Department of Health and Human Services 
Office of Inspector General 
 
 
Minnesota Medicaid Fraud 
Control Unit: 2022 Inspection 
 
Ann Maxwell 
Deputy Inspector General  
for Evaluation and Inspections 
September 2023, OEI-06-22-00430  Department of Health and Human Services 
 
Office of Inspector General 
Report in Brief 
September 2023, OEI-06-22-00430 
Case Outcomes  Minnesota Medicaid Fraud Control Unit: 
Federal fiscal years (FYs) 
2022 Inspection  
20202022 
  161 indictments  What OIG Found 
  150 convictions  We found that the Minnesota MFCU operated in accordance with 
  28 civil settlements and  applicable laws, regulations, and policy transmittals, and reported strong 
judgments  case outcomes for FYs 20202022.  From the data we reviewed, we found 
  $32.3 million in recoveries  that the Unit maintained positive working relationships with Federal 
  partners and investigated cases jointly.  The Unit also reported nearly all 
Unit Snapshot  convictions and adverse actions to Federal partners within the 
appropriate timeframes, including cases of patient abuse or neglect that 
The Minnesota Medicaid Fraud 
were investigated and prosecuted by local authorities. 
Control Unit (MFCU or Unit) is 
housed in the Minnesota Office 
However, we made four findings regarding the Units adherence to the 
of the Attorney General. 
MFCU performance standards and compliance with Federal regulations.  
First, we found that the director was the only supervisor in the Unit, 
At the time of our onsite 
which limited the oversight of Unit operations.  Second, we found that, 
inspection in OctoberNovember 
2022, the Unit had a total of  although the Unit took steps to coordinate with other State agencies, it 
received few referrals of patient abuse or neglect.  Third, we found that 
30 staff located in St. Paul. 
the Unit lacked a case management system that allowed efficient and 
secure access to case information and case outcomes data, which posed 
challenges for locating documents and tracking case statuses.  Finally, we 
found that the Unit did not consistently conduct periodic supervisory 
reviews or document supervisory approvals in its case files.  In addition to 
these findings, we made several observations regarding Unit operations 
and practices. 
What OIG Recommends and How the Unit Responded 
To address the findings, we recommend that the Unit (1) continue efforts 
to hire a second-line supervisor and assess whether additional 
supervisors are warranted to meet the Units oversight needs; (2) build 
upon its efforts to increase referrals of patient abuse or neglect;  
(3) implement a comprehensive case management system that allows for 
efficient access to case documents and information; and (4) take steps to 
ensure that periodic supervisory reviews are conducted on a consistent 
basis and that case files include documentation of supervisory approvals.  
The Unit concurred with all four recommendations. 
   
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 1 
Methodology ............................................................................................................................................................................. 5 
PERFORMANCE ASSESSMENT ................................................................................................................... 6 
Case Outcomes ......................................................................................................................................................................... 6 
Observation: The Unit reported 161 indictments; 150 convictions; and 28 civil settlements 
and judgments for FYs 20202022. 
Observation: The Unit reported total recoveries of nearly $32.3 million for FYs 20202022. 
Performance Standard 1: Compliance with Requirements ...................................................................................... 7 
Observation: From the data we reviewed, the Minnesota MFCU complied with applicable 
laws, regulations, and policy transmittals. 
Performance Standard 2: Staffing ..................................................................................................................................... 7 
Finding: The director was the only supervisor in the Unit, which limited the oversight of Unit 
operations. 
Observation: The Unit experienced significant staff turnover but was able to maintain 
adequate staffing levels during our review period. 
Performance Standard 3: Policies and Procedures ..................................................................................................... 9 
Observation: The Unit maintained policies and procedures, and staff were familiar with 
them. 
Performance Standard 4: Maintaining Adequate Referrals ..................................................................................... 9 
Finding: Although the Unit took steps to coordinate with other State agencies, it received 
few referrals of patient abuse or neglect. 
Observation: Although nearly all referrals from the State Medicaid agency involved personal 
care services, the Unit took steps to diversify its fraud referrals. 
Performance Standard 5: Maintaining Continuous Case Flow ............................................................................. 11 
Observation: The Unit took steps to maintain a continuous case flow and to complete cases 
within appropriate timeframes. 
Performance Standard 6: Case Mix ................................................................................................................................. 12 
Observation: The Units caseload consisted mostly of fraud cases, and the Unit worked a 
disproportionate number of fraud cases involving personal care services. 
 
 
   
Performance Standard 7: Maintaining Case Information ....................................................................................... 12 
Finding: The Unit lacked a case management system that allowed efficient and secure 
access to case information and case outcomes data. 
Finding: The Unit did not consistently conduct periodic supervisory reviews or document 
supervisory approvals in its case files during our review period. 
Performance Standard 8: Cooperation with Federal Authorities on Fraud Cases ......................................... 15 
Observation: The Unit maintained a positive working relationship with Federal law 
enforcement partners, including OIG and the U.S. Attorneys Office. 
Observation: The Unit reported nearly all convictions and adverse actions to Federal 
partners within the appropriate timeframes. 
Performance Standard 9: Program Recommendations .......................................................................................... 16 
Observation: The Unit made program recommendations to the State Medicaid agency and a 
statutory recommendation to the State legislature during our review period. 
Performance Standard 10: Agreement with Medicaid Agency ............................................................................ 16 
Observation: The Units MOU with the State Medicaid agency reflected current practice, 
policy, and legal requirements. 
Performance Standard 11: Fiscal Control ..................................................................................................................... 17 
Observation: From our limited review, we identified no significant deficiencies in the Units 
fiscal control of its resources. 
Performance Standard 12: Training ................................................................................................................................ 17 
Observation: The Unit maintained a training plan for each professional discipline, and Unit 
staff met training requirements. 
CONCLUSION AND RECOMMENDATIONS ........................................................................................... 18 
Continue efforts to hire a second-line supervisor and assess whether additional supervisors are 
warranted to meet the Units oversight needs ........................................................................................................... 18 
Build upon its efforts to increase referrals of patient abuse or neglect ........................................................... 18 
Implement a comprehensive case management system that allows for efficient access to case 
documents and information .............................................................................................................................................. 19 
Take steps to ensure that periodic supervisory reviews are conducted on a consistent basis and that 
case files include documentation of supervisory approvals .................................................................................. 19 
UNIT COMMENTS AND OIG RESPONSE ............................................................................................... 20 
DETAILED METHODOLOGY ....................................................................................................................... 21 
APPENDICES................................................................................................................................................. 24 
Appendix A: Unit Referrals by Source for FYs 20202022 ...................................................................................... 24 
Appendix B: Unit Turnover by Staff Discipline during FYs 20202022 .............................................................. 25 
   
Appendix C: Point Estimates and 95-Percent Confidence Intervals of Case File Reviews.......................... 26 
Appendix D: Unit Comments ............................................................................................................................................ 27 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 30 
ABOUT THE OFFICE OF INSPECTOR GENERAL ..................................................................................... 31 
 
 
   
BACKGROUND 
OBJECTIVE 
To examine the performance and operations of the Minnesota Medicaid Fraud 
Control Unit (MFCU or Unit). 
 
