Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
   
 
 
 
 
W S M
YOMING  TATE  EDICAID 
 
 
F C U :  
RAUD  ONTROL  NIT  
 
  2016 O R  
  NSITE  EVIEW
 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
 
September 2017 
OEI-09-16-00530 
 
   
   
WYOMING STATE MEDICAID FRAUD CONTROL UNIT:  
2016 ONSITE REVIEW 
OEI-09-16-00530 
WHY WE DID THIS STUDY  
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit 
(MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units' 
performance in accordance with the requirements of the grant.  As part of this oversight, 
OIG conducts periodic reviews of all Units and prepares public reports based on these 
reviews.  These reviews assess the Units adherence to the 12 MFCU performance 
standards and compliance with applicable Federal statutes and regulations.  
HOW WE DID THIS STUDY 
We conducted an onsite review of the Wyoming Unit in October 2016.  We based our 
review on an analysis of data from six sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; (2) financial 
documentation for fiscal years (FYs) 2013 through 2015; (3) structured interviews with 
key stakeholders; (4) structured interviews with Unit staff; (5) files for all cases that were 
open in FYs 2013 through 2015; and (6) observation of Unit operations. 
WHAT WE FOUND 
For FYs 2013 through 2015, the Wyoming Unit reported obtaining 11 criminal 
convictions; 25 global civil judgments and settlements; and total recoveries of over 
$3 million.  We found that the Wyoming Unit was generally in compliance with 
applicable laws, regulations, and policy transmittals, and the Unit overcame training 
barriers by working with another MFCU to train its newly hired investigator.  However, 
we identified three areas of concern:  (1) the Unit did not pursue civil fraud cases other 
than global civil fraud cases (i.e., cases that involve the National Association of 
Medicaid Fraud Control Units and typically involve a group of MFCUs) during the 
review period; (2) although the Unit referred cases to its Federal and State agency 
partners, its written procedures for such referrals were incomplete; and (3) the Unit did 
not employ any investigators for a period of approximately 6 months, which appeared to 
have negative consequences for Unit investigations. 
WHAT WE RECOMMEND 
We recommend that the Wyoming Unit (1) develop and implement a plan to improve its 
ability to pursue nonglobal fraud cases as civil matters; (2) incorporate procedures for 
referring cases to Federal partners and other State agencies into its written policies and 
procedures manual; and (3) take steps to ensure that it does not lack an investigator for a 
significant period of time.  The Unit concurred with all three recommendations. 
 
   
   
TABLE OF CONTENTS 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................5 
For FYs 2013 through 2015, the Unit reported 11 convictions,     
25 global civil judgments and settlements, and total recoveries     
of approximately $3.2 million..........................................................5 
The Unit did not pursue nonglobal cases of civil fraud during      
the FY 20132015 review period ....................................................6 
Although the Unit referred cases to its Federal and State       
agency partners, its written procedures for such referrals were 
incomplete ........................................................................................6 
The Unit did not employ any investigators for a period of 
approximately 6 months, which appeared to have negative 
consequences for Unit investigations...............................................7 
Other observation .........................................................................................8 
The Unit overcame training barriers by working with another 
MFCU to train its newly hired investigator .....................................8 
Conclusion and Recommendations ..............................................................9 
Unit Comments and Office of Inspector General Response .......... 11 
Appendixes ................................................................................................12 
A:  2012 Performance Standards ...................................................12 
B:  Referrals to the Wyoming MFCU, by Referral Source,                   
FYs 2013 Through 2015 ................................................................16 
C:  Investigations Opened and Closed by the Wyoming 
MFCU, by Case Type, FYs 2013 Through 2015 ...........................17 
D:  Detailed Methodology .............................................................18 
E:  Unit Comments.........................................................................21 
Acknowledgments......................................................................................26 
 
   
 
