the SSA, 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.   Currently, 49 States and the District of Columbia 
(States) have created such Units.3  In fiscal year (FY) 2012, combined 
Federal and State grant expenditures for the Units totaled $217.3 million, 
of which Federal funds represented $162.9 million.4, 5   That year, the 
50 Units employed 1,901 individuals.6  
To carry out its duties 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.7  The staff reviews complaints referred by the 
State Medicaid agency and other sources and determines their potential for 
criminal prosecution and/or civil action.  Collectively, in FY 2012, the 
50 Units reported 1,337 convictions and 823 civil judgments and 
 
1 Social Security Act (SSA)  1903(q).  

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.  Medicaid 

Fraud Control Units, Office of Inspector General (OIG) web site.  Accessed at 

http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp on May 21, 2013. 

4 All FY references in this report are based on the Federal FY (October 1  through  
September 30). 
 
5 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 
 
May 8,  2013.  

6 Ibid. 

7 SSA  1903(q)(6) and 42 CFR  1007.13. 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  1  
   
   
settlements.  That year, the Units reported recoveries of approximately 
$2.9 billion.8  
Units are required to have either Statewide authority to prosecute cases or 
formal procedures to refer suspected criminal violations to an office with 
such authority.9  In Utah and 43 other States, the Units are located within 
offices of State Attorneys General that have this authority.  In the 
remaining six States, the Units are located within other State agencies; 
generally, such Units must refer cases to offices with prosecutorial 
authority.10  Additionally, 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 
both to annually certify the Units and to administer grant awards to 
reimburse States for a percentage of their costs of operating them.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 whether it is 
approved and the Unit is certified. Approval and certification are valid for a 
1-year period; the Unit must be recertified each year thereafter.15    
Pursuant to Title XIX of the SSA, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.16   OIG 
 
8 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 
 
May 8,  2013.  Pursuant to 42  CFR   1007.17, Units report the total amount of recovered 
 
funds in their annual  reports to  OIG.  Recoveries are defined as the amount  of money 
 
that defendants are required to pay as a result of a judgment or settlement in criminal and 

civil cases, and may not  reflect actual collections.  Recoveries may involve cases that 
 
include participation by other Federal and State agencies. 

9  SSA  1903(q)(1). 
 
10 In States with  a Unit, 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, including Utah, also employ a Medicaid Inspector 
 
General who conducts and coordinates activities against fraud, waste, and  abuse for the 

State agency. 

11  SSA  1903(q)(2)  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  referred to as 

Federal Financial Participation.  

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). 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  2  
   
   
developed and issued 12 performance standards to define the criteria that 
OIG applies in assessing whether a Unit is effectively carrying out statutory 
functions and meeting program requirements.17  Examples of standards 
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), and establishing  
policy and procedures manuals to reflect the Units operations.  See 
Appendix A for a complete list of the performance standards.18  
Utah Unit  
The Unit is an autonomous entity within the Utah Attorney Generals 
Criminal Justice Division and has the authority to prosecute cases of 
Medicaid fraud and cases of patient abuse and neglect.  At the time of our 
review, all of the Units 13 employees were located in Murray, Utah.  The 
Unit Director serves as the Chief Attorney and directly supervises all Unit 
attorneys, the Chief Investigator, Unit auditors, and Unit support staff.  
The Chief Investigator directly supervises the five other Unit investigators. 
The Unit receives referrals of provider fraud from the Utah Office of 
Inspector General of Medicaid Services and from Federal agencies, such 
as OIG. The Unit receives referrals of patient abuse and neglect19 from the 
Utah Division of Aging and Adult Services (DAAS).  In addition, the Unit 
receives both types of referrals from  other State and local agencies.  For 
additional information on Unit referrals, see Appendix C. 
Upon receiving a referral, the Chief Investigator and Unit Director screen 
it to decide whether to open the referral as a case and proceed with an 
investigation or refer it to another agency.20 After a referral is accepted for 
investigation, the Unit paralegal opens it as a case in the Units electronic  
case tracking system.  Unit supervisors assign the case to an investigator,  
an attorney, and, as appropriate, an auditor.  The assigned Unit employees 
then meet to plan the case strategy.  
 
