Department of Health and Human Services 
 
OFFICE OF 
INSPECTOR GENERAL 
C S
ONNECTICUT  TATE 
M F C
EDICAID  RAUD  ONTROL 
U :  2013 O R
NIT      NSITE  EVIEW 
 
Suzanne Murrin  
Deputy Inspector General for 
Evaluation and Inspections 
 
September 2014 
OEI-07-13-00540  EXECUTIVE SUMMARY:  CONNECTICUT STATE MEDICAID FRAUD 
CONTROL UNIT:  2013 ONSITE REVIEW 
OEI-07-13-00540 
 
WHY WE DID THIS STUDY 
The Office of Inspector General (OIG) oversees the activities of all Medicaid Fraud 
Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic 
reviews of all Units and prepares public reports based on these reviews.  The reviews  
assess Unit performance in accordance with the 12 MFCU performance standards and 
monitor Unit compliance with Federal grant requirements.   
 
HOW WE DID THIS STUDY  
We conducted an onsite review in October 2013.  We based our review on an analysis of 
data from seven sources:  (1) a review of policies, procedures, and documentation 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 Unit Director and supervisors; (6) an onsite review of case files; and 
(7) an onsite observation of Unit operations. 
 
WHAT WE FOUND 
For fiscal years 2010 through 2012, the Connecticut Unit reported combined civil and 
criminal recoveries of nearly $84 million and 20 criminal convictions.  Our review 
identified instances in which the Unit did not fully meet Federal regulations or 
performance standards.  Specifically, the Unit did not always maintain case files in an 
effective manner.  The Unit also lacked policies and procedures sufficient to ensure 
timely completion of cases.  Further, the Unit did not provide OIG with adequate 
information to initiate exclusion of convicted individuals.  Additionally, the Unit worked 
on a case not related to Medicaid.  The Units vehicle expenditures were not properly 
allocated, but the Unit otherwise maintained proper fiscal control of its resources.  Lastly, 
during the period we reviewed, the Unit did not regularly communicate and coordinate 
with OIG to investigate and prosecute health care fraud. 
 
WHAT WE RECOMMEND   
The Unit should work with OIGs MFCU oversight division to ensure compliance with 
the 12 performance standards and adhere to Federal regulations.  The Unit concurred with 
all six of our recommendations.    TABLE OF CONTENTS 
Objective......................................................................................................1 

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

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

Findings........................................................................................................5 

For FYs 2010 through 2012, the Connecticut Unit reported 

combined civil and criminal recoveries of nearly $84 million  

and 20 criminal convictions .............................................................5 
 
The Unit did not always maintain case files in an effective  
manner..............................................................................................6 

The Unit did not follow policies and procedures for case 

management .....................................................................................6 

The Unit did not provide OIG with adequate information to  

initiate exclusion of convicted individuals ......................................7 

Unit staff did not work exclusively on Unit-related matters ............8 

The Units vehicle expenditures were not properly allocated, but 

the Unit otherwise maintained proper fiscal control of its  

resources ..........................................................................................9 

During the period we reviewed, the Unit did not regularly  

communicate and coordinate with OIG to investigate and  

prosecute health care fraud ............................................................10 

Other observations: Referrals from the State Medicaid agency ...10 

Conclusion and Recommendations ............................................................12 

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

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

A: 2012 Revised Performance Standards .....................................15 

B: 1994 Performance Standards....................................................22 

C: Methodology ............................................................................26 

D: Point Estimates and 95-Percent Confidence Intervals  

Based on Reviews of Case Files ....................................................29 

E: Investigations Opened and Closed By Provider Category  

for Fiscal Years 2010 Through 2012 ..............................................30 

F: Medicaid Fraud Control Unit Referrals by Referral Source  

for Fiscal Years 2010 Through 2012 ..............................................32 

G: Unit Comments ........................................................................33 

Acknowledgments......................................................................................37 
 OBJECTIVE 
To conduct an onsite review of the Connecticut 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  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.2  Currently, 49 States and the District of Columbia 
(States) have created such Units.3 In Federal fiscal year (FY)4 2012, 
combined Federal and State grant expenditures for the Units totaled 
$217.3 million, and Units employed 1,901 individuals.    
To carry out its duties and responsibilities in an effective and efficient 
manner, each Unit must employ an interdisciplinary staff that consists of at 
least an investigator, an auditor, and an attorney.5  Unit staff review 
complaints provided by the State Medicaid agency and other sources and 
determine the potential for criminal prosecution and/or civil action.  In 
FY 2012, the 50 Units obtained 1,337 convictions and 823 civil 
settlements or judgments.6   That year, the Units reported recoveries of 
more than $2.9 billion.7 
The Unit must be in an office of the State Attorney Generals office, 
another State government office with statewide prosecutorial authority, or 
operate under a formal arrangement with the State Attorney Generals 
office.8  Units are required to have either statewide authority to prosecute 
 
1 Social Security Act (SSA)  1903(q)(3). 
 
2 SSA   1902(a)(61).  Regulations at  42 CFR   1007.11(b)(1) add that the Units 

responsibilities may include reviewing complaints of misappropriation of patients 

private funds in  residential health care facilities. 

