Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
M   S M
ISSISSIPPI  TATE  EDICAID 
 
F C U :  
  RAUD  ONTROL  NIT  
 
2014 O R  
  NSITE  EVIEW 
Suzanne Murrin  
Deputy Inspector General for 
Evaluation and Inspections 
 
August 2014 
OEI-09-13-00700   
   
MISSISSIPPI STATE MEDICAID FRAUD CONTROL UNIT:  
2014 ONSITE REVIEW 
OEI-09-13-00700 
 
WHY WE DID THIS STUDY 
 
The Office of Inspector General (OIG) oversees the activities of all State Medicaid Fraud 
Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic 
reviews of all Units and prepares public reports based on these reviews.  The reviews  
assess Unit performance in accordance with the 12 MFCU performance standards and 
monitor Unit compliance with Federal grant requirements.   
 
HOW WE DID THIS STUDY  
 
We conducted an onsite review in January 2014.  We based our review on an analysis of 
data from seven sources:  (1) a review of policies, procedures, and documentation on the 
Units operations, staffing, and caseload for fiscal years (FYs) 2011 through 2013; 
(2) a review of financial documentation; (3) structured interviews with key stakeholders; 
(4) a survey of Unit staff; (5) structured interviews with the Units management and 
selected staff; (6) an onsite review of a sample of case files that were open in FYs 2011 
through 2013; and (7) an onsite observation of Unit operations.  
 
WHAT WE FOUND 
 
From FYs 2011 through 2013, the Unit reported recoveries of $52 million, 
174 convictions, and 37 civil judgments and settlements.  A Unit supervisor approved the 
opening and closing of most case files; however, 44 percent of case files lacked 
documentation of periodic supervisory reviews.  In addition, the Unit did not adequately 
safeguard some of its case files.  The Unit did not investigate 5 percent of cases before 
the statute of limitations expired, and may not have enough investigators assigned to 
patient abuse and neglect cases. The Unit also did not refer 11 sentenced individuals to 
OIG for program exclusion within an appropriate timeframe.  Finally, the Units policies 
and procedures manual did not reflect current Unit operations.   
  
WHAT WE RECOMMEND 
 
We recommend that the Mississippi Unit (1) ensure that supervisors approve the opening 
and closing of cases and that periodic supervisory reviews are conducted and documented 
in Unit case files; (2) ensure that case files are secure; (3) ensure that all cases are 
investigated or closed, as appropriate, before the statute of limitations expires; (4) assess 
the allocation of existing staff levels; (5) ensure that it refers all sentenced individuals for 
exclusion to OIG within an appropriate timeframe; and (6) revise its policies and 
procedures manual to reflect current operations.  The Unit concurred with all six of our 
recommendations.  
 
       
   
TABLE OF CONTENTS 
Objective......................................................................................................1 

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

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

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

From FY 2011 through FY 2013, the Unit reported recoveries  

of $52 million, 174 convictions, and 37 civil judgments and 

settlements........................................................................................6 

A Unit supervisor approved the opening and closing of most  

case files; however, 44 percent of case files lacked  

documentation of periodic supervisory reviews ..............................7 

The Unit did not adequately safeguard some of its case files ..........8 

The Unit did not investigate 5 percent of cases before the  
statute of limitations expired ............................................................9 

The Unit may not have enough investigators assigned to  
cases of patient abuse and neglect ...................................................9 

The Unit did not refer 11 sentenced individuals to OIG for  

program exclusion within an appropriate timeframe  .....................10 

The Units policies and procedures manual did not reflect  

current Unit operations ..................................................................11 
 
Conclusion and Recommendations ............................................................12 

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

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

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

B: Revised 2012 Performance Standards for MFCUs  ..................19 

C: Referrals of Provider Fraud and Patient Abuse and Neglect  

to the Mississippi MFCU by Source, FYs 2011 Through 2013 .....26 

D: Investigations Opened and Closed by the Mississippi  

MFCU, by Provider Category and Case Type, FYs 2011  

Through 2013.................................................................................27 