17 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at https://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/files/Performance%20Standards.pdf  on  May 8, 2013.   
18 The performance standards referred to in this report were published in  1994 and were  
in effect during most of our review  period (FYs  2010 through  2012).  In June 2012, OIG  
published a revision of the performance standards (77 Fed.  Reg. 32645, June 1, 2012).  
Our onsite data collection took place in September 2013.  When referring to the  
performance standards, we refer to  the 1994 standards, unless otherwise noted.   See  
Appendix B  for a complete list of the revised performance standards.    
19 For the purposes of this report, misappropriation of patients  private funds in  
residential health care facilities is included  in the category of patient abuse and neglect. 
20 For fraud referrals, the Chief Investigator  and  Unit Director also consult with the Chief 
Auditor to determine whether to open the referral as a case  and proceed with an 
investigation.    
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  3  
   
   
The Unit may open a case and pursue it through a variety of actions, 
including criminal prosecution, civil action, or a combination of the two.  
The Unit may close a case for a variety of reasons, including, but not 
limited to, resolving it through criminal and/or civil action or referring it 
to another agency. For additional information on the Units opened and 
closed investigations, including a breakdown by case type and provider 
category, see Appendix D. 
Previous Review  
In 2007, OIG conducted an onsite review of the Utah Unit and found it to 
be in general compliance with the Federal rules and regulations that 
govern the [MFCU] grant.  However, the review identified two areas of  
concern related to the Units case flow.  The review recommended that the 
Unit develop a case file index for locating documents within case files and  
that the Unit open case files only for referrals accepted for formal 
investigation.  According to the report on the 2007 review, the Unit 
Directors response to the review findings satisfied OIG that the MFCU 
[was] properly reporting its statistical information. 
METHODOLOGY 
We analyzed data from seven sources:  (1) a review of Unit 
documentation, including policies and procedures related to 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 and selected staff; (6) an onsite 
review of case files that were open at any point during FYs 2010 through 
2012; 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.  We also analyzed the data to identify 
any opportunities for improvement and any instances in which the Unit 
did not meet the performance standards or was not operating in 
accordance with laws, regulations, and/or policy transmittals.21  
In addition, we noted practices that appeared to benefit the Unit.  We  
based these observations on statements from Unit staff and an analysis of 
collected data.  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. 
We conducted the onsite review in September 2013. 
 
21 All relevant  regulations, statutes, and  policy transmittals are available online at 
http://oig.hhs.gov. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  4  
   
   
Data Collection and Analysis 
Review of Unit Documentation.  We collected and reviewed Unit 
documentation, including policies and procedures related to the Units 
operations, staffing, and cases. This documentation included the Units 
annual reports, quarterly statistical reports, and responses to recertification 
questionnaires. We reviewed the documentation to determine how the 
Unit investigates and prosecutes Medicaid cases. The documentation also  
included data such as the number of referrals received by the Unit and the  
number of investigations opened and closed.  Additionally, we confirmed 
with the Unit Director that the information we had was current at the time 
of our review and requested any additional data or clarification, as needed.   
Review of Financial Documentation. We reviewed Unit financial 
practices to determine compliance with applicable laws and regulations 
and to determine the need for additional internal controls.  Prior to the 
onsite review, we reviewed the Units financial policies and procedures, 
its response to an internal control questionnaire, and MFCU grant-related 
documents such as financial status reports.  During the onsite review, we 
reviewed a sample of the 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.  We conducted structured interviews 
with seven individual stakeholders among five agencies who were familiar 
with Unit operations. Specifically, we interviewed the Program Integrity 
Manager for the Utah Office of Inspector General of Medicaid Services; a 
regional director of DAAS; an Assistant U.S. Attorney based in Utah; the 
Utah Attorney Generals Criminal Justice Division Chief;22 two OIG 
Special Agents based in Salt Lake City; and the Utah Inspector General of  
Medicaid Services.  These interviews focused on the Units interaction 
with external agencies, Unit operations, opportunities for improvement, 
and any practices that appeared to benefit the Unit and that may be useful 
to other Units in their operations. 
Survey of Unit Staff. We conducted an online survey of Unit staff.23  We  
requested responses from 10 staff members and received responses from 
9 of them, a 90percent response rate.  Our questions focused on Unit 
operations, opportunities for improvement, and practices that appeared to 
benefit the Unit and that may be useful to other Units in their operations.  
 