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

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

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

7 Ibid. 

8  SSA  1903(q)(1).  

Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)   1  cases or formal procedures to refer suspected criminal violations to an 
office with such authority.9  In 44 States, the Units are located within 
offices of State Attorneys General; in the remaining 6 States, including 
Connecticut, the Units are located in other State agencies.10 Generally, 
Units outside of the offices of State Attorneys General must refer cases to 
other offices with prosecutorial authority. 
Each Unit must be a single identifiable entity of State government, distinct 
from the State Medicaid agency, and each Unit must develop a formal 
agreementi.e., a Memorandum of Understanding (MOU)that 
describes the Units relationship with that agency.11  
Oversight of the MFCU Program 
The Secretary of HHS delegated to the Office of Inspector General (OIG) 
the authority to both annually certify the Units and to administer grant 
awards to reimburse States for a percentage of their costs of operating 
certified Units.12   All Units are currently funded by the Federal 
Government on a 75-percent matching basis, with the States contributing 
the remaining 25 percent.13   To receive Federal reimbursement, each Unit 
must submit an initial application to OIG.14  OIG reviews the application 
and notifies the Unit if the application is approved and the Unit is 
certified. Approval and certification are for a 1-year period; the Unit must 
be recertified each year thereafter.15  
Pursuant to Title XIX of the SSA, States must operate Units that 
effectively carry out their statutory functions and meet program 
requirements.16  OIG developed and issued 12 performance standards to 
further define the criteria it applies in assessing whether a Unit is  
   
 
9 SSA  1903(q)(1). 

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

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

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

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

11 SSA  1903(q)(2) and  42 CFR   1007.9(d).  
 
12 The portion of funds reimbursed to States by the Federal  Government for its share of 
 
expenditures for the Federal  Medicaid program, including  the MFCUs, is  called Federal 
 
Financial Participation  (FFP). 

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

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

Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   2 
  effectively carrying out statutory functions and meeting program  
requirements.17  Examples of criteria include maintaining an adequate 
caseload through referrals from several sources, maintaining an annual 
training plan for all professional disciplines, and establishing policy and 
procedure manuals to reflect the Units operations.  See Appendix A for 
the 2012 performance standards used in this review and Appendix B for 
the 1994 performance standards.  
Connecticut State MFCU 
The Connecticut Unit is located in the Office of the Chief States Attorney  
within the Division of Criminal Justice and is one of seven State MFCUs 
that are not contained within an Office of Attorney General.  Although the 
Connecticut Unit has jurisdiction over all criminal Medicaid fraud cases, it 
is not authorized to prosecute civil matters and all civil matters are 
referred to the Attorney Generals Office.  For some civil referrals, the 
Unit provides support to the Attorney Generals office, such as data 
analysis and compiling and submitting data on behalf of the State for 
global settlements.18   The Unit must approve of and sign all global civil 
settlements as part of its membership and participation in NAMFCU.  In  
addition, the Unit reports to OIG the outcomes in civil recoveries of cases 
worked by the Attorney Generals Office.      
At the time of our review, the Units 10 employees were located in 
Rocky Hill, a suburb of Connecticuts State capital, Hartford. For 
FY 2012, the Connecticut Unit was authorized $1,229,548 in Federal 
funds but expended a total of only $1,150,457 in combined Federal and 
State funds. Total Medicaid expenditures in Connecticut increased from  
$5.7 billion in FY 2010 to $6.7 billion in FY 2012.  
The Unit receives referrals of fraud, abuse, or neglect from the State 
Medicaid agency, the State Department of Public Health, the Attorney 
Generals Office, and private citizens.   The Unit reports to OIG only those 
referrals that the Unit accepts.  
The Unit director receives complaints and determines whether to consider 
them as potential casesin which case the director counts the complaint 
as a referralor to decline the complaint.  All potential cases are entered 
into the electronic case-management  system, assigned a case number, and 
 
17 OIG initially published performance standards in  1994 (59  Fed. Reg. 49080) and issued  
revised standards on June 1,  2012. (See 77 Fed. Reg. 32645.)  Although the 
1994 Performance Standards were in effect  during most of  the review period, we apply  
the 2012 performance standards where appropriate in the findings and report 
recommendations.  
18 Global cases are civil false-claims actions involving the U.S. Department of Justice 
and other State MFCUs.  The National  Association of Medicaid Fraud Control Units  
(NAMFCU) facilitates the settlement of  global cases. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   3 
  assigned a lead investigator, prosecutor, and Forensic Fraud Examiner.  
The lead investigator may immediately open the case, or conduct a 
preliminary investigation to determine whether to open the referral as a 
case. If the referral is not opened as a case, the file will be closed and a 
letter is sent to the entity that referred the complaint.  If the referral is 
opened as a case, the investigation continues.    
Previous Review  
In 2008, OIG conducted an onsite review of the Connecticut MFCU and 
found that prior to December 2007, the Unit did not routinely include 
interim investigative memorandums in its official case files to reflect the 
progress made in investigation.  At that time, the Unit concurred with OIGs 
assessment and stated that the Unit would incorporate a more detailed 
process in the Units policies and procedures to ensure that (1) the Unit 
would routinely include in official Unit case files the interim investigative 
memorandums documenting the progress of Unit investigations, and (2) Unit 
investigative cases do not linger. 
METHODOLOGY 
We conducted an onsite review in October 2013.  We based our review on 
an analysis of data from seven sources:  (1) a review of policies, 
procedures, and documentation 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 Unit Director and supervisors; (6) an onsite review of 
case files; and (7) an onsite observation of Unit operations.  Appendix C 
provides a detailed methodology.  Appendix D contains the point 
estimates and 95-percent confidence intervals for the statistics in this 
report. 
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. 
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   4 
  FINDINGS 
For FYs 2010 through 2012, the Connecticut Unit 
reported combined civil and criminal recoveries of 
nearly $84 million and 20 criminal convictions 
The Unit reported total combined criminal and civil recoveries of nearly 
$84 million for FYs 2010 through 2012.  The majority of the recoveries 
were obtained from global settlements, which accounted for 84 percent of 
the Units recoveries during the period of our review.19  (See Table 1 for 
details regarding criminal and civil recoveries.)  Although the Unit did not 
have the authority to prosecute civil cases, the Unit reported to OIG 
non-global civil recoveries that were made up of global settlements 
obtained for Connecticut-only programs, and recoveries made by the 
Attorney Generals Office as a result of the Units criminal investigations.  
Table 1: Connecticut MFCU Criminal and Civil Recoveries,  
FYs 20102012  
Type of  Total  
FY 2010   FY 2011   FY 2012  
Recovery   Recoveries  
Criminal 
$1,127,194  $258,177  $174,496   $1,559,8676  
Recoveries 
Global Case 
$12,238,431  $38,688,571  $19,657,365   $70,584,367   
Recoveries  
Nonglobal 
 $3,405,848   $7,312,920   $806,862   $11,525,630  
Civil Recoveries 
 Total     
 $16,771,473   $46,259,668   $20,638,723    $83,669,863   
     Recoveries 
Source:  OIG review of Unit self-reported QSRs and other data, FYs 20102012. 
 