OBJECTIVE 
To conduct an onsite review of the Wyoming State Medicaid Fraud 
Control Unit (MFCU or Unit). 
BACKGROUND 
The mission of MFCUs is to investigate and prosecute Medicaid provider 
fraud and patient abuse or neglect under State law.1  The Social Security 
Act (SSA) requires each State to operate a MFCU, unless the Secretary of 
Health and Human Services determines that operation of a Unit would not 
be cost-effective because minimal Medicaid fraud exists in a particular 
State and 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 MFCUs.3   
Each Unit must employ an interdisciplinary staff that consists of at least an 
investigator, an auditor, and an attorney.4  Unit staff review referrals of 
provider fraud and patient abuse or neglect to determine their potential for 
criminal prosecution and/or civil action.  In fiscal year (FY) 2016, the 
50 Units collectively reported 1,564 convictions; 998 civil judgments or 
settlements; and almost $1.9 billion in recoveries.5, 6 
Units must meet a number of requirements established by the SSA and 
Federal regulations.  For example, each Unit must: 
  be a single, identifiable entity of State government, distinct from 
the single State Medicaid agency;7 
 
1 Social Security Act  1903(q)(3).  Regulations at 42 CFR  1007.11(b)(1) add that a 
Units responsibilities may include reviewing complaints of misappropriation of patients 
private funds in residential health care facilities. 
2 SSA  1902(a)(61).   
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 SSA  1903(q)(6); 42 CFR 1007.13. 
5 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2016, 
Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on March 7, 2017. 
6 All FY references in this report are based on the Federal FY (October 1 through 
September 30). 
7 SSA  1903(q)(2); 42 CFR  1007.5 and 1007.9(a). 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  1 
   
   
  develop a formal agreement, such as a memorandum of 
understanding (MOU) that describes the Units relationship with 
the State Medicaid agency;8 and   
  have either statewide authority to prosecute cases or formal 
procedures to refer suspected criminal violations to an agency with 
such authority.9   
MFCU Funding 
Each MFCU is funded jointly by its State and the Federal government.  
Federal funding for the MFCUs is provided as part of the Federal 
Medicaid appropriation, but it is administered by the Department of 
Health and Human Services (HHS) Office of Inspector General (OIG).10  
Each Unit receives Federal financial participation equivalent to 75 percent 
of its total expenditures, with State funds contributing the remaining 
25 percent.11  In FY 2016, combined Federal and State expenditures for the 
Units totaled approximately $259 million, approximately $194 million of 
which represented Federal funds.12 
Administration and Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to administer the 
MFCU grant program.13  To receive Federal reimbursement, each Unit 
must submit an initial application to OIG for approval and be recertified 
each year thereafter.    
In annually recertifying the Units, OIG evaluates Units compliance with 
Federal requirements and their adherence to performance standards.  The 
Federal requirements for Units are contained in the SSA, regulations, and 
policy transmittals.14  In addition, OIG has published 12 performance 
standards that it uses to assess whether a Unit is effectively performing its 
responsibilities.15  The standards address topics such as staffing, maintaining 
adequate referrals, and cooperation with Federal authorities.  Appendix A 
contains these performance standards.  
 
8 42 CFR  1007.9(d).  
9 SSA  1903(q)(1). 
10 SSA  1903(a)(6)(B). 
11 Ibid. 
12 OIG, MFCU Statistical Data for Fiscal Year 2016, Accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on March 7, 2017. 
13 The SSA authorizes the Secretary of HHS to award grants to the Units (SSA 
 1903(a)(6)(B)); the Secretary delegated this authority to the OIG. 
14 On occasion, OIG issues policy transmittals to provide guidance and instructions to 
MFCUs. 
15 77 Fed. Reg. 32645 (June 1, 2012).  
 