22 The Unit Director is supervised  by the Chief of the Attorney Generals Criminal Justice 
Division.  

23 We did not survey the Unit Director, Chief Investigator, or Chief Auditor because  we 
 
interviewed these staff members onsite.   

Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  5  
   
   
The survey also sought information about the Units compliance with 
applicable laws, regulations, and policy transmittals.   
Interviews With Unit Management and Selected Staff. We conducted 
structured interviews with the Units Director, Chief Investigator, and 
Chief Auditor. We asked them to provide us with additional information 
to better understand the Units operations, identify opportunities for 
improvement, identify practices that appeared to benefit the Unit and that 
may be useful to other Units in their operations, and to clarify information 
obtained from other data sources. 
Onsite Review of Case Files.  We selected a simple random sample of 
100 case files from the 258 cases24  that were open at any point from  
FY 2010 through FY 2012. The design of this sample allowed us to 
estimate the percentage of all 258 cases with various characteristics at the 
95-percent confidence level. We were  able to gather information on 98 of 
the 100 case files selected in the sample, a 98percent response rate.25 We  
reviewed these 98 sampled case files and the Units processes for 
monitoring the status and outcomes of cases.  From the 100 case files in 
the initial sample, we selected another simple random sample of 50 files 
for a more in-depth review of potential issues.  This second-phase sample 
allowed us to conduct a more comprehensive review of case files to 
identify any potential issues from a qualitative perspective.  We consulted 
Unit staff to address any apparent issues with individual case files, such as  
missing documentation.  For population and sample size counts, as well as 
confidence interval estimates, see Appendix E. 
Onsite Review of Unit Operations. While onsite, we reviewed the Units 
operations. Specifically, we observed the intake of referrals, data analysis 
operations, security of data and case files, and the general functioning of 
the Unit. We also checked to ensure that the Unit referred sentenced  
   
 
24 This  figure includes cases opened before FY  2010 that  remained open at some point  
during  FYs 20102012.  This figure does not include 72 multi-State (global) civil 
false-claims cases, which consist of both those worked  directly by the Unit and those 
worked by staff from the Federal government or  other Units.  For the purposes of our  
case file review, the Units global cases were not included  as part of the Units case file 
population.   Including  global  cases, the total  number of Unit cases open  during the review  
period was 330. 
25 Two of the case files selected  for our sample were sealed by court order and therefore  
unavailable for  review.  
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  6  
   
   
individuals to OIG for program exclusion and that the Unit reported 
adverse actions to the National Practitioner Data Bank (NPDB).26, 27  
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.28  
 
26 The NPDB  was established by the Department of Health and Human Services as a  
national  health care fraud and abuse data collection program ... for the reporting of 
certain final adverse actions ... against health  care providers, suppliers, or practitioners.  
SSA  1128E(a) and 45 CFR   61.1(2012).   This  portion of the NDPB  used to be a 
separate databank  called  the Healthcare Integrity and Protection  Databank  (HIPDB).  The 
HIPDB and the NPDB  were  merged into one databank in  May 2013.  78  Fed. Reg. 
20473 (April 5, 2013). 
27 Examples of adverse actions  include criminal convictions; civil judgments (but  not 
civil settlements); exclusions; and other negative actions or findings, including any  
action or finding that under the States law is publicly available information, and  
rendered  by a licensing  or certification authority, including  but  not limited to, limitations  
on the scope of practice, liquidations, injunctions and forfeitures.  SSA   1128E(g)(1)  
and 45 CFR  61.3 (2012).  We  reviewed the reporting  of adverse actions under  HIPDB 
requirements because the HIPDB and the NPDB had not yet been merged during the 
period of  our  review  (FYs  2010 through 2012).  Current Unit requirements for  reporting 
to the merged  NPDB are in  45 CFR pt. 60. 
28 Full text  of these standards is available online at http://www.ignet.gov/pande/standards/ 
oeistds11.pdf. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  7  
   