 
The number of opened cases decreased significantly during our review 
period, from 110 cases in FY 2010 to 44 cases in FY 2012.  The Unit 
director reported that the Unit was significantly understaffed from  
September 2011 to April 2012 as a result of staff retirements and that this 
understaffing could have contributed to the decline in opened cases.  
Referrals to the Unit also decreased by more than half during our review 
period, from 89 in FY 2010 to 38 in FY 2012.   
During the period we reviewed, the Unit closed 189 investigations, 
charged 21 individuals, obtained 20 criminal convictions, and had 
 
19 Global cases are civil false claims actions involving the U.S. Department of Justice 
and other State MFCUs.  The NAMFCU facilitates the settlement of global cases. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   5 
  4 dismissals.20  See Appendix E for details on investigations opened and 
closed in FYs 2010 through 2012, broken down by provider category.  
The Unit did not always  maintain case files in an 
effective manner 
According to the 2012 Performance Standard 7, the Unit must maintain 
case files in an effective manner and ensure that case files include all 
relevant facts and information. However, some of the case files we 
reviewed lacked basic organizational structure and documentation 
necessary to follow the progression of the case.  
Our review identified that certain case files did not contain documentation 
of relevant facts and information pertaining to the cases.  In 14 percent of 
case files, we were unable to determine when the Unit received the 
referral. Further, Performance Standard 7(c) requires that significant 
documentssuch as charging documents and settlement agreementsbe 
included in the file. Several case files that we reviewed contained only the 
initial complaint and opening and closing memoranda, with no other 
information regarding the investigation.   
In July 2013, subsequent to the period of cases we reviewed, the Unit 
implemented a new policy to standardize its case files.  This policy 
requires that there be a single file for each matter under investigation.  
Additionally, each file should contain  a chronological record, inspectors  
notes, investigation reports, attachments, correspondence, data files, 
evidence, miscellaneous documents, warrants, affidavits, and work 
product. 
The Unit did not follow policies and procedures for 
case management 
According to the 1994 Performance Standard 6 and the 2012 Performance  
Standard 5, the Unit should have a continuous case flow.  Further, the 
1994 Performance Standard 6(c) and the 2012 Performance Standard 7(a) 
state that supervisory reviews should be conducted periodically and noted 
in the case file. These reviews should be conducted in consistence with 
Unit policies and procedures. During our review period, the Unit had 
policies and procedures in place to ensure timely opening of cases and 
periodic supervisory reviews, but supervisors did not always follow these 
policies.  
   
 
20 These dismissals occurred upon the defendants completion of the pretrial diversion 
program, a condition  of which was full restitution. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   6 
  Sixteen percent of cases were not opened in a period of time 
consistent with Unit policy  
The Units policy requires that no more than 60 days elapse between the 
receipt of a referral and the opening of either a case or a preliminary 
investigation period.21 For the 86 percent of cases for which we could 
determine when the Unit received the referral, our review found that 
16 percent of referrals did not result in the opening of a case or the 
beginning of a preliminary investigation within that 60-day timeframe.  
These 16 percent of referrals had a median time of 83 days between when 
the referral was received and when the case was opened or the preliminary 
investigation was begun. The Unit director reported that the Unit was 
significantly understaffed from September 2011 to April 2012 as a result 
of staff retirements and that this understaffing could have contributed to 
the delay in opening cases. 
Supervisory reviews were not conducted in a timeframe 
consistent with Unit policy 
The Units policy during the period we reviewed was to conduct 
supervisory case file reviews once every 3 months.  The Unit policy states 
this is to ensure that cases are progressing at a reasonable pace.  
However, for 82 percent of cases that had been open long enough to 
warrant a supervisory review and that had been determined by the Unit 
director to be full case investigations, the files lacked documentation of  
supervisory reviews that should have taken place under Unit policy.   The 
Unit policy from July 2013 increased the frequency of the required 
supervisory reviews to once a month.  
An additional three cases, identified as preliminary investigations by the 
Unit director, remained open for more than 3 months.  There is no policy 
or procedure for supervisory reviews of such cases because it is the 
supervisor who conducts preliminary investigations.  These three cases 
remained open for 141, 190, and 439 days. 
The Unit did not provide OIG with adequate 
information to initiate exclusion of convicted 
individuals 
According to the 1994 Performance Standard 8(d) and the 
2012 Performance Standard 8(f), the Unit must transmit to OIG, for 
purposes of program exclusion, all pertinent information on Unit 
 