 
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OIG also performs periodic onsite reviews of the Units, such as this review 
of the Wyoming MFCU.  During these onsite reviews, OIG evaluates Units 
compliance with laws, regulations, and policy transmittals, as well as 
adherence to the 12 performance standards.  OIG also makes observations 
about beneficial practices, provides recommendations to the Units, and 
monitors the implementation of the recommendations.  These evaluations 
differ from other OIG evaluations, as they support OIGs direct 
administration of the MFCU grant program.  These evaluations are subject to 
the same internal quality controls as other OIG evaluations, including 
internal peer review.     
OIG provides additional oversight, including collecting and disseminating 
performance data; conducting training; and providing technical assistance. 
Wyoming MFCU  
The Wyoming Units office is located in Cheyenne.  The Unit is an 
autonomous entity within the States Office of the Attorney General.  At 
the time of our review, the Units staff was composed of an attorney (who 
also acted as the Units director), an investigator, an auditor, and a 
paralegal/office manager.  The Units attorney/director directly supervised 
the other three staff members.  
The Unit receives referrals from the States Division of Healthcare 
Financing, which is the program integrity unit within the State Medicaid 
agency.  The Unit also receives referrals from other sources, such as OIG, 
private citizens and other State agencies.  Appendix B illustrates the Units 
referrals, by source, for FYs 2013 through 2015.  When the Unit receives a 
referral, the Units investigator or auditor conducts a preliminary 
assessment to determine whether the allegation has the potential for full 
investigation and is within the Units MFCU grant authority.  If the 
referral meets these criteria, the director then decides whether to open a 
case, have Unit staff conduct further preliminary investigation, or send the 
referral to another agency. 
After the Unit opens a case, the Units investigator and/or auditor conducts 
a full investigation.  The Wyoming Unit has the authority to investigate 
matters of Medicaid fraud and cases of patient abuse and neglect,16 but 
does not have original authority to prosecute criminal matters, which 
instead is vested with the county District Attorneys located across the 
State.  However, District Attorneys may exercise their discretion to jointly 
prosecute cases with the Unit or authorize the Unit to proceed with the 
 
16 For the purposes of this report, the category of patient abuse and neglect includes the 
misappropriation or theft of private funds belonging to patients in residential health care 
facilities.  
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  3 
   
   
prosecution.  Appendix C illustrates the number and type of investigations 
that were opened and closed by the Unit for FYs 2013 through FY 2015.   
Previous Review 
In 2011, OIG issued a report regarding its August 2010 onsite review of 
the Wyoming Unit.  OIG made one recommendation in that report 
regarding the Units MOU with the State Medicaid agency.  That 
recommendation is now closed. 
METHODOLOGY 
We conducted the onsite review in October 2016.  We based our review 
on an analysis of data from six sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; 
(2) financial documentation for FYs 2013 through 2015; (3) structured 
interviews with key stakeholders; (4) structured interviews with Unit staff; 
(5) files for cases that were open at some point during FYs 20132015; 
and (6) observation of Unit operations.  Appendix D provides details of 
our methodology.   
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. 
 
 
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FINDINGS 
For FYs 2013 through 2015, the Unit reported 
11 convictions, 25 global civil judgments and 
settlements, and total recoveries of approximately 
$3.2 million 
The Unit reported 11 convictions over the 3-year period9 that involved 
provider fraud and 2 that involved patient abuse or neglect.  All 25 of the 
Units civil judgments and settlements for FYs 2013 through 2015 were 
the result of global cases.17  See Exhibit 1 for yearly convictions and 
global civil judgments and settlements.  
Exhibit 1:  Convictions and Global Civil Judgments and Settlements, 
FYs 2013 Through 2015 
3-Year 
Case Outcomes  FY 2013  FY 2014  FY 2015 
Total 
Convictions  3  5  3  11 
Global Civil Judgments and 
13  9  3  25 
Settlements 
Source:  OIG review of MFCU self-reported quarterly and annual statistical reports and other data, 2016. 
Approximately $140,000 of the Units $3.2 million in total recoveries 
were from criminal cases.  The Units criminal recoveries declined each 
year of the review period, from $76,388 in 2013 to $21,013 in 2015.  Unit 
management explained that the low criminal recoveries in FY 2015 
resulted in part from the departures of the Units sole investigator and 
attorney at the beginning of that FY.18  Approximately $3 million of the 
$3.2 million in total recoveries was from global civil cases.  See 
Exhibit 2 for yearly criminal recoveries, global civil recoveries, and Unit 
expenditures.19   
 