   
FINDINGS 
From FY 2010 through FY 2012, the Unit reported 
recoveries of $61 million, 26 convictions, and 51 civil 
judgments and settlements 
From FY 2010 through FY 2012, the Unit reported total criminal and civil 
recoveries of $61 million, an annual average of $20 million (see Table 1).  
Of the $61 million in total recoveries, the Unit attributed $47,887 to 
criminal recoveries.  Non-global29 civil judgments and settlements 
accounted for 77 percent ($46 million) of the total civil recoveries, and 
global cases accounted for 72 of the Units 330 total cases over the 3-year 
period. The Units annual average expenditures for FYs 2010 through 
2012 were $1.6 million.30      
Table 1: Funds Reported Recovered by the Utah Unit, FYs 2010 Through 
2012  
Annual  
FY 2010   FY 2011   FY 2012   3-Year Total  
  Average*  
Criminal 
$8,242   $35,405   $4,240   $47,887   $15,962  
Recoveries 
 
Global Civil 
$4,611,892   $6,514,376   $3,180,029  $14,306,297   $4,768,766  
Recoveries 
 
Nonglobal Civil 
$25,114,128   $7,166,357   $14,195,791   $46,476,276   $15,492,092  
Recoveries 
Total Civil 
$29,726,020  $13,680,733   $17,375,820   $60,782,573   $20,260,858  
Recoveries 
Total Civil and 
Criminal  $29,734,262   $13,716,138   $17,380,060   $60,830,460   $20,276,820  
Recoveries  
Total  
$1,446,999  $1,608,289   $1,669,284   $4,724,572   $1,574,857  
Expenditures 
Source:  OIG review of Unit self-reported Quarterly  Statistical Reports (QSRs) and other data, FYs 20102012. 
*Averages in  this  table are rounded. 
 
From FY 2010 through FY 2012, the Unit Reported 26 Convictions and 
51 Civil Judgments and Settlements. From FY 2010 through FY 2012, the 
Units convictions decreased, but civil judgments and settlements 
remained at a consistent level.  During this period, the Unit reported 
 
29 Unit-reported recoveries include funds recovered  from  multi-State, or global, civil 
false claims cases, which consist of both those worked  directly by the Unit and those 
worked by staff from other Units.    
30 The figures presented in this  paragraph are rounded.  
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  8  
   
   
26 convictions and 51 civil judgments and settlements, an annual average 
of 8.7 convictions and 17 civil judgments and settlements (see Table 2).   
Table 2: Unit Convictions and Civil Judgments and Settlements, 
FYs 2010 Through 201231  
3-Year  Annual  
FY 2010   FY 2011   FY 2012  
  Total   Average 
Convictions  12  10  4  26  8.7 
Civil Judgments and Settlements   18  18  15  51  17 
Source:  OIG review of Unit self-reported QSRs and other data, FYs 20102012. 
 
From FYs 2010 through 2012, the Unit opened an average of 69 cases 
annually, with an average of 41 cases of provider fraud and 27 cases of 
patient abuse and neglect. From  FYs 2010 through 2012, the Unit closed 
an average of 73 cases annually, averaging 34 cases of provider fraud and 
39 cases of patient abuse and neglect.32  From FYs 2010 through 2012, the 
Unit received an average of 69 referrals annually, with an average of 
41 referrals of provider fraud and 27 referrals of patient abuse and neglect.  
Although the number of patient abuse and neglect referrals to the Unit 
declined each year of the review period, Unit management and 
stakeholders did not identify any specific cause for the decline.33  
Unit case files did not consistently contain 
documentation of supervisory approval to open and 
close cases, and 60 percent of case files lacked 
documentation of periodic supervisory reviews  
According to Performance Standard 6(b), Unit supervisors should approve 
the opening and closing of cases to ensure a continuous case flow and the 
timely completion of cases.  Supervisory approval to open and close cases 
suggests that Unit supervisors are monitoring the intake and resolutions of 
cases, thereby facilitating progress in the cases.  According to Unit 
management, the Unit Director approves the opening and closing of all 
cases. However, 26 percent of the Units case files lacked documentation 
of supervisory approval to open cases, and 13 percent of the Units closed 
case files lacked documentation of supervisory approval to close cases. 
 