21 After our onsite review, the Unit director informed us that a revised MOU (effective 
January 17, 2014) with the State Medicaid Agency established a 45-day timeframe  
between when  a referral is received and when  a case should be opened  or a preliminary 
investigation  should begin.   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   7 
  convictions within 30 days of sentencing, including charging documents, 
plea agreements, and sentencing orders.  During the period we reviewed, 
the Unit obtained 20 convictions of 19 individuals. However, OIG found 
that the Unit did not transmit documentation sufficient to exclude 14 of 
these 19 individuals, and for the remaining 5 individuals, the Unit 
transmitted no documentation to OIG.  
The Units protocol is to send to OIG a completed electronic form for each 
conviction including name; Social Security number; name of the court; 
docket/court file number; statutory offense(s) and count(s); and a narrative 
description of the act(s) or omission(s) on which the conviction was based.  
The 2012 Performance Standard 8(f) also specifies that the MFCU should 
send OIG copies of Judgment and Sentence or similar court documents.  
For the 14 cases with incomplete information, OIG found that the Unit did 
not provide actual court documents showing conviction and sentencing.  
Also, as of May 2014, the Unit director had provided no documentation to 
OIG on the five remaining convicted individuals. 
Unit staff did not work exclusively on Unit-related 
matters 
According to the 1994 Performance Standard 1 and the 2012 Performance  
Standard 1, the Unit must conform to all applicable statutes, regulations, 
and policy directives.  Further, according to the Medicaid statute and 
Federal regulations, the Unit may receive FFP only for fraud 
investigations that involve allegations of fraud in the administration of the 
Medicaid program, in the provision of Medicaid services, or in the 
activities of Medicaid providers.22    
The Unit investigated one case in our sample that was 
unrelated to Medicaid 
We identified an investigation that involved a drug representative who was 
allegedly forging doctors signatures and obtaining samples of drugs.  The 
suspect was charged with six counts of forgery.  This was not a Medicaid 
case because no claims were made to the Medicaid program in connection 
with the activity.  Unit staff engaged in investigative activity on the case 
from May 20, 2007, through December 1, 2009.  The Unit director 
acknowledged that Unit staff should not have worked on this case; the 
case was opened by the previous director, who left in November 2007. 
   
 
22 SSA    1903(q)(3) and  42 CFR   1007.11(a) and 1007.19(d). 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   8 
  The Unit does not maintain sufficient documentation to 
support that it works exclusively on Unit-related matters 
According to Federal regulations and OIG Policy Transmittal 89-1,23  
professional staff from the Unit must  be full-time employees to receive 
Federal reimbursement.24  The full-time employee policy requires that a 
covered employee work exclusively on Unit matters.  In addition, pursuant 
to Federal regulations, a Unit may claim Federal reimbursement only for 
costs attributable to the establishment and operation of the Unit.  During 
the review period, a review of the Units vehicle usage documentation 
identified instances of at least one employee performing non-MFCU 
related work (e.g., traffic stops, motorist assists).  The Unit director stated 
that such non-MFCU work was performed outside the Medicaid work day 
and at no cost to the MFCU grant.  We were unable to determine, 
however, whether the non-MFCU work was performed during a normal 
workday or during evening or weekend hours, since (a) the Units vehicle 
usage documentation did not always identify the time of day these 
activities occurred and (b) the Units  salary accounting records do not list  
the specific hours or MFCU cases investigated during an employee 
workday.  Because of this lack of documentation, we were unable to 
determine whether the Unit claimed personnel costs for non-MFCU work  
performed by Unit professional staff. 
The Units vehicle expenditures were not properly 
allocated, but the Unit maintained proper fiscal control 
of its resources 
According to the 1994 Performance Standard 1 and the 2012 Performance  
Standard 1, the Unit must conform to all applicable statutes, regulations, 
and policy directives, including Federal cost principles contained in 
2 CFR, part 225.25 For Federal funding to be allocated, costs must be 
properly chargeable or assignable in accordance with the relative benefits 
received.26  Contrary to Federal regulations, the Unit did not properly 
allocate vehicle maintenance and depreciation costs.   
 
23 OIG Policy Transmittal 89-1 was in effect  during our review  period.  On June 3,  2014, 
OIG issued State Fraud Policy Transmittal No. 2014-1, which  superseded Policy 
Transmittal 89-1 regarding the employment of full-time and part-time employees by the  
Units. 
24 42 CFR   1007.19(e)(4). Professional staff includes attorneys, investigators,  
auditors, and managers.  OIG Policy Transmittal 89-1. 
 
25 2 CFR pt. 225 establishes principles for  determining the allowable costs incurred  by  

State, local, and federally recognized Indian tribal governments (governmental units) 

under grants, cost reimbursement contracts, and other agreements with the Federal 
 
Government. 