17 Global cases are civil False Claims Act cases that are litigated in Federal courts by 
the U.S. Department of Justice and typically involve a group of MFCUs.  The National 
Association of Medicaid Fraud Control Units facilitates the settlement of global cases on 
behalf of the States. 
18 For about a 6-month period during FY 2015, the Unit did not employ any investigators, 
and its sole attorney (appointed to the Unit by the Attorney Generals Office) served the 
Unit on an interim rather than a long-term basis.  The Unit did not provide further 
explanation for the decline in recoveries from FY 2013 to FY 2014.      
19 Figures in this paragraph and Exhibit 2 are rounded. 
 
 
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Exhibit 2:  Wyoming MFCU-Reported Recoveries and Total Expenditures, 
by Year, FYs 2013 Through 2015 
Recovery Types  FY 2013  FY 2014  FY 2015  3-Year Total 
Total Civil and Criminal Recoveries  $1,623,272  $1,512,626  $44,448  $3,180,346 
     Global Civil Recoveries  $1,546,884   $1,469,685  $23,435  $3,040,004 
     Criminal Recoveries  $76,388  $42,941  $21,013  $140,342 
Total Expenditures  $489,024   $485,829  $410,907  $1,385,760 
    
Source:  OIG review of MFCU self-reported quarterly and annual statistical reports and other data, 2016. 
 
The Unit did not pursue nonglobal cases of civil fraud 
during the FY 2013-2015 review period 
Although the Wyoming Unit reported judgments, settlements, and 
recoveries from global civil cases, Unit management reported no nonglobal 
civil judgments, settlements, or recoveries for the 3-year review period.20  
Wyoming enacted a Medicaid False Claims Act in 2013,21 and OIG State 
Fraud Policy Transmittal 99-01 states that all provider fraud cases that are 
declined criminally [should] be investigated and/or analyzed fully for their 
civil potential.22  However, Unit management reported that if a case did not 
have potential for criminal prosecution, the Unit would not pursue it as a 
civil fraud case and would refer the case to another agency. 
 During interviews at the time of our onsite review, Unit management 
reported that it had made pursuing nonglobal civil fraud cases a priority 
beginning in FY 2016.  Consequently, the Unit settled its first nonglobal 
civil fraud case in January 2017. 
 
20 One consequence of not pursuing civil fraud cases was that the Unit did not maintain a 
balance of criminal and civil fraud cases in adherence with OIG performance standards.  
Performance standard 6(E) states As part of its case mix, the Unit seeks to maintain, 
consistent with its legal authorities, a balance of criminal and civil fraud cases. 
21 The Wyoming Medicaid False Claims Act includes civil penalties for false Medicaid 
claims.  Wyoming Statute  42-4-301 to -306 (2013). 
22 OIG, State Fraud Policy Transmittal 99-01, p. 2.  This policy transmittal further states 
that Units should either try meritorious civil cases under State law or refer them to the 
U.S. Department of Justice or the U.S. Attorneys Office. 
 
 
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Although the Unit referred cases to its Federal and 
State agency partners, its written procedures for such 
referrals were incomplete 
Unit stakeholders, specifically Federal and State agency partners, 
confirmed that the Unit referred cases to them and reported no concerns 
about the number or quality of Unit referrals.  However, although the 
Units policies and procedures manual contained a written procedure for 
referring cases to the State Medicaid agency, the manual contained no 
such procedure for referring cases to other State agencies (such as the 
Wyoming Department of Family Services) or to Federal partners (such as 
the Department of Justice or OIG).  Performance standard 3(C) states that 
a Units written policies and procedures should include a process for 
referring cases, when appropriate, to Federal and State agencies.  Unit 
management explained that the Unit has processes for referring cases to 
Federal partners and to other State agencies, but acknowledged that these 
processes were not documented in the Units policies and procedures 
manual.   
The Unit did not employ any investigators for a period 
of approximately 6 months, which appeared to have 
negative consequences for Unit investigations
 