E: Methodology ............................................................................29 

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

Confidence Interval Estimates .......................................................32 

       
   
G: Unit Comments ........................................................................34   

Acknowledgments......................................................................................36
 
       
OBJECTIVE 
To conduct an onsite review of the Mississippi State Medicaid Fraud 
Control Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse and 
neglect under State law.1  Pursuant to Title XIX of the SSA, each State 
must maintain a certified Unit unless the Secretary of Health and Human 
Services determines that operation of a Unit would not be cost-effective 
because (1) minimal Medicaid fraud exists in that State; and (2) the State 
has other, adequate safeguards to protect Medicaid beneficiaries from  
abuse and neglect.2   Currently, 49 States and the District of Columbia 
(States) have created such Units.3  In fiscal year (FY) 2013, combined 
Federal and State grant expenditures for the Units totaled $230 million.4, 5   
That year, the 50 Units employed 1,912 individuals.6  
To carry out its duties in an effective and efficient manner, each Unit must 
employ an interdisciplinary staff that consists of at least an investigator, an 
auditor, and an attorney.7  The staff reviews complaints referred by the 
State Medicaid agency and other sources and determines their potential for  
   
 
1 Social Security Act (SSA)  1903(q).  

2 SSA  1902(a)(61).  Regulations at  42 CFR  1007.11(b)(1) add that the Units 

responsibilities may include reviewing complaints of misappropriation of patients 

private funds in  residential health care facilities.   

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

Islands, Puerto Rico, and the U.S. Virgin  Islands have not established Units.  Medicaid 

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

http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp  on February 11, 

2014 . 

4 All FY references in this report are based on the Federal FY (October 1  through  
September 30). 
 
5 OIG,  MFCU  Statistical Data  for Fiscal Year 2013. Accessed at 

http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/ on  March 10, 2014. 
 
6 Ibid. 

7 SSA  1903(q)(6) and 42 CFR  1007.13. 
 
 
  
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)  1 
   
   
criminal prosecution and/or civil action.  Collectively, in FY 2013, the 
50 Units reported 1,341 convictions and 879 civil judgments and 
settlements.  That year, the Units reported recoveries of approximately 
$2.5 billion.8  
Units are required to have either Statewide authority to prosecute cases or 
formal procedures to refer suspected criminal violations to an office with 
such authority.9  In Mississippi and 43 other States, the Units are located 
within offices of State Attorneys General that have this authority.  In the  
remaining six States, the Units are located within other State agencies; 
generally, such Units must refer cases to offices with prosecutorial 
authority.10, 11   Additionally, each Unit must be a single, identifiable entity 
of State government, distinct from  the State Medicaid agency, and each 
Unit must develop a formal agreementi.e., a memorandum of 
understanding (MOU)that describes the Units relationship with that 
agency.12   
Oversight of the MFCU Program 
The Secretary of Health and Human Services delegated to OIG the authority 
both to annually certify the Units and to administer grant awards to 
reimburse States for a percentage of their costs of operating them.13 All 
Units are currently funded by the Federal Government on a 75-percent 
matching basis, with the States contributing the remaining 25 percent.14   To  
receive Federal reimbursement, each Unit must submit an initial application 
to OIG.15  OIG reviews the application and notifies the Unit whether it is 
 
8 OIG,  MFCU  Statistical Data  for Fiscal Year 2013. Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/ on  March 10, 2014.   
Pursuant to 42  CFR   1007.17, Units report the total amount of recovered funds in their  
annual  reports  to OIG.   Recoveries are defined as the amount  of money that defendants 
are required to pay as a result of a judgment  or settlement in criminal and civil cases, and 
may not reflect actual collections.  Recoveries may involve cases that include  
participation by other Federal and State agencies. 
9  SSA  1903(q)(1).  
10  Medicaid Fraud Control Units, OIG web site.  Accessed at 
 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp on March 18, 2014. 