26 2 CFR pt. 225, Appendix A (C)(3)(a).  
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   9 
  The Division of Criminal Justice authorizes police inspectors to use 
assigned vehicles while off duty. However, the Unit claimed 100 percent 
of the vehicle maintenance and depreciation expenditures for Federal 
reimbursement, including the use of the vehicles while off duty.  
Therefore, off-duty use occurred for which the Federal government did not 
receive any relative benefits.  As a result, the Unit overclaimed vehicle 
maintenance and depreciation expenditures. 
Further, according to the 1994 Performance Standard 11 and the 
2012 Performance Standard 11, the Unit director should exercise proper 
fiscal control over the Units resources.  From FYs 2010 through 2012, 
our review found that the Unit reported program income in accordance 
with applicable Federal requirements and maintained adequate internal 
controls related to accounting, budgeting, personnel, procurement, 
property, and equipment.  During the review period, most of the Units 
expenditures that we examined represented allowable costs in accordance 
with applicable Federal requirements. 
During the period we reviewed, the Unit did not 
regularly communicate and coordinate with OIG to 
investigate and prosecute health care fraud  
42 CFR  1007.11(e) requires units to cooperate with OIG and other 
Federal agencies in the investigation and prosecution of Medicaid and 
other health care fraud. However, OIG reported having irregular, and in 
some instances limited, communication with the Unit for extended periods 
of time during the review period.  According to Unit recertification 
documents, joint OIG-MFCU work on cases declined over the period we 
reviewed, from 30 cases in 2010 to 13 cases in 2012.  Following this 
period, OIG and Unit staff reported that relations between OIG and the 
Unit were improving. 
Other observation:  Referrals from the State Medicaid 
agency  
According to the 1994 Performance Standard 4 and the 2012 Performance  
Standard 4, the Unit should take steps to ensure that it maintains an 
adequate volume and quality of referrals from the State Medicaid agency 
and other sources. During FYs 20102012, the Unit received only 
22 referrals from the State Medicaid agency and accepted 16 referrals.  
The Unit director reported a low volume of referrals from the State 
Medicaid agency.  State Medicaid agency staff attributed the low volume 
of referrals to insufficient staffing.  See Appendix F for more information 
on referrals by referral source. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   10 
  In an attempt to address the low volume of referrals, the Unit director and 
Unit staff collaborated with State Medicaid agency staff to develop an 
Immediate Advisement protocol, which allows the State Medicaid 
agency to informally notify the Unit of a potential fraud case prior to 
making a formal referral.  The Unit integrated this protocol into its 
policies and procedures effective January 1, 2013.  The Unit director 
reported that the protocol increased the volume of potential cases that the 
State Medicaid agency identified.    
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   11 
  CONCLUSION AND RECOMMENDATIONS 
For FYs 2010 through 2012, the Unit reported combined civil and criminal 
recoveries of nearly $84 million.  During the review period, the Unit 
closed 189 investigations with 21 individuals charged, obtained 
20 criminal convictions, and had 4 dismissals. 
However, our review identified instances in which the Unit did not fully  
meet performance standards and adhere to Federal regulations.  
Specifically, the Unit did not always maintain case files in an effective 
manner.  The Unit also lacked policies and procedures sufficient to ensure 
timely completion of cases.  Further, the Unit did not provide OIG with 
adequate information to initiate exclusion of convicted individuals.  
Additionally, the Unit worked on a case not related to Medicaid.  Our 
review determined that the Unit maintained proper fiscal control of its 
resources, but the Units vehicle expenditures were not properly allocated.   
Lastly, during the review period, the Unit did not always communicate 
and coordinate with OIG on a regular basis to investigate and prosecute 
health care fraud.   
We recommend that the Connecticut Unit: 
Ensure that case files are maintained in an effective manner 
The Unit should maintain all case files in an effective manner and ensure 
that case files include all relevant facts and information necessary to 
follow the progression of the case.  
Adhere to Unit policies and procedures for case management  
The Unit should ensure that complaints referred to the Unit are opened and 
investigated, if appropriate, within the 45-day timeframe established in the 
Units new MOU.  The Unit should ensure that all case files contain 
documentation of supervisory reviews in accordance with Unit policy.  
Additionally, the Unit should develop policies and procedures related to 
processing cases that are in preliminary investigation status.  
Refer individuals for exclusion to OIG with the appropriate 
information for exclusion 
The Unit should ensure that individuals convicted of fraud, abuse, and/or 
neglect are reported to OIG within 30 days of their sentencing, in 
accordance with 2012 Performance Standard 8(f).  This referral should 
include information necessary for exclusion, including available court 
documents recording the conviction and sentencing of the defendant. 
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   12 
  Ensure Unit professional staff perform only Unit-related duties 
in accordance with performance standards and Federal 
regulations 
The Unit should not investigate cases outside the scope of the Federal 
grant and should work with OIG to identify the staff hours and related 
expenditures that should be repaid.  The Unit should develop internal 
controls to document that professional staff work only on MFCU-related 
matters while on duty.   
Properly allocate vehicle costs  
The Unit should institute a policy to ensure that maintenance and 
depreciation expenditures that are not related to allowable MFCU 
activities are not allocated to the Federal grant.   
Regularly communicate and coordinate with OIG to investigate 
and prosecute Medicaid fraud 
The Unit should continue to improve cooperation with OIG to investigate 
and prosecute Medicaid fraud. 
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   13 
  UNIT RESPONSE AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Connecticut Unit concurred with all six of our recommendations. 
The Unit concurred with our recommendation that it ensure that case files 
are maintained in an effective manner.   The Unit stated that in July 2013, it 
implemented a new policy designed to ensure that 100 percent of the files 
are dated and organized correctly. 
The Unit concurred with our recommendation that it adhere to its policies 
and procedures for case management.  The Unit stated that it has already 
taken steps to cure lapses in supervisory review documentation by 
requiring the supervisor who reviews investigations to forward written 
documentation to the director for approval before filing.  Further, the Unit 
stated that it will adjust policy and procedures for cases in preliminary 
investigation status. 
The Unit concurred with our recommendation that it refer individuals for 
exclusion to OIG with the appropriate information for exclusion.   
The Unit stated that it provides OIG with adequate information to initiate  
the exclusion of convicted individuals. We wish to clarify that if the Unit 
were to provide OIG with a certified copy of the court document called an 
Information, this would be sufficient to initiate an exclusion. 
The Unit concurred with our recommendation that it ensure that its 
professional staff perform only Unit-related duties in accordance with 
performance standards and Federal regulations.   
The Unit stated that its documentation is adequate to demonstrate when 
professional staff are working in the Unit and when they are not, and 
added that the examples we provided involved hours that fell outside of 
the regular Unit workday.  OIG continues to find that documentation of 
non-Unit work does not contain discernible hours for such incidents; 
further, Unit timecards do not contain discernible start and end 
times.  Therefore, we advise the Unit to improve its documentation.  
The Unit concurred with our recommendation that it properly allocate 
vehicle costs. The Unit will institute a policy that maintenance and 
depreciation expenditures related to the night and weekend usage of 
assigned State vehicles not be allocated to the Federal grant.  
The Unit concurred with our recommendation that it regularly 
communicate and coordinate with OIG to investigate and prosecute 
Medicaid fraud. The Unit agreed that the working relationship has 
improved, and said that it will do its part to continue the positive trend.   
The full text of the Units comments is provided in Appendix G. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   14 
  APPENDIX A 
2012 Revised Performance Standards27   
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 
 
27 77 Fed. Reg. 32645, June  1, 2012. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   15 
  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). 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   16 
  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.  
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   17 
  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 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   18 
  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. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   19 
  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 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. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   20 
  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. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   21 
  APPENDIX B 
1994 Performance Standards28   
1. 	A Unit will be in conformance with all applicable statutes, 
regulations and policy transmittals.  In meeting this standard, the 
Unit must meet, but is not limited to, the following requirements:  
a. 	  The Unit professional staff must consist of permanent employees 
working full-time on Medicaid fraud and patient abuse matters. 
b.	   The Unit must be separate and distinct from the State Medicaid 
agency.  
c. 	  The Unit must have prosecutorial authority or an approved formal 
procedure for referring cases to a prosecutor. 
d. 	  The Unit must submit annual reports, with appropriate 

certifications, on a timely basis. 
 
e. 	  The Unit must submit quarterly reports on a timely basis. 
f. 	  The Unit must comply with the Americans with Disabilities Act, 
the Equal Employment opportunity requirements, the Drug Free 
workplace requirements, Federal lobbying restrictions, and other 
such rules that are made conditions of the grant. 
2. 	A Unit should maintain staff levels in accordance with staffing 
allocations approved in its budget. In meeting this standard, the 
following performance indicators will be considered: 
a. 	  Does the Unit employ the number of staff that was included in the 
Units budget as approved by the 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: 
a. 	  Does the Unit have policy and procedure manuals? 
 