After the Units sole investigator went on sick leave in October 2014 and 
then subsequently retired, the Unit did not employ an investigator for 
approximately 6 months, hiring a new investigator in April 2015.23  
Although the Unit used investigators from other agencies as support on a 
part-time, case-by-case basis during this period, Federal regulations 
require that the Unit be staffed by a full-time senior investigator with 
substantial experience in commercial or financial investigations.24  
 
23 According to Federal regulations, employ is defined as full-time duty intended to 
last at least a year, whether the Unit directly hires someone or employs that person on 
the basis of full-time detail from another agency.  42 CFR  1007.1.  The Wyoming 
Unit is the only MFCU that has an approved budget authorizing the employment of only 
one investigator.   
24 42 CFR  1007.13(a)(3).   
 
 
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MFCU performance standards also state that Units should employ an 
appropriate number of staff.25 
The loss of the Units sole investigator appeared to have at least two 
negative implications for Unit investigations:  investigation delays and a 
lack of continuity once the Unit hired a new full-time investigator.  Our 
review of the Units case files found that some lacked documentation of 
any investigative activity during this 6-month period.  This suggests that 
the lack of an investigator resulted in delays in these investigations.26   
Performance standard 5 states that a Unit should maintain a continuous 
case flow to complete cases in an appropriate timeframe.  Further, once 
the Unit hired a new investigator in April 2015, he did not have an 
existing investigator to provide context and background for ongoing 
investigations or help train him in the investigation of Medicaid provider 
fraud and patient abuse or neglect cases in Wyoming.   
Other observation:  The Unit overcame training 
barriers by working with another MFCU to train its 
newly hired investigator
 
To overcome training barriers associated with the high cost of extensive 
travel and the lack of an experienced investigator to train its newly hired 
investigator, the Units newly hired investigator drove to the adjacent 
State of Colorado to train with staff from the Colorado MFCU.  During 
this 3-day period, the investigator observed active investigations and met 
with the Colorado MFCUs management and attorneys to discuss the 
investigation and prosecution of Medicaid provider fraud.  Both the 
Wyoming Units management and investigator reported that this practice 
was a highly cost-effective way to train the investigator and offered the 
additional benefit of furthering a positive working relationship with the 
other MFCU.   
 
25 Performance standard 2(A) states that a Unit should employ the number of staff that is 
included in the Units budget estimate, as approved by OIG.  In addition, performance 
standard 2(C) states that a Unit should employ an appropriate mix and number of 
professional staff (such as investigators) to enable the Unit to effectively investigate and 
prosecute an appropriate volume of cases of Medicaid fraud and patient abuse and 
neglect. 
26 Because the Units director and sole investigator were no longer employed by the Unit 
at the time of our onsite review, we could not conclusively verify whether the case files 
simply lacked documentation of investigation activities or whether the activities did not 
occur. 
 