11 In States with  a Unit, the Unit shares responsibility for protecting the integrity of the 

Medicaid program with the section of the State Medicaid agency that functions as the 
 
Program Integrity Unit.  Some States also employ a Medicaid Inspector General who 

conducts and coordinates activities against fraud, waste, and abuse for the State agency. 

12 SSA    1903(q)(2) and  42 CFR   1007.5 and  1007.9(d). 

13 The portion of funds reimbursed to States by the Federal  Government for its share of 
 
expenditures for the Federal  Medicaid program, including  the MFCUs, is  referred to as 

Federal Financial Participation.  

14  SSA  1903(a)(6)(B). 
  
15 42 CFR   1007.15(a). 

 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   2 
   
   
approved and the Unit is certified. Approval and certification are valid for a 
1-year period; the Unit must be recertified each year thereafter.16    
Pursuant to Title XIX of the SSA, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.17   OIG 
developed and issued 12 performance standards to define the criteria that 
OIG applies in assessing whether a Unit is effectively carrying out statutory 
functions and meeting program requirements.18  Examples of standards 
include maintaining an adequate caseload through referrals from several 
sources, maintaining an annual training plan for all three of the professional 
disciplines (i.e., for auditors, investigators, and attorneys), and establishing  
policy and procedures manuals to reflect the Units operations.  See 
Appendix A for a complete list of the performance standards.19  
Mississippi Unit  
Located in Jackson, the Unit is an autonomous entity within the 
Mississippi Office of the Attorney General and has the authority to 
prosecute cases of Medicaid fraud and cases of patient abuse and neglect.20   
The Unit Director serves as the Chief  Attorney and directly supervises all 
Unit attorneys, the Chief Investigator, Unit auditors, and Unit support 
staff. The Chief Investigator supervises all Unit investigators and the 
Fraud Supervisor. The Fraud Supervisor shares supervisory duties with 
the Chief Investigator by directly supervising the Unit investigators who 
specialize in provider fraud. At the time of our review, 30 of the Units 
employees were located in Jackson, and 1 attorney and 1 investigator were 
located in Biloxi. 
Mississippi State law mandates that any person who has knowledge of or 
reasonable cause to believe that any patient or resident of a care facility 
has been the victim of abuse, neglect or exploitation must file a report 
with the Unit.21  Unit management stated that this reporting requirement 
leads to an average of 1,900 referrals of patient abuse and neglect from  
 
16 42 CFR   1007.15(b) and  (c). 

17  SSA  1902(a)(61). 
 
18 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov  on February  11, 

2014.   

19 The performance standards referred to in this report were published in  1994 and were 
 
in effect during FYs 2011 and  2012, which  constitutes most of our review period.  In 

June 2012, OIG published a  revision of the performance standards (77 Fed. Reg.  32645, 
 
June 1, 2012). Our onsite data collection took place in January 2014.  When referring to 
 
the performance standards, we refer to the 1994 standards,  unless otherwise noted. See 
 
Appendix B  for a complete list of the revised performance standards.
  
20 For the purposes of this report, misappropriation of patients  private funds in
  
residential health care facilities is included  in the category of patient abuse and neglect. 