28 59 Fed. Reg. 49080, Sept. 26, 1994. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   22 
  b. 	  Is an adequate, computerized case management and tracking 
system in place? 
4. 	A Unit should take steps to ensure that it maintains an adequate 
workload through referrals from the State Medicaid agency and 
other sources. In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit work with the State Medicaid agency to ensure 
adequate fraud referrals? 
b. 	  Does the Unit work with other agencies to encourage fraud 
referrals? 
c. 	  Does the Unit generate any of its own fraud cases? 
d. 	  Does the Unit ensure that adequate referrals of patient abuse 
complaints are received from all sources? 
5. 	A Units case mix, when possibl e, should cover all significant 
provider types. In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit seek to have a mix of cases among all types of 
providers in the State? 
b. 	  Does the Unit seek to have a mix of Medicaid fraud and Medicaid 
patient abuse cases? 
c. 	  Does the Unit seek to have a mix of cases that reflect the 
proportion of Medicaid expenditures for particular provider 
groups? 
d. 	  Are there any special Unit initiatives targeting specific provider 
types that affect case mix? 
e. 	  Does the Unit consider civil and administrative remedies when  
appropriate? 
6. 	A Unit should have a continuous case flow, and cases should be 
completed in a reasonable time. In meeting this standard, the 
following performance indicators will be considered:  
a. 	  Is each stage of an investigation and prosecution completed in an 
appropriate time frame?  
b. 	  Are supervisors approving the opening and closing of 

investigations?
   
c. 	  Are supervisory reviews conducted periodically and noted in the 
case file? 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   23 
  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? 
b. 	  Does the Unit provide program recommendations to State 

Medicaid agency when appropriate? 

Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   24 
  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 MOU with the State 
Medicaid agency and seek amendments, as necessary, to ensure 
it reflects current law and practice.  In meeting this standard, the 
following performance indicators will be considered:  
a. 	  Is the MOU more than 5 years old? 
b. 	  Does the MOU meet Federal legal requirements? 
c. 	  Does the MOU address cross-training with the fraud detection staff  
of the State Medicaid agency? 
d. 	  Does the MOU address the Units responsibility to make program  
recommendations to the Medicaid agency and monitor actions  
taken by the Medicaid agency concerning those recommendations? 
11. 	The Unit director should exercise proper fiscal control over the 
Unit resources.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit director receive on a timely basis copies of all fiscal 
and administrative reports concerning Unit expenditures from the 
State parent agency? 
b. 	  Does the Unit maintain an equipment inventory?  
c. 	  Does the Unit apply generally accepted accounting principles in its 
control of Unit funding? 
12. 	A Unit should maintain an annual training plan for all 
professional disciplines.  In meeting this standard, the following 
performance indicators will be considered:  
a. 	  Does the Unit have a training plan in place and funds available to 
fully implement the plan? 
b. 	  Does the Unit have a minimum number of hours training 
requirement for each professional discipline, and does the staff 
comply with the requirement? 
c. 	  Are continuing education standards met for professional staff? 
d. 	  Does the training undertaken by staff add to the mission of the 
Unit? 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   25 
  APPENDIX C 
Methodology  
Data collected from the seven sources below was used to describe the 
caseload and assess the performance of the Unit.   
Data Collection 
Review of Unit Documentation. Prior to the onsite visit, we analyzed 
information from several sources regarding how the Unit investigated 
Medicaid cases and referred them  for prosecution.  Specifically, we 
collected and analyzed information about the number of referrals the Unit 
received, the number of investigations the Unit opened and closed, the 
outcomes of those investigations, and the Units case mix.  We also 
collected and analyzed information about the number of cases that the 
Unit referred for prosecution and the outcomes of those prosecutions.  We  
gathered this information from several sources, including the Units QSRs, 
its annual reports, its recertification questionnaire, its policy and 
procedures manuals, its MOU with the State Medicaid agency, and the 
2008 OIG report on the previous onsite review.  Additionally, we 
confirmed with the Unit director that the information we had was current 
as of October 2013, and as necessary, we requested any additional data or 
clarification.    
Review of Fiscal Control.  We reviewed the Units control over its fiscal 
resources to identify any internal control issues or other issues involving 
use of resources. Prior to the onsite review, we reviewed the Units 
financial policies and procedures; its response to an internal control 
questionnaire; and documents (such as financial status reports) related to 
MFCU grants. During the onsite review, we reviewed a sample of the 
Units purchase and travel transactions.  In addition, we reviewed vehicle 
records, the equipment inventory, and a sample of time and effort records.  
Interviews With Key Stakeholders. In September 2013, we interviewed key 
stakeholders, such as officials in the United States  Attorneys Offices, the 
Attorney Generals Office, and other agencies that interacted with the Unit 
(i.e., the State Department of Public Health, the State Department of Social 
Services, the Office of the State Long Term Care Ombudsman, and the State 
Bureau of  Aging).  We focused these interviews on the Units relationship 
and interaction with OIG and other Federal and State authorities, and we 
identified opportunities for improvement.  We used the information collected 
from these interviews to develop subsequent interview questions for Unit 
management. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   26 
  Survey of Unit Staff.  In September 2013, we conducted an online survey 
of all nonmanagerial Unit staff within each professional discipline 
(i.e.,  investigators, auditors, and attorneys) as well as support staff.  The 
response rate was 100 percent. Our questions focused on operations of the 
Unit, opportunities for improvement, and practices that contributed to the 
effectiveness and efficiency of Unit operations and/or performance.  The  
survey also sought information about the Units compliance with 
applicable laws and regulations. 
Onsite Interviews With Unit Management.   We conducted structured 
interviews with the Units management in October 2013.  We interviewed 
the Unit director (who also served as the Units lead attorney) and the 
supervisory investigator.  We asked these individuals to provide additional 
information to better understand the Units operations and clarify 
information obtained from other data sources.  Finally, we discussed the 
status of their actions with respect to recommendations from the 
2008 report. 
Onsite Review of Case Files and Other Documentation. The Unit 
provided a list of 246 cases that were open at any point during FYs 2010 
through 2012. We excluded from our analysis 68 of these cases that the 
Unit had categorized as global. We then selected a simple random  
sample of 100 cases from the remaining 178 cases.  We reviewed all 
sampled case files for documentation of supervisory reviews for the 
opening and closing (as appropriate) of cases, as well as to see whether 
supervisors conducted periodic case file reviews.  From these 100 case 
files, we selected a further simple random sample of 50 files for a more 
in-depth review of selected issues, such as the timeliness of investigations  
and case development.  Subsequent to our review, we removed one case 
from our sample because it was a case that had been assigned a new 
number when it was reopened following a parole violation.  We projected 
the results of our review of the 99 case files to the population of Unit 
cases. 
Onsite Review of Unit Operations.  During our October 2013 site visit, we 
reviewed the Units workspace and operations.  Specifically, we visited 
the Unit headquarters in the State capital.  While onsite, we observed the 
Units offices and meeting spaces, security of data and case files, location 
of select equipment, and the general functioning of the Unit. 
Data Analysis  
We analyzed data to identify any opportunities for improvement and any 
instances in which the Unit did not fully meet the performance standards  
or was not operating in accordance with laws, regulations, and policy 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   27 
  transmittals.29  In addition, we noted practices that appeared to be 
beneficial to the Unit. We based these observations on statements from  
Unit staff, data analysis, and our own judgment.  We did not 
independently verify the effectiveness of these practices, but included the 
information because it may be useful to other Units in their operations.  
 