Medicaid Fraud Control Units 
MFCUs investigate Medicaid provider fraud and patient abuse or neglect and 
prosecute those cases under State law or refer them to other prosecuting offices.1, 2, 3  
Under the Social Security Act (SSA), a MFCU must be a single, identifiable entity of 
State government, separate and distinct from the State Medicaid agency, and 
employ one or more investigators, attorneys, and auditors.4  Each State must operate 
a MFCU or receive a waiver.5  Currently, 50 States, the District of Columbia, Puerto 
Rico, and the U.S. Virgin Islands operate MFCUs.6   
MFCUs are funded jointly by Federal and State governments.  Each Unit receives a 
Federal grant award equivalent to 90 percent of total expenditures for new Units and 
75 percent for all other Units.7  In Federal fiscal year (FY) 2022, combined Federal and 
State expenditures for the MFCUs totaled approximately $343 million, of which 
approximately $257 million represented Federal funds.8   
   
_____________________________________________________________________________________________________________________________ 
1 SSA  1903(q)(3)-(4).  Regulations at 42 CFR  1007.11(b)(1) clarify that a Units responsibilities include 
the review of complaints of misappropriation of patients private funds in health care facilities. 
2 As of December 27, 2020, MFCUs may also receive Federal financial participation to investigate and 
prosecute abuse or neglect of Medicaid beneficiaries in a noninstitutional or other setting.  Consolidated 
Appropriations Act, 2021, Public Law 116-260, Division CC, Section 207. 
3 References to State in this report refer to the States, the District of Columbia, and the U.S. territories. 
4 SSA  1903(q). 
5 SSA  1902(a)(61). 
6 The territories of American Samoa, Guam, and the Northern Mariana Islands have not established Units. 
7 SSA  1903(a)(6).  For a Units first 3 years of operation, the Federal Government contributes 90 percent 
of funding, and the State contributes 10 percent.  Thereafter, the Federal Government contributes 
75 percent, and the State contributes 25 percent. 
8 OIG analysis of MFCU annual statistical reporting data for FY 2022.  The Federal FY begins on October 1 
and ends on September 30 of the following year. 
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OIG Grant Administration and Oversight of MFCUs 
The Office of Inspector General (OIG) administers the grant award to each Unit and 
provides oversight of Units.9, 10  As part of its oversight, OIG conducts a desk review of 
each Unit during the annual recertification process.  OIG also conducts periodic 
inspections and reviews.  Finally, OIG provides ongoing training and technical support 
to the Units. 
In its annual recertification review, OIG examines the Units reapplication materials, 
case statistics, and questionnaire responses from Unit stakeholders.  Through the 
recertification review, OIG assesses a Units performance, as measured by the Units 
adherence to published performance standards;11 the Units compliance with 
applicable laws, regulations, and OIG policy transmittals;12 and the Units case 
outcomes. 
OIG further assesses Unit performance by conducting inspections and reviews of 
selected Units.  These inspections and reviews result in public reports of findings and 
recommendations for improvement.  OIG reports may also include observations 
regarding Unit operations and practices, including beneficial practices that may be 
useful to share with other Units.  OIG also provides training and technical assistance 
to Units, as appropriate, during inspections and reviews. 
Minnesota MFCU 
The Minnesota MFCU is located within the State Attorney Generals Office in St. Paul.  
At the time of our onsite inspection in OctoberNovember 2022, the Unit had  
30 staff13 investigators (including a nurse investigator), 7 attorneys (including the 
Unit director), 2 analysts, 1 auditor, and 7 other staff.13  The director was the only 
supervisor in the Unit.  During our review period of FYs 20202022, the Unit spent 
approximately $10.8 million, with a State share of approximately $2.7 million. 
 
 
_____________________________________________________________________________________________________________________________ 
9 As part of grant administration, OIG receives and examines financial information from Units, such as 
budgets and quarterly and final Federal Financial Reports that detail MFCU income and expenditures. 
10 The SSA authorizes the Secretary of Health and Human Services to award grants (SSA  1903(a)(6)) and 
to certify and annually recertify the Units (SSA  1903(q)).  The Secretary delegated these authorities to 
OIG in 1979. 
11 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  The performance 
standards were developed by OIG in conjunction with the MFCUs and were originally published at 59 
Fed. Reg. 49080 (Sept. 26, 1994). 
12 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  Policy 
transmittals are located at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.  
13 The seven other staff were three paralegals, three legal secretaries, and an administrative specialist. 
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Referrals  
During FYs 20202022, the MFCU reported receiving Medicaid provider fraud referrals 
from several sources, including the State Medicaid agencys program integrity unit, 
managed care organizations, and private citizens.  The MFCU may also receive 
referrals of patient abuse or neglect from the Minnesota Department of Health 
(MDH), the State Medicaid agencys licensing division, and local adult protective 
teams.14, 15, 16  See Appendix A for a list of Unit referrals by source for FYs 20202022. 
When the Unit receives a referral of fraud or patient abuse or neglect, the auditor 
conducts an initial review of the information and submits a referral analysis to the 
Unit director, who decides whether the Unit should accept or decline the referral.  If 
the director declines to open a referral for investigation, the Unit closes the referral, 
notifies the referring agency of its decision, and evaluates the referral for possible 
administrative action by the State Medicaid agency.   
The Unit may also generate internal referrals from its own casework or analysis.  For 
example, Unit attorneys and investigators may submit a request to open a new 
investigation, or a spinoff investigation, based on evidence obtained in another 
investigation.  As with other referrals, the director reviews these internal requests and 
decides whether to proceed with an investigation. 
Investigations and Prosecutions 
Once the Unit opens a case, the director assigns the matter to a team consisting of at 
least one attorney and one investigator.  The Units analysts may also assist with the 
investigation and conduct analysis of Medicaid claims data and other information 
relevant to the case.  The director oversees all investigations through periodic 
supervisory reviews of the Units case files and employees monthly case status 
reports.  Upon completion of the investigation, the director determines whether to 
proceed with a criminal or civil prosecution or to close the case if there is insufficient 
evidence to support prosecution. 