21  MS  Code  43-47-37.   

 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   3 
   
   
providers to the Unit each year. The Unit also receives referrals of  
provider fraud from the Mississippi Division of Medicaid, private citizens, 
and from Federal agencies such as OIG.  For additional information on 
Unit referrals, see Appendix C. 
According to the Unit, upon receiving a referral of patient abuse and 
neglect, the Chief Investigator should review the information and 
determine whether to refer it to another agency or open it as a case and 
assign it to an investigator. Fraud referrals should be reviewed by the Unit 
Director and Fraud Supervisor before being assigned to a team consisting 
of an investigator, auditor, and attorney.  After a referral is accepted for 
investigation, one of the legal secretaries should open it as a case in the 
Units electronic case tracking system.  The Unit may open a case and 
pursue it through a variety of actions, including criminal prosecution, civil 
action, or a combination of the two.  The Unit may close a case for a 
variety of reasons, including but not limited to resolving it through 
criminal and/or civil action or referring it to another agency.  For 
additional information on the Units opened and closed investigations, 
including a breakdown by case type and provider category, see 
Appendix D. 
Previous Review  
In 2008, while the Mississippi Unit was under the supervision of a 
previous director, OIG conducted an onsite review of the Unit and 
identified two concerns related to the MFCU performance standards.  The 
review found that the Unit did not have standardized MFCU-specific 
policies and procedures in place governing MFCU activities.  The review 
also noted that supervisory case file reviews were not conducted on a 
periodic basis. In its response to the review, the Unit stated that it would 
incorporate MFCU-specific policies and procedures into a written manual.  
The Unit also noted that it had begun documenting supervisory reviews in 
the case files since the 2008 onsite review.  According to current Unit 
staff, the staff at that time developed draft policies and procedures that 
were formally implemented in July 2010 after the current director was 
hired. 
METHODOLOGY 
We conducted the onsite review in January 2014.  We based our review on 
an analysis of data from seven sources:  (1) a review of Unit 
documentation, including policies and procedures related to the Units 
operations, staffing, and caseload for FYs 2011 through 2013; (2) a review 
of financial documentation for FYs 2011 through 2013; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   4 
   
   
interviews with the Units management and selected staff; (6) an onsite 
review of a sample of case files that were open at any point during 
FYs 2011 through 2013; and (7) an onsite review of Unit operations.  
Appendix E contains a detailed methodology.  Appendix F contains the 
point estimates and 95-percent confidence intervals for the statistics in this 
report. 
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.22  
 
22 Full text  of these standards is available online at 

http://www.ignet.gov/pande/standards/oeistds11.pdf. 

 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   5 
   
   
FINDINGS 
From FY 2011 through FY 2013, the Unit reported 
recoveries of $52 million, 174 convictions, and 37 civil 
judgments and settlements 
From FY 2011 through FY 2013, the Unit reported total criminal and civil 
recoveries of $52 millionan annual average of $17 million (see Table 1).  
Of the $52 million in total recoveries, the Unit attributed $16 million to 
criminal recoveries.  The Units criminal recoveries were significantly 
higher in FYs 2012 and 2013 than in FY 2011.  The Unit reported that this 
increase resulted from one case in FY 2012 and one case in FY 2013 that 
each had significant recoveries.  Over the 3-year period, global case 
judgments and settlements accounted  for $33 million of the total civil 
recoveries and global cases accounted for 35 of the Units 2,121 cases.23   
The Units annual average expenditures for FYs 2011 through 2013 were 
$2.8 million.24      
Table 1: Funds Reported Recovered by the Mississippi Unit,  
FYs 2011 Through 2013  
3-Year  Annual  
FY 2011   FY 2012   FY 2013  
  Total   Average 
Criminal 
$139,989   $7,241,534   $8,784,328   $16,165,851   $5,388,617  
Recoveries 
Global Civil 
$15,044,539   $1,459,454  $16,789,721  $33,293,714   $11,097,905 
Recoveries 
Nonglobal Civil 
$6,500   $154,000   $2,234,068   $2,394,568  $798,189  
Recoveries 
Total Civil 
$15,051,039   $1,613,454  $19,023,789  $35,688,282   $11,896,094 
Recoveries 
Total Civil and 
Criminal  $15,191,028   $8,854,988   $27,808,117  $51,854,133  $17,284,711 
Recoveries  
Total  
$2,386,432  $2,802,537   $3,068,990   $8,257959   $2,752,653  
Expenditures 
Source:  OIG review of Unit self-reported quarterly statistical reports and other data, FYs 20112013. 
 