   
 
29 All relevant  regulations, statutes, and  policy transmittals are available online at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu.  
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   28 
  APPENDIX D 
Point Estimates and 95-Percent Confidence Intervals Based on  
Reviews of Case Files 
We calculated confidence intervals for key data points for our reviews of 
case files. The sample sizes, point  estimates, and 95-percent confidence 
intervals are given for the each of the following:  
Table D-1: Confidence Intervals for Case File Review  Data  
Sample 
Data Element Description   Point Estimate   95-Percent Confidence Interval  
Size 
Case files lacking documentation of when 
99  14.1%   10.1%19.5%  
the referrals  were received by the Unit  
Case files were not opened within 60 days  
85  16.5%*   11.8%22.5%  
from receipt of a referral 
Case files lacking documentation of 
supervisory reviews consistent with Unit  51**  82.4%   74.1%88.4%  
policy   
*The actual percentage of  files for cases not opened within 60 days of receipt is 16.47 percent.  The number 16.47 rounds to 16.5.  As a 
 
whole number, however, this percentage rounds to 16 percent. 

**We reviewed only the  files for cases that were open for longer than 3 months.  The review of one case file did not indicate whether the 
 
periodic supervisory reviews were consistent with Unit policy, so  that case file was excluded. 

Source:  OIG analysis of Connecticuts MFCU case files, 2014. 