The Minnesota Unit has Statewide jurisdiction to investigate and prosecute all 
criminal and civil Medicaid fraud offenses.17  The Unit may investigate patient abuse 
_____________________________________________________________________________________________________________________________ 
14 MDH is the State survey and certification agency, responsible for investigating maltreatment 
complaints in Minnesota health care facilities. 
15 Local adult protective teams are composed of local welfare agency staff, County Attorneys, local law 
enforcement, and other entities to assist with reporting adult patient abuse, neglect, and financial 
exploitation. 
16 MDH, the State Medicaid agencys licensing division, and local adult protective teams receive 
complaints of potential health care facility violations through a centralized system for reporting 
suspected patient abuse or neglect.  When there is reason to believe a crime has been committed, these 
agencies must immediately notify law enforcement, such as the MFCU or the local police department, 
and they may coordinate with these law enforcement agencies throughout the investigation. 
17 Minnesota Statutes 2022 Section 256B.12 and Section 609.466 state that the Minnesota Office of the 
Attorney General and Minnesotas County Attorneys have primary authorities to prosecute Medicaid 
fraud cases. 
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and neglect cases, but requires a referral from the respective County Attorney in order 
to criminally prosecute these cases.18, 19, 20  The Unit may also pursue civil cases in 
State court under the States False Claims Act.21 
Minnesota Medicaid Program 
The Minnesota Department of Human Services (DHS) administers the State Medicaid 
program.  As of September 2022, the program served more than 1.3 million 
enrollees.22  Approximately 88 percent of Minnesotas Medicaid enrollees received 
services through nine managed care organizations.23  In FY 2022, Minnesotas 
Medicaid expenditures were approximately $16.9 billion.24   
DHSs Surveillance & Integrity Review Section (DHS-SIRS) is responsible for Medicaid 
program integrity efforts.  DHS-SIRS investigates Medicaid fraud complaints and, 
when appropriate, refers credible allegations to the MFCU.  
Prior OIG Report 
OIG conducted a previous onsite review of the Minnesota Unit in 2013.25  In that 
review, which covered FYs 20102012, OIG found that (1) the Units memorandum of 
understanding (MOU) with the State Medicaid agency did not reflect all current 
practices; (2) the Units training plan did not include a minimum number of training 
hours; (3) some Unit case files lacked documentation of supervisory reviews and 
_____________________________________________________________________________________________________________________________ 
18 Minnesota Statutes 2022 Section 626.557, subdivision 9b, states that law enforcement, which includes 
the MFCU, has primary authority to investigate all complaints of abuse or neglect of vulnerable adults. 
19 Minnesota Statutes 2022 Section 388.051.  Minnesotas County Attorneys have primary authority to 
prosecute all cases. 
20 Minnesota Statute 2022 Section 8.01 sets forth that the Minnesota Office of the Attorney General must 
obtain a referral from the respective County Attorney to prosecute criminal cases where the Attorney 
Generals Office does not have primary authority.  The Governor may also request that the Attorney 
General prosecute cases, in which case the Attorney General may exercise the powers of a County 
Attorney. 
21 Minnesota Statutes 2022, Chapter 15C. 
22 CMS, State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data, September 
2022.  Accessed at https://data.medicaid.gov/dataset/6165f45b-ca93-5bb5-9d06-
db29c692a360/data?conditions[0][property]=report_date&conditions[0][value]=2022-09-
01&conditions[0][operator]=%3D&conditions[1][property]=preliminary_updated&conditions[1][value]=P
&conditions[1][operator]=%3D&conditions[2][property]=state_abbreviation&conditions[2][value]=MN&
conditions[2][operator]=%3D on January 27, 2023. 
23 Kaiser Family Foundation, Share of Medicaid Population Covered under Different Delivery Systems, July 
2022.  Accessed at https://www.kff.org/medicaid/state-indicator/share-of-medicaid-population-covered-
under-different-delivery-
systems/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22
%7D on January 30, 2023. 
24 OIG analysis of MFCUs reporting of expenditures for FY 2022. 
25 OIG, Minnesota State Medicaid Fraud Control Unit: 2013 Onsite Review, OEI-06-13-00200, March 2014. 
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approvals; and (4) the Unit stored some case files in a location accessible to non-Unit 
staff.  
OIG recommended that the Unit (1) update its MOU with the State Medicaid agency; 
(2) establish a minimum number of training hours for each professional discipline;  
(3) include appropriate documentation of periodic supervisory reviews and approval 
in all case files; and (4) store its case files in a secure location.  On the basis of 
information received from the Unit, OIG considered the recommendations 
implemented as of December 2014.  As we discuss further below, two issues identified 
in the prior OIG report regarding missing documentation of periodic supervisory 
reviews and approvals in case files and risk of potential unauthorized access to case 
files by non-Unit staff recurred in this inspection. 
Methodology 
OIG conducted an onsite inspection of the Minnesota MFCU in OctoberNovember 
2022.  Our inspection covered the 3-year period of FYs 20202022.  We based our 
inspection on an analysis of data and information from 7 sources: (1) Unit 
documentation; (2) financial documentation; (3) structured interviews with key 
stakeholders; (4) structured interviews with the Unit director and selected staff; (5) a 
review of a random sample of 86 case files from the Units 442 nonglobal case files 
that were open at any point during the review period; (6) a review of all convictions 
submitted to OIG for program exclusion and all adverse actions submitted to the 
National Practitioner Data Bank (NPDB) during the review period; and (7) an onsite 
review of Unit operations.  See the Detailed Methodology on page 21. 
In examining the Units operations and performance, we applied the published MFCU 
performance standards, but we did not assess adherence to every performance 
indicator for every standard. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.  
These inspections differ from other OIG evaluations in that they support OIGs direct 
administration of the MFCU grant program, but they are subject to the same internal 
quality controls as are other OIG evaluations, including internal and external peer 
review.
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PERFORMANCE ASSESSMENT 
In assessing the performance and operations of the Minnesota Unit, we identified the 
Units case outcomes, evaluated whether the Unit complied with legal requirements, 
and assessed whether the Unit adhered to each of the 12 MFCU performance 
standards.  We made four findings along with several observations regarding the 
Units performance and operations, and we made four recommendations for 
improvement. 
 