 
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CONCLUSION AND RECOMMENDATIONS 
The Wyoming Unit was generally in compliance with applicable laws, 
regulations, and policy transmittals.  For FYs 2013 through 2015, the Unit 
reported 11 convictions; 25 global civil judgments and settlements; and 
total recoveries of approximately $3.2 million.  The Unit also overcame 
training challenges by working with another MFCU to train its newly 
hired investigator. 
However, we identified three areas of concern.  Specifically, the Unit did 
not pursue fraud cases as civil matters under Wyomings civil fraud statute 
and therefore reported no nonglobal civil judgments, settlements, or 
recoveries for the review period.  In addition, although the Unit referred 
cases to Federal and State agency partners, the Units written procedures 
for such referrals were incomplete.  Finally, the Unit did not employ any 
full-time investigators for a period of approximately 6 months, which 
appeared to have at least two negative implications for Unit investigations:  
delays in investigations and a lack of continuity once the Unit hired a new 
full-time investigator.   
Therefore, we recommend that the Wyoming Unit:   
Develop and implement a plan to improve its ability to pursue 
nonglobal fraud cases as civil matters  
The Unit should develop and implement a plan to pursue appropriate fraud 
cases as civil matters.  As part of the plan, the Unit could provide training 
to staff and further develop litigation strategies to pursue nonglobal fraud 
cases as civil matters.  We note that the Unit has already made progress 
with regard to pursuing nonglobal fraud cases since the time period we 
reviewedit reports having settled its first nonglobal civil case. 
Incorporate procedures for referring cases to Federal partners 
and other State agencies into its written policies and 
procedures manual 
The Unit should revise its policies and procedures manual to document 
procedures for referring cases to Federal partners (such as the Department 
of Justice and OIG) and State agencies other than the State Medicaid 
agency.  This will help ensure that staff, including new employees, 
become familiar with and adhere to these procedures. 
   
 
 
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Take steps to ensure that it does not lack an investigator for a 
significant period of time 
Because the Wyoming Unit employs a sole investigator, the loss of that 
investigator can have a significant effect on Unit performance, as it did 
when the Units sole investigator retired in FY 2015.  To ensure that Unit 
investigations do not sit idle for significant periods of time, the Unit 
should take steps to ensure that it continuously employs an investigator, 
such as seeking approval for and hiring an additional investigator or 
developing a contingency plan to ensure that an investigator with the 
requisite qualifications is available to the Unit on a full-time, interim 
basis.   
Unit management and stakeholders said that hiring a second investigator 
would (1) ease the burden on its sole investigator during busy periods, 
(2) allow the Unit to expand its caseload, and (3) help prevent 
investigative delays when an investigator leaves employment.  Additional 
potential benefits include facilitating investigator safety in the field and 
during interviews, providing better training for a newly hired investigator, 
and improving continuity when moving cases between investigators. 
If the Unit is unable to hire an additional investigator, the Unit should 
work with the Wyoming Attorney Generals Office and OIG to develop a 
written contingency plan with other options to ensure that an investigator 
who meets the requirements for that position is readily available to the 
Unit.  
 
 
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UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Wyoming Unit concurred with all three of our recommendations.   
OIG anticipates that the Units actions will implement our 
recommendations. 
With regard to our recommendation for the Unit to develop and implement 
a plan to improve its ability to pursue nonglobal fraud cases as civil 
matters, the Unit stated that it revised its policies to ensure that all cases 
not pursued criminally are assessed for civil merit.  In the attachment to its 
comments, the Unit included the revised language. 
With regard to our recommendation for the Unit to incorporate procedures 
for referring cases to Federal partners and other State agencies into its 
written policies and procedures manual, the Unit stated that it revised its 
policies to reflect its current referral practices.  In the attachment to its 
comments, the Unit included the revised language. 
With regard to our recommendation for the Unit to take steps to ensure 
that it does not lack an investigator for a significant period of time, the 
Unit explained that, due to State economic limitations, it is unable to hire 
an additional investigator at this time.  However, the Unit reported that it 
has already implemented (as part of its regular process) several approaches 
that will help it to avoid investigative delays should it lose its investigator 
again.  These actions include:  (1) having the Units paralegal and auditor 
contribute to investigations; (2) using on an as needed basis the 
assistance of an investigator (not paid from the MFCU grant) from another 
division of the Attorney Generals Office; and (3) working with State and 
Federal law enforcement partners on joint investigations.  Furthermore, 
the Unit stated that it will reach out to OIG for assistance on any 
additional steps that may be desirable to incorporate into a contingency 
plan. 
The full text of the Units comments is provided in Appendix E. 
 