31 Civil judgments and settlements include those received from global cases.   
32 Closures include multiple cases opened before FY 2010.  The averages in  this 
paragraph are rounded.  
33 As noted in Table C-1 in Appendix C, total patient abuse and neglect referrals to the 
Unit declined from 41 in  FY 2010 to 28 in FY  2011 and 13 in FY  2012. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  9  
   
   
According to Performance Standard 6(c), supervisory reviews should be 
conducted periodically and noted in the case file to ensure timely case 
completion.34  According to Unit management, all open cases are reviewed 
by supervisors on a weekly basis, and Unit supervisors regularly document 
supervisory reviews in the case files or electronic case file tracking 
system.  However, 60 percent of the Units cases lacked documentation of 
periodic supervisory reviews either in the case files or in the electronic 
case file tracking system.   
The Unit did not refer three sentenced individuals to 
OIG for program exclusion 
According to Performance Standard 8(d), when a convicted individual is  
sentenced, the Unit should send a referral letter to OIG within 30 days or 
other reasonable time period for the purpose of program exclusion.35, 36   
The Unit reported 26 total convictions  within the review period, but did not 
refer 3 of those sentenced individuals  to OIG for program exclusion within 
an appropriate timeframe.  Each of these individuals had been sentenced at 
least 2 years prior to our onsite review, but none had been referred to OIG 
for program  exclusion.  Unit management acknowledged this oversight and 
provided documentation that all three individuals were referred to OIG for  
program exclusion immediately following our onsite review. 
The Units policies and procedures manual did not 
reflect current Unit operations 
According to Performance Standard 3, the Unit should establish policies 
and procedures for its operations, which should be included in a manual. 
The Units policies and procedures manual had last been updated in 2013, 
prior to our onsite review. However, the manual did not address Unit 
operations specific to its case file review process or its procedures for 
documenting supervisory approval to open and close cases and periodic 
 
34 For the purposes of this report, supervisory approval to  open and close a case does not  
constitute a periodic supervisory review.  Periodic supervisory reviews indicate that a 
supervisor reviewed a case more than  once  between the cases opening and closing and 
documented those reviews in  the case file.  
35 Pursuant to section 1128(a) of the SSA, OIG excludes from participation in Federal  
health care programs any person or entity convicted of a criminal offense related to the 
delivery  of an item or service under the Medicaid program or to the neglect or abuse of  
patients in residential health care facilities.  No payment may be made by  Medicaid,  
Medicare, or  other Federal  health care programs for an item or service provided,  ordered, 
or prescribed by an excluded individual or entity.  42 CFR  1001.1901.  
36 According to  2012 Performance Standard  8(f), all referrals for exclusion should be  
transmitted  to OIG within 30 days.  That 2012  standard does not  allow the option of  
transmitting referrals for exclusion  within an other reasonable time period. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  10  
   
   
supervisory reviews in the Units case files and/or electronic case file 
tracking system.  
The Unit did not report adverse actions to the NPDB  
Pursuant to Federal regulations, all State and Federal government agencies 
must report any adverse actions, generated as a result of investigations or 
prosecutions of healthcare providers, to the NPDB.37 In addition, 
according to 2012 Performance Standard 8(g), the Unit should report 
qualifying cases to the NPDB. However, the Unit was not registered 
with the NPDB and did not report adverse actions to the NPDB during the 
review period. During our onsite review, Unit management acknowledged 
this oversight and provided documentation that the Unit is now registered 
with the NPDB.  
Other Observations: 
During our onsite review, we noted two practices that may have been 
beneficial to Unit operations:  (1) efforts to ensure that appropriate Unit 
personnel become Certified Fraud Examiners (CFEs), and (2) the tracking 
of investigators workloads. In addition, Unit management reported 
concerns about the lack of referrals from managed care organizations 
(MCOs). 
Certified Fraud Examiner training  
According to Performance Standard 12(e), training undertaken by Unit 
staff should aid in the mission of the Unit.  During our onsite review, 
Unit management reported that all Unit auditors and investigators were  
either trained as CFEs or in training to become CFEs.  Unit management 
and staff reported that CFE training benefitted the Units performance by 
improving the efficiency and effectiveness of Unit provider fraud 
investigations.  
Investigator workload tracking 
According to Performance Standard 6, a Unit should have a continuous 
case flow and cases should be completed in a reasonable time.  According  
to Unit management, the tracking of Unit investigators workloads helps 
ensure the timely completion of investigations.  The Chief Investigator 
maintains a spreadsheet documenting the number of cases assigned to each 
 