Case Outcomes 
Observation: The Unit reported 161 indictments; 150 convictions; and 28 civil 
settlements and judgments for FYs 20202022.   
Of the 150 convictions, 146 involved provider fraud and 4 involved patient abuse or 
neglect.26, 27   
 
   
 
 
 
 
 
 
 
 
 
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26 During our 3-year review period, the Minnesota Unit had the highest number of fraud convictions and 
among the lowest number of patient abuse or neglect convictions compared to those of other similarly 
sized MFCUs.  We compared the Minnesota Unit, which had 30 staff in FY 2022, to 14 similarly sized 
MFCUs, such as those with staff sizes that ranged from 22 to 38 employees.  Although comparison across 
similarly sized MFCUs provides context for the case outcomes of a particular MFCU, many factors other 
than the size of a MFCUs staff can affect case outcomes. 
27 OIG provides information on MFCU operations and outcomes but does not direct or encourage MFCUs 
to investigate or prosecute a specific number of cases.  MFCU investigators and prosecutors should apply 
professional judgment and discretion in determining what criminal and civil cases to pursue. 
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Observation: The Unit reported total recoveries of nearly $32.3 million for 
FYs 20202022. 
 
Source: OIG Analysis of Unit statistical data, FYs 20202022.   
Note: Global civil recoveries derive from civil settlements or judgments in global cases, which are cases that involve 
the U.S. Department of Justice and a group of State MFCUs and are facilitated by the National Association of Medicaid 
Fraud Control Units. 
Performance Standard 1: Compliance with Requirements 
A Unit conforms with all applicable statutes, regulations, and policy directives. 
Observation: From the data we reviewed, the Minnesota MFCU complied with 
applicable laws, regulations, and policy transmittals. 
From the information we reviewed, we found that the Unit complied with applicable 
requirements. 
Performance Standard 2: Staffing 
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.  
Finding: The director was the only supervisor in the Unit, which limited the 
oversight of Unit operations.  
Performance Standard 2(c) states that the Unit should employ an appropriate mix and 
number of professional staff that allows the Unit to effectively investigate and 
prosecute an appropriate volume of case referrals and workload for both Medicaid 
fraud and patient abuse and neglect.  Further, 42 CFR  1007.13(b)(3) requires the Unit 
to employ a senior investigator who is capable of supervising and directing the 
investigative activities of the Unit.  Though the Unit has a lead investigator capable of 
supervising staff, this position does not have supervisory authority.  We found that 
the Units organizational structure of having only one supervisor created workload 
and oversight challenges for the Unit director.   
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As the sole supervisor, the Unit director was not only supervising all staff but also 
responsible for reviewing incoming referrals; overseeing investigations; building and 
maintaining relationships with stakeholders; and conducting outreach, among other 
responsibilities.  The director told OIG that this structure impeded his ability to 
effectively review cases and that hiring a supervisory investigator could help with his 
workload and ensure more frequent oversight of cases.  Several staff echoed the 
director and reported that having only one supervisor limited how often they could 
receive supervisory feedback on their cases.  Staff believed that having an additional 
supervisor would make the Unit more efficient and provide more support for them.   
At the time of this report, the Minnesota Unit was the only MFCU of its size that did 
not have a second-line supervisor, such as a deputy director or a chief investigator.  In 
fact, most MFCUs of its size had more than one second-line supervisor.  We found 
that the Minnesota MFCU followed the same supervisory structure as did most of the 
other divisions in the State Attorney Generals Office.28  Having only one supervisor in 
the Unit may have been sufficient at an earlier time, but as the Unit grew over the 
years to become the largest of all the Attorney Generals divisions, the workload of 
the Unit director also increased.  In OIGs judgment, the large workload of the director 
raises concern about the Units ability to ensure sufficient oversight of cases.  One or 
more additional supervisors would alleviate the directors various responsibilities, 
increase oversight of the Unit, and enhance its operational efficiencies.  Following the 
onsite visit, the Unit director agreed with OIGs concern about the lack of one or more 
second-line supervisors and reported requesting approval from the Attorney 
Generals Office to add one second-line supervisor. 
Observation: The Unit experienced significant staff turnover but was able to 
maintain adequate staffing levels during our review period.  
We found that a total of 14 professional staff left the Unit during FYs 20202022.  At 
the time of our onsite inspection, more than half (52 percent) of the Units 30 staff 
had worked in the Unit less than 2 years.  See Appendix B for Unit turnover by staff 
discipline. 
In interviews, Unit staff primarily attributed the high turnover to the Units low salaries 
and lack of training and advancement opportunities.  Staff reported that the Units 
turnover negatively impacted its operations.  One staff member reported that the 
high turnover limited the Units ability to adequately train and provide mentorship to 
new employees.  Another staff member said it was challenging for new staff to learn 
the nuances of a case that they inherited when another employee left.  Although the 
Unit experienced challenges, OIG did not observe any issues with case delays in our 
review of the Units case files. 
_____________________________________________________________________________________________________________________________ 
28 The Attorney General's Office requires its divisions to seek permission to re-classify any staff position 
as supervisory, and it recently approved one of its divisions to do so. 
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The Unit mitigated the impact of its high turnover by promptly filling its staff 
positions with qualified candidates.29  At the time of our onsite visit, the Unit was 
nearly fully staffed with 30 of its 32 positions filled.   
Performance Standard 3: Policies and Procedures 
A Unit establishes written policies and procedures for its operations and ensures 
that staff are familiar with, and adhere to, policies and procedures. 
Observation: The Unit maintained policies and procedures, and staff were 
familiar with them. 
The Unit maintained a policies and procedures manual, which it updated during our 
review period.  Unit staff were familiar with Unit policies and procedures and could 
access the manual electronically on the Units shared drive.  
Performance Standard 4: Maintaining Adequate Referrals 
A Unit takes steps to maintain an adequate volume and quality of referrals from 
the State Medicaid agency and other sources. 
Finding: Although the Unit took steps to coordinate with other State agencies, it 
received few referrals of patient abuse or neglect. 
According to Performance Standard 4(d), for States in which Units have original 
jurisdiction to investigate or prosecute patient abuse and neglect cases, the Unit 
should take steps to ensure that pertinent agencies refer such cases to the Unit.  
While the Minnesota Unit requires a referral from the County Attorneys to prosecute 
patient abuse and neglect cases, it may investigate all such referrals.  However, we 
found that the Unit received only six referrals of patient abuse or neglect from its 
referral sources during FYs 20202022, which amounted to 1 percent of the Units 
total referrals (see Appendix A for a list of the patient abuse and neglect referrals by 
source).30  This number of patient abuse and neglect referrals is particularly low given 
that Minnesota agencies and organizations responsible for initially reviewing these 
 