 
 
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APPENDIX A 
2012 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 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. 
Continued on next page 
 
27 77 Fed. Reg. 32645, June 1, 2012. 
 
 
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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). 
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 PRACTICABLE, 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.  
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. 
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. 
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. 
Continued on next page 
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  13 
   
   
 
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 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. 
6.  The number of criminal convictions and the number of civil judgments. 
7.  The dollar amount of overpayments identified. 
8.  The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
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. 
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). 
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Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  14 
   
   
 
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. 
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.  
 
 
 
 
 
 
 
 
 
 
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  15 
   
   
APPENDIX B 
Wyoming MFCU Referrals, by Referral Source, 
FYs 2013 Through 2015 
   
FY 2013  FY 2014  FY 2015 
Abuse/  Abuse/  Abuse/ 
Referral Source  Fraud  Fraud  Fraud  Total 
Neglect*  Neglect*  Neglect* 
HHS OIG  14  0  8  0  11  0  33 
State Medicaid 
1  0  8  2  1  0  12 
Agency 
Provider  1  2  1  0  0  0  4 
Private Citizen  2  0  1  0  0  1  4 
State Agencies  
1  0  0  0  1  0  2 
Other 
Law Enforcement  0  0  0  0  1  0  1 
State Survey and 
0  0  0  0  0  1  1 
Certification Agency 
   Total  19  2  18  2  14  2  57 
 
   Annual Total  21  20  16 
Source:  OIG analysis of Unit Quarterly and Annual Statistical Reports, 2016. 
*The category of referrals of abuse and neglect includes referrals of misappropriation of patient funds. 
 
 
 
 
 
 
 
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  16 
   
   
APPENDIX C 
Investigations Opened and Closed by the Wyoming MFCU, by 
Case Type, FYs 2013 Through 2015 
 
  Annual    
Case Type  FY 2013  FY 2014  FY 2015  3-Year Total 
Average* 
Opened  32  20  16  68  23 
Patient Abuse and 
3  2  2  7  2 
Neglect 
Provider Fraud  29  18  14  61  20 
Closed  15  22  13  50  17 
Patient Abuse and 
2  2  1  5  2 
Neglect 
Provider Fraud  13  20  12  45  15 
Source:   OIG analysis of Unit Quarterly and Annual Statistical Reports, 2016. 
*Averages in this column are rounded. 
 
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  17 
   
   
APPENDIX D 
Detailed Methodology 
To describe the caseload and assess the performance of the Wyoming 
MFCU, we collected data from six sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; 
(2) financial documentation for FYs 2013 through 2015; (3) structured 
interviews with key stakeholders; (4) structured interviews with Unit staff; 
(5) files for all cases that were open in FYs 2013 through 2015; and 
(6) observation of Unit operations. 
Data Collection 
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information regarding the Units investigation of Medicaid cases, 
including 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 prosecuted 
or referred for prosecution and the outcomes of those prosecutions.   
We gathered this information from several sources, including the Units 
quarterly statistical reports, its annual reports, its recertification 
questionnaire, its manuals of policy and procedures, and its MOU with the 
State Medicaid agency.  We requested any additional data or clarification 
from the Unit as necessary. 
Review of Unit Financial Documentation.  We reviewed the Units 
internal fiscal controls and use of fiscal resources.  Prior to conducting 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. 
We reviewed four purposive samples to assess the Units internal control 
of fiscal resources.  The first three samples listed below were limited to 
the review period of FYs 2013 through 2015.  These four samples 
included the following: 
1.  To assess the Units expenditures, we selected a purposive sample 
of 24 items from the Units 287 expenditure transactions.  We 
selected routine and nonroutine transactions representing a variety 
of budget categories and payment amounts.  
2.  To assess the Units travel expenditures, we selected a purposive 
sample of 24 items from the Units 124 travel transactions.  We 
selected a variety of travel expenditure categories related to both 
 