37 Under requirements established in 2012, Units must report adverse actions to the 
NPDB within  30 calendar days from the date the final adverse action was 
taken.   45 CFR  61.5(a).  
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  11  
   
   
investigator, as well as the number of hours spent on each case.  This 
spreadsheet also monitors the complexity of each case, which is taken into  
account when assigning new cases to investigators.  The Chief 
Investigator reported using this spreadsheet to help ensure that each Unit 
investigator spends a similar amount of time working on investigations 
and to help ensure that cases are progressing in a timely manner. 
Managed care referrals 
According to 2012 Performance Standard 4(a), the Unit should take steps 
to ensure that MCOs refer to the Unit all suspected provider fraud cases.  
As of 2011, 98 percent of Utah Medicaid enrollees received their health 
care services through MCOs.38 However, the Unit received no referrals 
from MCOs during the review period.  Unit management reported that it is 
concerned about the lack of referrals and has taken steps to ensure fraud 
referrals from MCOs. These steps included discussions among the Unit, 
the State Medicaid agency (Utah Department of Health), and MCOs. The 
purpose of these discussions was to develop provisions in MCO contracts 
to ensure that MCOs send fraud referrals to the Unit.   
 
 
 
 
 
 
 
 
 
 
 
 
38 CMS, 2011 Medicaid Managed Care Enrollment Report, accessed at 
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-
Systems/Downloads/2011-Medicaid-MC-Enrollment-Report.pdf  on October 24, 2013.  
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  12  
   
   
CONCLUSION AND RECOMMENDATIONS 
From FY 2010 through FY 2012, the Unit reported recoveries of 
$61 million, 26 convictions, and 51 civil judgments and settlements.  Unit 
management and staff reported that CFE training improved the efficiency 
and effectiveness of Unit provider fraud investigations.  Finally, Unit 
management reported that the tracking of investigators workloads helps 
ensure the timely completion of investigations. 
Opportunities for Unit improvement exist.  Specifically, Unit case files did 
not consistently contain documentation of supervisory approval to open 
and close cases or periodic supervisory reviews.  In addition, the Unit did 
not refer three sentenced individuals to OIG for program exclusion.  The 
Units policies and procedures manual did not reflect the Units periodic 
case file review process. Finally, the Unit did not report adverse actions to 
the NPDB. Other than the failures to report three providers to OIG for 
program exclusion and to report adverse actions to the NPDB, we found 
no evidence of noncompliance with applicable laws, regulations, or policy 
transmittals.  
We recommend that the Utah Unit: 
Ensure that supervisory approval to open and close cases and 
periodic supervisory reviews are documented in Unit case files 
The Unit should ensure that supervisors are approving the opening and 
closing of cases and consistently reviewing case files; approval to open 
and close cases and periodic supervisory reviews should be documented in 
the case files. 
Ensure that letters referring providers for exclusion are 
submitted to OIG within an appropriate timeframe 
The Unit should ensure that letters referring individuals and entities for 
exclusion are sent within 30 days of defendant sentencing, consistent with 
2012 Performance Standard 8(f).  
Revise its policies and procedures manual to reflect current 
Unit operations 
The Unit should revise its policies and procedures manual to include its 
periodic case file review process.  
Ensure that adverse actions are reported to the NPDB 
The Unit should ensure that it reports all adverse actions, generated as a 
result of investigations or prosecutions of healthcare providers, to the 
NPDB, as specified in Federal regulations. 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  13  
   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Unit concurred with the four report recommendations. 
Regarding the first recommendation, the Unit reported that it has 
instructed staff to include case-referral approval forms signed by Unit 
management in the case files.  The Unit also reported that it has instructed  
supervisors to note periodic supervisory reviews in the Units electronic 
case-management system.  
Regarding the second recommendation, the Unit explained that it did not 
report the three cases to OIG for exclusion because it misunderstood 
OIGs exclusion policy. The Unit reported that it now understands this 
policy and has since referred the three cases in question to OIG for 
exclusion. 
Regarding the third recommendation, the Unit agreed to update its policies 
and procedures manual to reflect current Unit operations.  The Unit 
reported that it anticipates that the update will be completed by June 2014.  
Regarding the fourth recommendation, the Unit reported that it is now 
registered with the NPDB and will report all adverse actions as required.  
   