 
_____________________________________________________________________________________________________________________________ 
29 We found that investigators had experience in law enforcement, the nurse investigator had worked as 
a nurse, and several other staff had previously worked for MFCU stakeholders (e.g., a managed care 
organization, the Federal Bureau of Investigation, and OIG). 
30 The Units six referrals of patient abuse or neglect were from other law enforcement agencies and local 
prosecutors.  On the basis of data available from the MFCUs Quarterly Statistical Reports and Annual 
Statistical Reports, OIG found that the Unit received only one referral of patient abuse or neglect from 
MDH. 
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complaints received an average of 75,000 patient abuse and neglect complaints 
during each year of our review period.31 
Although the Unit reported taking steps to increase referrals of patient abuse and 
neglect, those referrals remained low during our review period.  For example, the Unit 
reported conducting outreach to the Minnesota Department of Health (MDH), local 
law enforcement, local adult protective teams, and County Attorneys during our 
review period.32  However, OIGs case file review identified that the Unit received only 
one referral of patient abuse or neglect from MDH during our review period.  MDH 
officials explained that their process was to triage referrals and to investigate patient 
abuse and neglect complaints themselves.  MDH would then send completed patient 
abuse and neglect investigations directly to the County Attorneys for prosecution and 
share the list of investigations with the Unit on a weekly basis. 
MDH, DHS, and local adult protective teams receive all State health care facility 
patient abuse and neglect complaints and should be significant referral sources for 
the Unit for cases that have criminal potential.  One MDH official found it challenging 
for the agency to investigate the high volume of patient abuse and neglect 
complaints, and MDH and Unit officials expressed interest in establishing a 
partnership regarding referrals.  After our onsite visit, the Unit met with MDH to 
discuss how best to coordinate on patient abuse or neglect referrals.   
Observation: Although nearly all referrals from the State Medicaid agency 
involved personal care services, the Unit took steps to diversify its fraud 
referrals. 
During FYs 20202022, the MFCU received a total of 598 fraud referrals and nearly 
half of those (287 referrals) were from DHS-SIRS, the State Medicaid agencys 
program integrity unit.  While the number of referrals appears high, the MFCU 
reported that nearly all fraud referrals from DHS-SIRS involved personal care services 
(PCS).33  See Appendix A for a full list of MFCU referrals by source.   
A DHS-SIRS official commented that the agency was inundated with a large number 
of PCS complaints from PCS agencies and private citizens, which resulted in a skewed 
representation of PCS in the agencys referrals.  In our review of the Units data, we 
_____________________________________________________________________________________________________________________________ 
31 The average number of referrals is based on Minnesota Adult Abuse Reporting Center (MAARC) data 
from calendar years 20192022.  The three agencies and organizations responsible for reviewing these 
complaints are MDH, DHS, and local adult protective teams.  Minnesota Department of Human Services, 
Vulnerable Adult Protection Dashboard, 20192022 MAARC Report.  Accessed at 
https://mn.gov/dhs/partners-and-providers/news-initiatives-reports-workgroups/adult-
protection/dashboard.jsp on June 21, 2023. 
32 OIG could not verify the Units reported outreach efforts to MDH. 
33 A common type of fraud scenario involving PCS attendants is a conflict case, in which a PCS 
attendant claims to have provided services, such as meal preparation or light housework, to a Medicaid 
beneficiary during the same hours that the PCS attendant worked at another place of employment (e.g., 
doctors office, convenience store).  OIG, MFCUs: Investigation and Prosecution of Fraud and Beneficiary 
Abuse in Medicaid Personal Care Services, OEI-12-16-00500, December 2017.  Accessed at 
https://www.oig.hhs.gov/oei/reports/oei-12-16-00500.pdf on February 15, 2023. 
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found that the number of PCS referrals was also high in the years prior to our review 
period, indicating that this has been a historical issue. 
In accordance with Performance Standard 4(b), we found the Unit provided feedback 
to DHS-SIRS in its bimonthly meetings, during which the Unit discussed the lack of 
diversity in the provider types represented in the fraud referrals from DHS-SIRS.34  To 
identify additional referrals and strengthen program integrity efforts, the Unit 
recommended that DHS-SIRS conduct its own data mining.35  In 2022, DHS-SIRS had 
not yet begun conducting its own data mining, and the Unit expressed interest in 
requesting a waiver from OIG to conduct its own data mining.36 
Additionally, in accordance with Performance Standard 4(a), the Unit took steps to 
diversify referrals from managed care organizations (MCOs) during our review period.  
For example, the Unit implemented quarterly meetings and conducted multiple 
outreach presentations to MCOs, which the Unit director reported led to additional 
fraud referrals. 
OIG found that the Units ongoing efforts to encourage a diversity of strong referrals 
from both DHS-SIRS and MCOs have the potential to improve program integrity 
protections among the many provider types who serve program beneficiaries. 
Performance Standard 5: Maintaining Continuous Case 
Flow 
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. 
Observation: The Unit took steps to maintain a continuous case flow and to 
complete cases within appropriate timeframes. 
We found that, consistent with Performance Standard 5, the Unit took steps to 
maintain a continuous flow for cases worked and completed most of its cases in a 
timely manner.  For the cases worked, the director monitored staffs monthly case 
status reports, which staff prepared for both the Unit director and the Deputy 
Attorney General who oversees the Unit.37  The Unit also held biweekly meetings with 
all staff and quarterly meetings with the investigators and attorneys to discuss the 
Units casework.  Although the Unit maintained a continuous case flow, several staff 
expressed that they would benefit from more one-on-one meetings with the director. 
_____________________________________________________________________________________________________________________________ 
34 Performance Standard 4(b) states that the Unit should provide periodic feedback to the State Medicaid 
agency and other referral sources on the adequacy of both the volume and quality of its referrals.   
35 Data mining is the practice of electronically uncovering patterns and relationships within Medicaid 
data to identify aberrant utilization or billing, or other practices that are potentially fraudulent. 
36 A data mining waiver permits Federal financial participation in costs of data mining if certain criteria 
are satisfied (see 42 CFR  1007.20).   
37 Since Performance Standard 7(a) states that supervisory reviews should be noted in case files, OIG did 
not review monthly status reports as the Unit did not document them in its case files.  For information 
about periodic supervisory reviews, see Performance Standard 7, second finding. 
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Performance Standard 6: Case Mix 
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.  
Observation: The Units caseload consisted mostly of fraud cases, and the Unit 
worked a disproportionate number of fraud cases involving personal care 
services. 
Performance Standard 6(c) states that the Unit should allocate its resources among 
provider types on the basis of levels of Medicaid expenditures or other risk factors.  
Of the Units 506 cases that were open during FYs 20202022, 96 percent (486 cases) 
involved provider fraud and 4 percent (20 cases) involved patient abuse or neglect.  
Although more than half of the Units fraud cases involved PCS during our review 
period, the Units fraud cases covered 31 different provider types, including 
transportation and mental health facilities.  The Unit balanced its case mix by 
conducting outreach and meeting periodically with its main fraud referral sources to 
encourage an examination of potentially fraudulent claims across a wider range of 
provider types (see Performance Standard 4, observation). 
We observed that, while the Unit investigated a very large number of PCS cases, it 
also had a strategy to focus on the PCS agencies, which were responsible for many of 
the individual incidents of fraud by PCS attendants.  Nearly 25 percent of the Unit's 
PCS investigations during our review period were PCS agency cases, with some 
identified as "spinoffs" from individual PCS attendant fraud complaints.  One 
investigator explained that PCS agencies are often connected to other agencies like a 
spider web of agencies committing the same types of fraud.  As a result of these 
investigations, the Unit successfully prosecuted multiple large PCS agency fraud 
schemes during our review period.38  We observed that this focus on PCS agencies 
not only maximized the Units impact and the deterrent value of its work but also 
provided Unit staff opportunities to gain experience and investigate larger, more 
complex fraud cases.   
Performance Standard 7: Maintaining Case Information 
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. 
Finding: The Unit lacked a case management system that allowed efficient and 
secure access to case information and case outcomes data. 
Performance Standard 7(e) states that the Unit should have an information 
management system that manages and tracks case information from initiation to 
resolution.  We found that the Unit lacked an electronic case management system 
with functionality to effectively organize its case data and track case progression.   
_____________________________________________________________________________________________________________________________ 
38 One of the Units PCS agency cases resulted in the largest Medicaid fraud recovery in the Attorney 
Generals history ($7.7 million), and two other large PCS agency cases recovered more than $4.8 million 
for the Medicaid program. 
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The Unit director explained that the State Attorney Generals Office procured a data 
storage system for each of its divisions, including the Unit, but the system was not 
designed to be used as a case management system.  Instead, it was intended to store 
large datasets.  The Unit mitigated the lack of an effective case management system 
by using its own electronic file structure on the Units network drive; however, we 
found that it was insufficient and did not meet the Units needs.  
Unit staff reported that the electronic file structure primarily served as a document 
repository and did not allow efficient access to case information and other pertinent 
data.  We also observed these inefficiencies in our review of the Units case files.  We 
found that the electronic file structure lacked basic features, such as the ability to 
search closed cases and uniformity in file names and folder structures.  We also found 
that it lacked the ability to generate case outcomes data and other case status 
information that could aid the Unit director in overseeing and tracking cases. 
In our interviews, the director and staff remarked on the difficulties in locating 
documents and quickly tracking the status of cases in the electronic file structure.  For 
example, one investigator expressed frustration with having to open every file 
individually in the case folder structure to determine which tasks had been completed.  
Other staff raised concerns that the electronic file structure sometimes inadvertently 
deleted files and updates made to the folder structure.  In OIGs judgment, these 
inefficiencies may be particularly burdensome for new employees learning to navigate 
case files inherited from a previous investigator.  Following our onsite visit, the 
director reported that the Attorney Generals Office approved a new case 
management system, which the Unit was reviewing to ensure that the system meets 
its needs. 
While onsite, we also found an issue of unauthorized access to information in the 
Units electronic file structure.39  We identified nine staff in other divisions of the 
Attorney Generals Office who had access to the Units network drive and its case 
files.40  The Attorney Generals Offices Information Technology staff rectified the 
security access issue within 48 hours after our onsite visit.  In OIGs opinion, if the Unit 
obtained its own case management system, Unit officials could better ensure access 
control for its case files and other sensitive data. 
Finding: The Unit did not consistently conduct periodic supervisory reviews or 
document supervisory approvals in its case files during our review period. 
According to Performance Standards 7(a) and 5(b), supervisors should periodically 
review cases and approve the opening and closing of all investigations, as well as 
including documentation in the case file.  The Unit director reported that the Units 
practice was to conduct supervisory reviews at least every 6 months during most of 
our review period (October 2019 to July 2022).  However, in August 2022, the Unit 
_____________________________________________________________________________________________________________________________ 
39 OIGs 2013 report also identified a risk of potential unauthorized access, which the Unit rectified by 
moving paper case files to a locked storage room accessible only to Unit staff. 
40 The nine staff consisted of four former Unit staff who retained access to Unit files after transferring to 
another division, and five non-Unit staff who were granted access to assist with various tasks.   
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updated this practice to conduct supervisory reviews periodically in its policies and 
procedures manual, which did not specify a required frequency for these reviews.41, 42  
The Unit director explained that he made this change to allow flexibility in how often 
he would review different types of cases.  For example, global civil cases did not need 
to be reviewed as frequently as the Units other cases. 
We found that 53 percent of the Units case files during FYs 20202022 did not have 
documentation of periodic supervisory reviews at least every 6 months.  Of those case 
files, 25 percent did not contain documentation of any supervisory reviews at all (see 
Exhibit 1).  In our interviews, staff confirmed that the periodic supervisory reviews 
were conducted inconsistently, as we identified in the case files.  See Appendix C-1 for 
the point estimates and confidence  intervals of our case file reviews. 
Exhibit 1: More than half of the Units case files were missing documentation 
of periodic supervisory reviews.
    