   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   29 
  APPENDIX E 
Investigations Opened and Closed By Provider Category for 
FYs 2010 Through 2012 
Table E-1:  Fraud Investigations  
Provider Category   FY 2010   FY 2011   FY 2012  
Facilities   Opened  Closed  Opened  Closed  Opened   Closed 
 Hospitals  3  3  0  0  0  0 
     Nursing Facilities   3  4  3  2  0  1 
     Other Long-Term Care   
0  0  0  0  0  0 
     Facilities  
     Substance Abuse Treatment            
0  0  0  0  0  0 
Centers  
     Other   0  0  0  0  0  0 
   Subtotal   6  7  3  2  0  1 
Practitioners   Opened  Closed  Opened  Closed  Opened   Closed 
     Doctors of Medicine or  
8  5  7  6  6  5 
     Osteopathy  
Dentists  3  3  3  2  4  1 
Podiatrists  0  0  0  0  0  0 
     Optometrists/Opticians  1  1  1  1  0  0 
     Counselors/Psychologists  3  3  1  2  1  0 
Chiropractors  0  0  1  0  0  1 
     Other   1  1  1  0  1  1 
   Subtotal   16  13  14  11  12  8 
Medical Support  Opened   Closed   Opened   Closed   Opened   Closed 
 Pharmacies 
0  2  4  3  2  2 
Pharmaceutical 
     Manufacturers   17  11  11  19  3  4 
Suppliers of Durable Medical 
Equipment and/or Supplies  8  5  5  4  2  4 
Labs 
1  1  0  3  0  0 
     Transportation Services 
1  1  0  0  0  0 
     Home Health Care Agencies  
3  1  3  3  1  2 
     Home Health Care Aides  
2  7  2  5  1  1 
     Nurses, Physicians Assistants,  
Nurse Practitioners, Certified  
Nurse Aides  1  1  0  1  3  4 
Radiologists 
0  0  0  0  0  0 
     Medical SupportOther  
1  1  1  0  2  4 
   Subtotal   34  30  26  38  14  21 
 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   30 
  Table E-1 (Continued):  Fraud Investigations  
Program  Related   Opened  Closed  Opened  Closed  Opened   Closed 
     Managed Care    0  0  1  0  0  0 
Medicaid Program  
0  0  0  0  0  0 
Administration 
Billing Company   0  0  0  0  0  0 
     Other  6  7  3  4  0  1 
   Subtotal   6  7  4  4  0  1 
   Total Provider Categories   62  57  47  55  26  31 
Source:  OIG analysis of Unit-submitted documentation, FYs 20102012. 
Table E-2:  Patient Abuse and Neglect Investigations  
Provider Category   FY 2010   FY 2011   FY 2012  
  Opened  Closed  Opened  Closed  Opened   Closed 
     Nursing Facility   19  23  4  2  9  5 
     Other Long-Term Care   2  2  1  1  0  0 
Nurses, Physicians 
Assistants, Nurse 
0  1  0  0  0  0 
Practitioners, Certified Nurse 
Aides 
     Home Health Aides  1  0  0  1  0  0 
     Other   2  3  4  2  2  3 
Total   24  29  9  6  11  8 
Source: OIG analysis of Unit-submitted documentation, FYs 20102012. 
.Table E-3: Patient Funds Investigations  
Provider Category   FY 2010   FY 2011   FY 2012  
  Opened  Closed  Opened  Closed  Opened   Closed 
     Nondirect Care   2  1  0  0  0  1 
Nurses, Physicians 
Assistants, Nurse 
0  0  0  0  0  0 
Practitioners, Certified Nurse 
Aides 
     Home Health Aides  0  0  0  0  0  0 
     Other  0  0  0  0  0  0 
Total   2  1  0  0  0  1 
Source: OIG analysis of Unit-submitted documentation, FYs 20102012. 
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   31 
  APPENDIX F 
Medicaid Fraud Control Unit Referrals by Referral Source for 
FYs 2010 Through 2012 
FY 2010   FY 2011   FY 2012  
Abuse &   Patient  Abuse &   Patient  Abuse &   Patient 
Referral Source   Fraud   Fraud   Fraud  
Neglect   Funds   Neglect   Funds   Neglect   Funds  
Medicaid Agency  
(Office of Quality 
Assurance)  
30 
PI/SURS   4  1  0   6  0  0  5  0  0 
Medicaid Agency  
Attorney General  
33  15  1  26  0  0  12  3  1 
State Survey & 
Certification 
0  0  0  0  0  0  0  0  0 
Other State 
Agencies 
0  0  0  0  0  0  1  0  0 
Licensing Board 
10  5  1  1  4  0  1  5  0 
Law Enforcement 
2  1  0  1  0  0  2  0  0 
Office of Inspector 
General 
2  0  0  2  0  0  0  0  0 
Prosecutors 
0  0  0  0  0  0  0  0  0 
Providers 
3  0  0  2  0  0  0  0  0 
Provider 
Associations  
0  0  0  0  0  0  0  0  0 
Private Health 
Insurer 
0  0  0  0  0  0  1  0  0 
Long Term Care 
Ombudsman  
0  0  0  0  1  0  0  0  0 
Adult Protective 
Services  
0  0  0  0  0  0  0  0  0 
Private Citizens 
9  2  0  8  4  0  4  2  0 
MFCU Hotline 
0  0  0  0  0  0  0  0  0 
Other  
0  0  0  0  0  0  0  1  0 
   Total   63  24  2  46  9  0  26  11  1 
   Annual Total  89  55  38 
Source:  OIG analysis of Unit-submitted documentation, FYs 20102012. 
   
 
30 PI = program integrity; SURS  = Surveillance and  Utilization Review 
Subsystem. 
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   32 
  APPENDIX G 
Unit Comments 
 
 
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   33 
   
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   34 
   
 
 
   
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   35 
  July 16, 2014 
Page 4 
Contrary to the statement in the report, the Inspectors' employment contract and 
our employee time sheets, both of which were provided to the auditors, clearly show 
that Inspectors do not work either at night or on weekends.  Accordingly, I conclude 
that our documentation is adequate to demonstrate when Inspectors are working in the 
MFCU and when they are not. 
Recommendation 5:  Properly allocate vehicle costs. 
Response:  I concur.  Proper fiscal control is paramount.  I appreciate the comment in 
the  report that the  Unit maintained proper fiscal  control of its  resources.  We will 
continue to ensure that we do so by instituting a policy which provides that maintenance 
and depreciation expenditures related to the night and weekend usage of assigned 
state vehicles are not allocated to the federal grant. 
Recommendation  6:  Regularly  communicate  and  coordinate  with  OIG  to 
investigate and prosecute Medicaid fraud. 
Response:  I  concur.  The  Unit's  working  relationship  with  OIG,  like  all  such 
relationships, has had both its good and less-than-good moments.  For that reason 
alone,  the relationship  should  be judged over time,  not at a specific point in  time. 
Communication and cooperation is a two-way street.  Maintenance of good working 
relationships is a priority for us.  As noted in the report, the working relationship has 
improved and we will do our part to continue the positive trend. 
The Connecticut Medicaid Fraud Control Unit appreciates the professional and 
courteous efforts of your office during the  review process.  We look forward  to  a 
continued good working relationship. 
Very truly yours, 
CHRISTOPHER T. GODIALIS 
Supervisory Assistant State's Attorney 
Director-Medicaid Fraud Control Unit 
Connecticut State Medicaid Fraud Control Unit: 2013 Onsite Review (OEI-07-13-00540)  36  ACKNOWLEDGEMENTS 
This report was prepared under the direction of Brian T.  Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City 
regional office.   
Teresa Dailey served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff who conducted the study include 
Thomas Brannon, Jordan R. Clementi, and Rae Hutchison.  Office of 
Investigations staff who conducted the study include Dwight Q. Jackson.  
Central office staff who provided support include Christine Moritz and 
Sherri Weinstein.  
Connecticut State Medicaid Fraud Control Unit:  2013 Onsite Review  (OEI-07-13-00540)                                   37 
  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.