 
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in-State and out-of-State travel, such as hotel stays, airfare, and 
conference expenses.   
3.  To assess employees time and efforti.e., their work hours 
spent on various MFCU taskswe selected a sample of three pay 
periods, one from each fiscal year.  We then requested and 
reviewed documentation (e.g., timecard records) to support the 
time and effort of the MFCU staff during the selected pay periods. 
4.  To assess the Units control of its equipment, we selected and 
verified a purposive sample of 15 items from the current inventory 
list of 77 items maintained in the Units office.   
Interviews With Key Stakeholders.  In September and October 2016, we 
interviewed six individual stakeholders from five agencies who were 
familiar with MFCU operations.  Specifically, we interviewed a program 
integrity manager from the State Medicaid agencys Division of 
Healthcare Financing; an Assistant U.S. Attorney; the Chief Deputy 
Attorney General (from the Wyoming Attorney Generals Office);28 a 
manager from the State Medicaid agencys Behavioral Health Division; 
and two OIG Special Agents who work closely with the Unit.  We focused 
these interviews on the Units relationship and interaction with OIG and 
other Federal and State authorities, and on opportunities for improvement.  
We used the information collected from these interviews to develop 
subsequent interview questions for Unit staff. 
Onsite Interviews With Unit Staff.  We conducted structured interviews 
with the MFCUs director, investigator, auditor, and paralegal/office 
manager in October 2016.  We asked these individuals to provide 
information related to (1) the Units operations, (2) Unit practices that 
contributed to the effectiveness and efficiency of Unit operations and/or 
performance, (3) opportunities for the Unit to improve its operations 
and/or performance, and (4) clarification regarding information obtained 
from other data sources. 
Onsite Review of Case Files.  We asked the Unit to provide us with a list 
of cases that were open at any point during FYs 20132015.  For the 
108 open cases, we requested data that included, but were not limited to, 
the current status of the case; whether the case was criminal, civil, or 
global; and the date on which the case was opened.  Because global cases 
are civil false claims actions that typically involve multiple agencies, such 
as the U.S. Department of Justice and a group of State MFCUs, we 
excluded those cases from our review of the Units case files.  Therefore, 
 
28 The Chief Deputy Attorney General supervises the MFCU director. 
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  19 
   
   
we excluded 69 cases that were categorized as global from the list of 
cases.  The remaining number of case files was 39. 
We determined that all 39 cases had been open longer than 60 days.  We 
reviewed the 39 case files to determine whether documentation for 
required supervisory reviews was present.  We also reviewed these case 
files to determine whether there had been investigation or prosecution 
delays that were not explained in the case files.   
For all 39 case files, we also performed a qualitative review of selected 
issues, such as case development.  While onsite, we consulted MFCU staff 
to address any apparent issues with individual case files, such as missing 
documentation.   
Onsite Review of Unit Operations.  During our October 2016 onsite visit, 
we reviewed the Units workspace and operations.  Specifically, we 
visited the Unit headquarters in Cheyenne, Wyoming.  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 
instances in which the Unit did not fully meet the performance standards 
or was not operating in accordance with laws, regulations, or policy 
transmittals.29 
 
 
 
 
 
 
 
 
 
 
 
29 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
 
 
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APPENDIX E 
           Unit Comments 
 
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ACKNOWLEDGMENTS 
Matthew DeFraga served as the project leader for this study.  Others in the 
Office of Evaluation and Inspections who conducted the study include 
Jordan Clementi.  Office of Evaluation and Inspections central office staff 
who provided support include Christine Moritz. 
We would also like to acknowledge the contributions of other Office of 
Inspector General staff, including Lonie Kim of the Office of Counsel to the 
Inspector General and staff from the Office of Investigations. 
This report was prepared under the direction of Blaine Collins, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Abby Amoroso and Michael Henry, Deputy Regional 
Inspectors General.  The report was prepared in consultation with 
Richard Stern, Director of the Medicaid Fraud Policy and Oversight 
Division. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
 
 
Wyoming State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-09-16-00530)  26 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals 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 individuals.  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.