 
Source: OIG analysis of Unit case files, FYs 20202022. 
We also found that many case files were missing documentation of supervisory 
approvals to open and close cases.  Specifically, case files lacked documentation of 
supervisory approval for 11 percent of case openings and 19 percent of case 
closings.43  However, we did not identify any impact on the Units case development 
from the missing documentation.  See Appendix C-2 for the point estimates and 
confidence intervals of our case file reviews. 
The director explained that his workload as the sole supervisor for 29 Unit staff 
impeded his ability to consistently review all cases, which contributed to the 
_____________________________________________________________________________________________________________________________ 
41 For our review of the Units case files, we used every 6 months as the minimum frequency at which 
supervisory reviews should occur. 
42 In addition to supervisory reviews, the director reported, he reviewed case status reports prepared 
monthly by Unit staff to monitor case progression.  We did not include these report reviews as part of 
our assessment since they were not noted in the Units case files, and therefore did not meet the 
guidelines outlined in Performance Standard 7. 
43 The previous OIG report also found inconsistent documentation in the Units applicable case files 
58 percent were missing documentation of periodic supervisory reviews, 19 percent were missing 
documentation of supervisory approval to open, and 23 percent were missing supervisory approval to 
close.  OIG, Minnesota State Medicaid Fraud Control Unit: 2013 Onsite Review, OEI-06-13-00200, March 
2014. 
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inconsistent documentation in the case files.  Staff also attributed the inconsistent 
frequency of supervisory reviews and missing documentation of supervisory approvals 
in the case files to the Units lack of second-line supervisors (see Performance 
Standard 2, finding).  In addition, our review of the case files found that the Unit's 
limited case management system further exacerbated the documentation issues. 
Performance Standard 8: Cooperation with Federal 
Authorities on Fraud Cases 
A Unit cooperates with OIG and other Federal agencies in the investigation and 
prosecution of Medicaid and other health care fraud. 
Observation: The Unit maintained a positive working relationship with Federal 
law enforcement partners, including OIG and the U.S. Attorneys Office. 
We found that the Unit maintained a strong partnership with OIGs Office of 
Investigations (OI) and jointly investigated a total of 18 cases during the review 
period.  The Unit and OI leadership communicated monthly, and Unit investigators 
and OI agents communicated daily to discuss joint cases.  OI leadership characterized 
the Unit as a strong team and their working relationship as a great partnership.   
We observed a strong working relationship between the MFCU and the civil division 
of the U.S. Attorneys Office.  The Assistant U.S. Attorney who served as the civil health 
care fraud coordinator attributed the strong working relationship to open 
communication and good coordination between the agencies.  The U.S. Attorneys 
Office led the regional Health Care Task Force, which the MFCU and OI attended, 
among other Federal and State agencies.44  Since our onsite visit, the MFCU has 
continued to meet regularly with OI and the U.S. Attorneys Office. 
Observation: The Unit reported nearly all convictions and adverse actions to 
Federal partners within the appropriate timeframes.   
During the 3-year review period, the Unit submitted nearly all (99 percent) of its  
150 convictions to OIG within 30 days of sentencing, as required by Federal 
regulations and outlined in Performance Standard 8(f).45  The Unit also submitted 
nearly all (97 percent) of its 146 adverse actions to the NPDB within 30 days of the 
final adverse action, as required by Federal regulations and consistent with 
_____________________________________________________________________________________________________________________________ 
44 The COVID-19 health emergency paused the U.S. Attorneys Offices quarterly task force meetings. 
45 42 CFR  1007.11(g) requires the Unit to transmit information on convictions within 30 days of 
sentencing, or as soon as practicable if the Unit encounters delays in receiving the necessary information 
from the court. 
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Performance Standard 8(g).46, 47  In addition to reporting its own convictions to OIG, 
the Unit reported convictions of patient abuse and neglect obtained by local 
authorities for possible program exclusion. 
Performance Standard 9: Program Recommendations 
A Unit makes statutory or programmatic recommendations, when warranted, to the 
State government. 
Observation: The Unit made program recommendations to the State Medicaid 
agency and a statutory recommendation to the State legislature during our 
review period. 
Performance Standard 9 states that the Unit should make program or statutory 
recommendations, when warranted, to the State government.  The Unit made 
informal program recommendations to DHS and one statutory recommendation to 
the Minnesota legislature during the review period.  For its statutory 
recommendation, the Unit worked with DHS to draft a proposal for anti-kickback 
legislation; however, the Minnesota legislature did not pass the bill for the 2020 
session.  The proposed legislation would allow the Unit to prosecute providers in 
State court for paying illegal kickbacks; such prosecution is currently only possible at 
the Federal level in the State of Minnesota.  The Unit reported that it plans to re-
propose this legislation in 2023. 
Performance Standard 10: Agreement with Medicaid 
Agency 
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. 
Observation: The Units MOU with the State Medicaid agency reflected current 
practice, policy, and legal requirements. 
The MOU between the Unit and DHS was amended in April 2022 and reflected current 
practice, policy, and legal requirements. 
 
_____________________________________________________________________________________________________________________________ 
46 45 CFR  60.5.  Examples of adverse actions include, but are not limited to, health care-related criminal 
convictions and civil judgments (but not civil settlements), and program exclusions.  See SSA  1128E(a) 
and (g)(1). 
47 45 CFR  60.1.  The NPDB is intended to restrict the ability of physicians, dentists, and other health care 
practitioners to move from State to State without disclosure or discovery of previous medical malpractice 
and adverse actions.  NPDB, About Us.  Accessed at 
https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp on April 3, 2023. 
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Performance Standard 11: Fiscal Control 
A Unit exercises proper fiscal control over its resources.  
Observation: From our limited review, we identified no significant deficiencies in 
the Units fiscal control of its resources. 
From the Units responses to a detailed fiscal controls questionnaire and from follow-
up with fiscal staff and Unit officials, we identified no significant issues related to the 
Units budget process, accounting system, cash management, procurement, property, 
or personnel.  In our inventory review, we located 30 of the 30 sampled inventory 
items. 
Performance Standard 12: Training 
A Unit conducts training that aids in the mission of the Unit.  
Observation: The Unit maintained a training plan for each professional 
discipline, and Unit staff met training requirements. 
Performance Standards 12(a) and 12(b) state that the Unit should maintain a training 
plan for each professional discipline and that the Unit should ensure that professional 
staff comply with the training plans and maintain records of this compliance.  We 
found that the Unit maintained a training plan that included annual training hours for 
professional staff and that staff generally met those requirements.  Professional staff 
attended several trainings that aided in the Units mission, including training 
conferences by the National Association of Medicaid Fraud Control Units. 
In addition to annual training requirements, new Unit investigators received 4 weeks 
of formal orientation training, which included 2 weeks of lecture-based guidance and 
procedures and 2 weeks of on-the-job training in the field with an experienced 
investigator.  While staff recognized the value of the onboarding training, some staff 
expressed that new staff could benefit from more training.  During the inspection, OIG 
 