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  14  
   
   
APPENDIX A 
Performance Standards for MFCUs (Units)39   
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 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: 
 
39 59 Fed. Reg. 49080  (Sept. 26, 1994).  These performance standards were in effect 
during most of our review  period and precede the performance standards published in 
June 2012.  
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  15  
   
   
a. 	  Does the Unit have policy and procedure manuals? 
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 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 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? 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  16  
   
   
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 States statutes when necessary and appropriate 
to do so? 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  17  
   
   
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 periodica lly 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? 
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? 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  18  
   
   
APPENDIX B 
Revised 2012 Performance Standards for MFCUs (Units)40   
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 
 
40  77  Fed.  Reg. 32645 (June 1, 2012). 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  19  
   
   
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). 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  20  
   
   
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.  
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  21  
   
   
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 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  22  
   
   
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. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  23  
   
   
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. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  24  
   
   
 
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. 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  25  
   
   
APPENDIX C 
Referrals of Provider Fraud and Patient Abuse and Neglect to  
the Utah MFCU by Source, FYs 2010 Through 2012 
Table C-1: Total MFCU Referrals of Fraud and Abuse and Annual Average 
Annual  
  Case Type   FY 2010   FY 2011   FY 2012   3-Year Total  
Average*  
Patient Abuse and Neglect  41  28  13  82  27 
 
Provider Fraud   52  34  38  124  41 
 
  Total   93  62  51  206  69 
 
Source:  Unit response to OIG data request. 
 
  *Averages in  this  column are rounded. 
Table C-2: MFCU Referrals, by Referral Source  
 
 
FY 2010   FY 2011   FY 2012  
   
Abuse  Abuse  Abuse  Percentage 
Referral 
Fraud   and  Fraud   and  Fraud   and  Total   of All 
Source  
Neglect   Neglect   Neglect   Referrals*  
Adult 
Protective  0  27  1  24  0  9  61  29.6%  
Services  
Other   32  1  15  0  9  0  57  27.7%  
State Medicaid 
10  6  6  4  12  4  42  20.4%  
Agency 
OIG  1  0  2  0  13  0  16  7.8%  
Licensing 
5  4  2  0  0  0  11  5.3%  
Board  
Providers  3  1  4  0  0  0  8  3.9%  
Law  
0  1  2  0  2  0  5  2.4%  
Enforcement  
MFCU Hotline  1  0  0  0  0  0  1  0.5%  
Private 
0  0  1  0  0  0  1  0.5%  
Citizens 
Other State 
0  0  1  0  0  0  1  0.5%  
Agencies 
Ombudsman   0  1  0  0  0  0  1  0.5%  
Prosecutors  0  0  0  0  1  0  1  0.5%  
State Survey  
and  0  0  0  0  1  0  1  0.5%  
Certification 
Total   52  41  34  28  38  13  206  100%  
Annual    
93  62  51 
Total    
Annual    
69 
Average*    
Source:  Unit response to OIG data request. 

*This average is rounded. 

 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  26  
   
   
APPENDIX D 
Investigations Opened and Closed by the Utah MFCU, by  
Provider Category and Case Type, FYs 2010 Through 2012 
 
Table D-1: Total Annual Opened and Closed Investigations  
 
  Annual   
 Case Type   FY 2010   FY 2011   FY 2012   3-Year Total   Average*  
 Opened   93  62  51  206  69 
Patient Abuse and 
  41  28  13  82  27 
Neglect 
  Provider Fraud   52  34  38  124  41 
Closed  105  33  80  218  73 
 
Patient Abuse and 
66  25  26  117  39 
  Neglect 
Provider Fraud   39  8  54  101  34 
 
S ource:  Unit response to OIG data request. 
*Averages in  this  column are rounded. 
   
 
Table D-2: Patient Abuse and Neglect Investigations  
 
Provider Category   FY 2010   FY 2011   FY 2012  
        
Opened  Closed  Opened  Closed  Opened  Closed 
Home Health Aides  0  2  0  0  0  0 
Nondirect Care   0  1  0  0  1  0 
Nurses/Doctors Assistants   9  13  2  4  1  5 
Nursing Facilities   3  5  4  5  0  2 
Other Long-Term  Care 
1  1  2  1  0  2 
Facilities  
Other   28  44  20  15  11  17 
Total   41  66  28  25  13  26 
Source:  Unit response to OIG data request. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  27  
   
   
 