provided technical assistance to further strengthen the Units onboarding training. 
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CONCLUSION AND RECOMMENDATIONS 
The Minnesota MFCU reported strong case outcomes, with 161 indictments;  
150 convictions; 28 civil settlements and judgments; and nearly $32.3 million in 
recoveries for FYs 20202022.  From the information we reviewed, we observed that 
the Unit maintained strong working relationships and investigated cases jointly with 
Federal partners.  The Unit also reported nearly all convictions and adverse actions to 
Federal partners within the appropriate timeframes, including cases of patient abuse 
or neglect that were investigated and prosecuted by local authorities.  However, we 
identified four areas in which the Unit should improve its adherence to performance 
standards or program requirements, and for which we are issuing recommendations. 
First, we found that the director was the only supervisor in the Unit, which limited the 
oversight of Unit operations.  Second, we found that although the Unit took steps to 
coordinate with other State agencies, it received few referrals of patient abuse or 
neglect.  Third, we found that the Unit lacked a case management system that 
allowed efficient and secure access to case information and case outcomes data, 
which posed challenges for locating documents and tracking case statuses.  Finally, 
we found that the Unit did not consistently conduct periodic supervisory reviews or 
document supervisory approvals in the case files. 
To address the findings identified in this report, we made the following 
recommendations to the Minnesota Unit.   
We recommend that the Minnesota Unit: 
Continue efforts to hire a second-line supervisor and assess 
whether additional supervisors are warranted to meet the Units 
oversight needs 
The Unit should continue pursuing approval from the Attorney Generals Office to hire 
a second-line supervisor.  The Unit should also continue to assess its oversight needs 
and the potential benefits of additional second-line supervisors, such as a chief 
investigator or deputy director, to the Unit.  If warranted by the assessment, the Unit 
should further increase supervisory support. 
Build upon its efforts to increase referrals of patient abuse or 
neglect 
To ensure that the Unit receives an adequate number of patient abuse or neglect 
referrals, the Unit should increase its coordination and outreach with potential referral 
sources of patient abuse and neglect complaints.  For example, the Unit could 
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establish a process with referral sources that receive patient abuse and neglect 
complaints (e.g., MDH, DHS, and local adult protective teams) for how to best send 
referrals to the Unit.  Further, the Unit should conduct additional outreach to build 
upon its relationships with other potential referral sources for patient abuse and 
neglect complaints.  The Unit could consider involving its nurse investigator in the 
outreach efforts to educate referral sources on the Units authority to investigate 
patient abuse and neglect.   
Implement a comprehensive case management system that 
allows for efficient access to case documents and information 
The Unit reported that the Minnesota Office of the Attorney General approved its 
request to procure a new case management system.  When selecting the new system, 
the Unit should ensure that the system allows for efficient access to case information 
and case outcomes data.  The Unit should also ensure that the system meets the 
functional needs for Unit investigations and has the ability to protect and store case 
information and other pertinent data in a secure, logical, and user-friendly manner.  
While awaiting implementation of a new case management system, the Unit should 
take steps to mitigate the shortcomings of its electronic file structure.  For example, 
the Unit could implement a uniform folder structure and file names, which would 
make it easier to locate documents. 
Take steps to ensure that periodic supervisory reviews are 
conducted on a consistent basis and that case files include 
documentation of supervisory approvals 
The Unit should specify a frequency for conducting periodic supervisory reviews in its 
policies and procedures manual and take steps to ensure adherence to the policy.  
The Unit should also take steps to ensure that case files include documentation of 
supervisory approvals to open and close cases.  The Unit could implement automatic 
reminders to ensure that reviews are conducted and that case files are checked for 
completeness.  As stated in the first recommendation, OIG encourages the Unit to 
assess whether additional supervisory support is needed, which could help the Unit 
ensure consistency of supervisory reviews and approvals. 
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UNIT COMMENTS AND OIG RESPONSE 
The Minnesota MFCU concurred with all four of our recommendations.  
First, the Unit concurred with our recommendation to continue efforts to hire a 
second-line supervisor and assess whether additional supervisors are warranted to 
meet the Units oversight needs.  The Unit reported that it has drafted a position 
description for a managing investigator and intends to publicly post the position 
after receiving approval from the State Attorney Generals Office.  
Second, the Unit concurred with our recommendation to build upon its efforts to 
increase referrals of patient abuse and neglect.  The Unit reported that it intends to 
continue its outreach with potential sources of patient abuse and neglect referrals, 
including MDH, DHS, local law enforcement, and County Attorneys.  The Unit also 
noted that, once hired, its managing investigator will serve as the primary point of 
contact for outreach with law enforcement organizations and State agencies.  Further, 
the Unit reported that it is considering pursuing legislation to expand its prosecutorial 
authority for patient abuse and neglect cases.      
Third, the Unit concurred with our recommendation to implement a comprehensive 
case management system that allows for efficient access to case documents and 
information.  The Unit reported that following our onsite review, the State Attorney 
Generals Office approved a contract with a vendor that will provide a case 
management system, which the Unit expects to implement in 2024. 
Fourth, the Unit concurred with our recommendation to take steps to ensure that 
periodic supervisory reviews are conducted on a consistent basis and that case files 
include documentation of supervisory approvals.  The Unit reported that, once hired, 
its managing investigator will share the responsibility for conducting periodic 
supervisory reviews with the Unit director.      
We appreciate the steps the Unit has taken and plans to take to address the 
recommendations in the report.  We believe that these steps will improve the Units 
adherence to performance standards and program requirements and will strengthen 
its operations. 
For the full text of the Units comments, see Appendix D. 
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OEI-06-22-00430                                                                                                                 Unit Comments and OIG Response | 20    
DETAILED METHODOLOGY 
Data Collection and Analysis 
We collected and analyzed data from the seven sources described below to identify 
any opportunities for improvement and instances in which the Unit did not adhere to 
the MFCU performance standards or was not operating in accordance with laws, 
regulations, or policy transmittals.  We also used the data sources to make 
observations about the Units case outcomes as well as the Units operations and 
practices concerning the performance standards.    
Review of Unit Documentation 
Before the onsite inspection, we reviewed the recertification materials for  
FYs 2020-2022, including (1) the Units recertification questionnaires, (2) the Units 
MOU with DHS-SIRS, (3) the DHS-SIRS program integrity unit questionnaire, and  
(4) the OIG Special Agent in Charge questionnaires.  We also reviewed the Units 
policies and procedures manual and the Units self-reported case outcomes and 
referrals included in its annual statistical reports for FYs 20202022.  Additionally, we 
examined the recommendations from the 2013 OIG onsite inspection report and the 
Units implementation of those recommendations.   
Review of Unit Financial Documentation 
We conducted a limited review of the Units control over its fiscal resources.  Before 
the onsite inspection, we analyzed the Units responses to a questionnaire about 
internal controls and conducted a desk review of the Units quarterly financial reports.  
We followed up with the Minnesota Office of the Attorney General to clarify issues 
identified in the questionnaire about internal controls.  We also selected a purposive 
sample of 30 items from the Units inventory list of 210 items maintained by the Unit 
and verified those items onsite. 
Interviews with Key Stakeholders 
In October 2022, we interviewed key stakeholders, including officials in DHS-SIRS, 
MDH, OI, and the U.S. Attorneys Office.  We focused these interviews on the Units 
relationship and interaction with the stakeholders, as well as opportunities for 
improvement.  We used the information collected from these interviews to develop 
subsequent interview questions for Unit management and staff.   
 
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Onsite Interviews with Unit Management and Selected Staff 
We conducted structured interviews with the Unit director and selected staff in 
OctoberNovember 2022.  Among the selected Unit staff were five investigators,  
two attorneys, one auditor, and one nurse investigator.  In addition, we interviewed 
the Unit directors supervisor, the Deputy Attorney General.  We asked these 
individuals questions related to (1) Unit 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;  
(4) clarification regarding information obtained from other data sources; and (5) the 
Units training and technical assistance needs. 
Onsite Review of Case Files 
To craft a sampling frame, we requested that the Unit provide us with a list of cases 
that were open at any time during FYs 20202022 and include the status of each case; 
whether the case was criminal, civil, or global; and the dates on which the case was 
opened and closed, if applicable.  The total number of cases was 506.  
We excluded all global cases from our review of the Units case files 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 64 global 
cases, leaving 442 case files.  
We then selected a simple random sample of 86 cases from the population of  
442 cases.  This sample allowed us to make estimates of the overall percentage of 
case files with various characteristics with absolute precision of no more than  
+/- 10 percent at the 95-percent confidence level.   
We reviewed the 86 case files for adherence to the relevant performance standards 
and compliance with statutes, regulations, and policy transmittals.  During our review 
of the sampled case files, we consulted MFCU staff to address any apparent issues 
with individual case files, such as missing documentation. 
Review of Unit Submissions to OIG and the National Practitioner 
Data Bank 
We also reviewed all 150 convictions submitted to OIG for program exclusion and all 
146 adverse actions submitted to the NPDB during our review period.  We reviewed 
whether the Unit submitted information on all sentenced individuals and entities to 
OIG for program exclusion and all adverse actions to the NPDB for FYs 20202022.  
We also assessed the timeliness of the submissions to OIG and the NPDB.   
 
 
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Onsite Review of Unit Operations 
During the onsite inspection, we observed the workspace and operations of the Units 
office in St. Paul.  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. 
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APPENDICES 
Appendix A: Unit Referrals by Source for FYs 20202022 
 
FY 2020  FY 2021  FY 2022  3-Year Total 
Abuse or  Abuse or  Abuse or  Abuse or 
Referral Source  Fraud  Fraud  Fraud  Fraud  Total 
Neglect  Neglect  Neglect  Neglect 
Adult Protective 
0  0  0  0  0  0  0  0  0 
Services 
Anonymous  0  0  0  0  0  0  0  0  0 
HHS-OIG  2  0  0  0  2  0  4  0  4 
Law Enforcement
2  2  1  0  2*  0  5  2  7 
Other 
Licensing Board  0  0  2  0  2  0  4  0  4 
Local Prosecutor  1  0  2  1  0  1  3  2  5 
Long-Term Care 
0  0  0  0  0  0  0  0  0 
Ombudsman 
Managed Care 
25  0  21  0  35  0  81  0  81 
Organizations 
Medicaid Agency
0  0  0  0  1  0  1  0  1 
Other 
Medicaid Agency
89  0  98  0  100  0  287  0  287 
PI/SURS 
Private Citizen  47  0  30  0  34  0  111  0  111 
Private Health Insurer  0  0  0  0  0  0  0  0  0 
Provider  0  0  0  0  0  0  0  0  0 
Provider Association  0  0  0  0  0  0  0  0  0 
State Agency 
0  0  2  0  1  0  3  0  3 
Other 
State Survey and 
0  0  0  0  0  0  0  0  0 
Certification Agency 
Other  32  2  55  0  12  0  99  2  101 
Sub-Total  198  4  211  1  189  1  598  6  604 
Total  202  212  190  604 
Source: OIG Analysis of Unit Annual Statistical Reports for FYs 20202022.    
* Based on OIGs analysis of a random sample of Unit case files, one of these referrals was sent jointly with the State Survey and Certification 
agency.
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Appendix B: Unit Turnover by Staff Discipline during FYs 20202022 
Staff  Staff  Average Staff 
New Staff Hired  Staff Departures 
Employed at  Employed at  Turnover Rate 
Staff Discipline  Start of FY  End of FY  during FYs  during FYs  during FYs 
20202022  20202022 
2020  2022  20202022 
All Professional Disciplines  20  23  17  14  22.8% 
Investigator  13  13  10  10  27.9% 
Attorney  5  7  5  3  17.9% 
Auditor/Analyst  2  3  2  1  11.1% 
Source: OIG analysis of Unit-provided documentation, FYs 20202022.
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Appendix C: Point Estimates and 95-Percent Confidence Intervals of 
Case File Reviews 
Exhibit C-1: Estimates for Periodic Supervisory Reviews 
95-Percent Confidence 
Interval 
Estimate Description  Sample Size  Point Estimate 
Lower  Upper 
Percentage of cases open at least 6 months  86  83.7%  75.1%  90.3% 
Percentage of cases open at least 6 months that did not have 
72  52.8%  41.4%  63.8% 
periodic supervisory reviews at least every 6 months; of these: 
  Percentage of cases with periodic supervisory 
72  27.8%  18.6%  38.7% 
reviews less frequent than every 6 months 
  Percentage of cases with no periodic supervisory 
72  25.0%  16.1%  35.7% 
reviews 
Source: OIG analysis of Minnesota MFCU case files, FYs 20202022. 
Exhibit C-2: Estimates for Case Documentation 
95-Percent Confidence 
Interval 
Estimate Description  Sample Size  Point Estimate 
Lower  Upper 
Percentage of all cases closed at the time of our review  86  61.6%  51.6%  71.0% 
Percentage of all cases that did not have supervisory 
86  10.5%  5.2%  18.1% 
approval to open the referral 
Percentage of closed cases that did not have supervisory 
52  19.2%  10.0%  31.9% 
approval to close 
Source: OIG analysis of Minnesota MFCU case files, FYs 20202022.
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Appendix D: Unit Comments 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Keith Peters of the Medicaid Fraud Policy and Oversight Division served as the team 
leader for this study, and Kristen Calille served as the lead analyst.  Others in the 
Office of Evaluation and Inspections who conducted the study include Kaisee Riddell 
and Jordan Swoyer.  Office of Evaluation and Inspections headquarters staff who 
provided support include Robert Gibbons and Sara Swisher.  
We would also like to acknowledge contributions of two special agents from the 
Office of Investigations.  Finally, Mark Collins of the Nebraska MFCU served as a peer 
reviewer. 
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector 
General for Evaluation and Inspections in the Dallas regional office, and Petra Nealy, 
Deputy Regional Inspector General, as well as in consultation with Richard Stern, 
Director of the Medicaid Fraud Policy and Oversight Division. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
 
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ABOUT THE OFFICE OF INSPECTOR GENERAL 
Office of Inspector General 
https://oig.hhs.gov 
The mission of the Office of Inspector General (OIG) is to provide objective oversight 
to promote the economy, efficiency, effectiveness, and integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and welfare of the 
people they serve.  Established by Public Law No. 95-452, as amended, OIG carries out 
its mission through audits, investigations, and evaluations conducted by the following 
operating components: 
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.  The audits examine the performance of HHS programs, funding recipients, 
and contractors in carrying out their respective responsibilities and provide 
independent assessments of HHS programs and operations to reduce waste, abuse, 
and mismanagement. 
The Office of Evaluation and Inspections.  OEIs national evaluations 
provide HHS, Congress, and the public with timely, useful, and reliable information on 
significant issues.  To promote impact, OEI reports also provide practical 
recommendations for improving program operations. 
The Office of Investigations.  OIs criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs and operations 
often lead to criminal convictions, administrative sanctions, and civil monetary 
penalties.  OIs nationwide network of investigators collaborates with the Department 
of Justice and other Federal, State, and local law enforcement authorities.  OI works 
with public health entities to minimize adverse patient impacts following enforcement 
operations.  OI also provides security and protection for the Secretary and other 
senior HHS officials. 
The Office of Counsel to the Inspector General.  OCIG provides legal 
advice to OIG on HHS programs and OIGs internal operations.  The law office also 
imposes exclusions and civil monetary penalties, monitors Corporate Integrity 
Agreements, and represents HHSs interests in False Claims Act cases.  In addition, 
OCIG publishes advisory opinions, compliance program guidance documents, fraud 
alerts, and other resources regarding compliance considerations, the anti-kickback 
statute, and other OIG enforcement authorities. 
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