Table D-3: Provider Fraud Investigations  
 
Provider Category   FY 2010   FY 2011   FY 2012  
Facilities   Opened  Closed   Opened  Closed   Opened  Closed  
Hospitals  0  0  0  0  1  0 
Nursing Facilities   1  0  0  1  0  1 
Other Long-Term  Care 
0  1  0  0  1  0 
Facilities  
Other  Facilities   3  2  5  0  1  2 
  Subtotal   4  3  5  1  3  3 
Practitioners   Opened  Closed  Opened  Closed  Opened  Closed 
Counselors/ 
0  0  0  0  1  1 
Psychologists 
Dentists  0  1  0  0  1  3 
Optometrists/Opticians  0  0  0  0  2  1 
Physicians  4  0  2  2  2  4 
Other Practitioners  1  6  4  0  3  5 
  Subtotal   5  7  6  2  9  14 
Medical Support  Opened  Closed   Opened  Closed   Opened  Closed  
Durable Medical 
1  0  1  0  0  2 
Equipment Suppliers 
Home Health Care 
0  3  2  0  0  0 
Agencies 
Laboratories  0  1  0  0  0  1 
Nurses/Doctors 
2  1  0  1  3  2 
Assistants  
Pharmaceutical 
31  15  14  1  6  18 
Manufacturers 
Pharmacies  1  1  3  1  5  2 
Radiologists  0  0  0  0  0  1 
Transportation Services  0  0  0  0  1  0 
Other Medical Support   3  3  1  1  5  4 
  Subtotal   38  24  21  4  20  30 
Program  Related   Opened  Closed  Opened  Closed  Opened  Closed 
Other Program Related  5  5  2  1  6  7 
  Subtotal   5  5  2  1  6  7 
  Total   52  39  34  8  38  54 
 
Source:  Unit response to OIG data request. 
 
 
 
 
 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  28  
   
   
APPENDIX E 
Case File Review Population, Sample Size Counts, and 
Confidence Interval Estimates 
Table E-1 shows population and sample counts and percentages by case 
type. Note that both samples have percentages of case types similar to the 
general population, though sample counts for some case types are very 
small.  Because of these small sample sizes, we cannot reliably generalize 
what we found in our sample review to each case type in the population, 
and only our overall estimates project to the population of all case files.  
We estimated the 4 population values for all 258 nonglobal case files from 
the results of our review of the case files selected in our simple random  
samples.  Table E-2 includes the estimate descriptions, sample sizes, point 
estimates, and 95-percent confidence intervals for these four estimates.  
 
Table E-1:  Population and Sample Size Counts for Case Types 
Population Count  Sample Count*    Sample Count* 
Case Type  
and (%)  n=258   and (%)  n=98   and (%)  n=50  
Closed  208 (81%)   80 (82%)   42 (84%)  
Open   50 (19%)   18 (18%)   8 (16%)  
Civil (Nonglobal)  19 (7%)   8 (8%)   5 (10%)  
Criminal  239 (93%)   90 (92%)   45 (90%)  
Patient Abuse/Neglect  142 (55%)   47 (48%)   22 (44%)  
Provider Fraud 
116 (45%)   51 (52%)   28 (56%)  
(Nonglobal)  
Source: The Utah MFCU provided a list of all  case files open during FYs 2010 through 2012. 
*OIG generated this random sample. 
 
 
 
 
 
 
 
   
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  29  
   
   
Table E-2:  Confidence Intervals for Key Case File Review  Data  
Point  95-Percent Confidence 
Estimate Description  Sample Size 
Estimate  Interval  
Case Files With No 
Documented Supervisory   98   25.5%   18.633.3%  
Approval for Opening  
Case Files With No 
Documented Supervisory   80  12.5%   7.020.5%  
Approval for Closing  
Case Files With No 
Documentation of at 
98   33.7%   26.041.9%  
Least One Supervisory 
Review  
Case Files With No 
Documentation of 
98  60.2%   51.668.2%  
Periodic Supervisory  
Review  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  30  
   
   
APPENDIX F 
Unit Comments 
 
 
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  31  
   
   
 
   
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  32  
   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy S. Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry,  Deputy Regional Inspector General.  
Matthew DeFraga served as the lead analyst for this study.  Other Office 
of Evaluation and Inspections staff from the San Francisco regional office 
who provided support include Rosemary Rawlins.  Central office staff 
who provided support include Susan Burbach, Kevin Farber, 
Christine Moritz, Andrew VanLandingham, and Sherri Weinstein.  Office 
of Investigations staff who provided support include Scott Frye.   
Utah State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-09-13-00490)  33  
   
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.