 
   
 
23 Unit-reported recoveries include funds recovered  from  multi-State, or global civil 
false claims cases, which consist of both those worked  directly by the Unit and those 
worked by staff from other Units.   
24 The figures presented in this  paragraph are rounded.  
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   6 
   
   
From FY 2011 through FY 2013, the Unit Reported 174 Convictions and 
37 Civil Judgments and Settlements. From FY 2011 through FY 2013, the 
Units convictions and civil judgments and settlements remained relatively 
consistent. During this period, the Unit reported 174 convictions and 
37 civil judgments and settlementsan annual average of 58 convictions 
and 12 civil judgments and settlements (see Table 2).  Of the Units 
174 convictions over the 3-year period, 166 were for patient abuse and 
neglect cases and 8 were for provider fraud cases.   
Table 2: Unit Convictions and Civil Judgments and Settlements, 
FYs 2011 Through 201325  
3-Year  Annual  
FY 2011   FY 2012   FY 2013  
  Total   Average 
Convictions  52  69  53  174  58 
Civil Judgments and Settlements   13  10  14  37  12.3 
Source:  OIG review of Unit self-reported quarterly statistical reports and other data, FYs 2011-2013. 
 
From FYs 2011 through 2013, the Unit opened an average of 247 cases 
annually, with an average of 207 cases of patient abuse and neglect and 
41 cases of provider fraud. During this time, the Unit closed an average of 
463 cases annually, averaging 442 cases of patient abuse and neglect and 
21 cases of provider fraud.26  From FYs 2011 through 2013, the Unit 
received an average of 1,926 referrals annually, with an average of 
1,885 referrals of patient abuse and neglect and 41 referrals of provider 
fraud.27    
A Unit supervisor approved the opening and closing of 
most case files; however, 44 percent of case files 
lacked documentation of periodic supervisory reviews  
According to Performance Standard 6(b), Unit supervisors should approve 
the opening and closing of cases to ensure a continuous case flow and the 
timely completion of cases.  Supervisory approval to open and close cases 
suggests that Unit supervisors are monitoring the intake and resolutions of 
cases, thereby facilitating progress in the cases.  According to Unit 
management, the Chief Investigator should approve the opening of all 
cases of patient abuse and neglect, and the Fraud Supervisor should 
approve the opening of all fraud cases.  Unit management also reported 
 
25 Civil judgments and settlements include those received from global cases.   

26 Closures include multiple cases opened before FY 2011.   

27 The averages in this paragraph are rounded. 
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   7 
   
   
that during the review period, supervisory approval to close a case should 
have been documented in all case files except for cases of patient abuse 
and neglect that were closed due to court dispositions (for example, 
convictions). The Unit documented supervisory approval to open cases in 
93 percent of the case files; the remaining 7 percent contained no 
indication of supervisory approval to open the cases.  The Unit 
documented supervisory approval to close cases in 88 percent of the 
closed case files; the remaining 12 percent contained no indication of 
supervisory approval to close the cases. 
According to Performance Standard 6(c), supervisory reviews should be 
conducted periodically and noted in the case file to ensure timely case 
completion.28  According to Unit management, the Chief Investigator 
meets with each investigator at least three times a year to review all of the 
investigators open cases. According to Unit management, each 
investigator should document these conversations (and any other 
conversations with Unit management) as supervisory reviews in the case 
files or electronic case file tracking system.  However, 44 percent of Unit 
case files lacked documentation of periodic supervisory reviews.29    
The Unit did not adequately safeguard some of its 
case files 
According to Performance Standard 1, a Unit will conform to all 
applicable statutes, regulations, and policy transmittals.  Pursuant to 
Federal regulations and OIG policy,  a Unit must prevent the misuse of 
information under the Units control by safeguarding the privacy rights of 
witnesses, victims, and informants.30  A Unit must also safeguard the 
identities of suspects when the allegations are unsubstantiated, unless such 
identities are already in the public record or the individuals clearly 
consented to the release of their private information.31 In addition, the 
Units policies and procedures manual states that personnel will at no 
time leave case material unattended in the public areas of the office.   
   
 
28 For the purposes of this report, supervisory approval to  open and close a case does not  
constitute a periodic supervisory review.  Periodic supervisory reviews are demonstrated 
by a supervisors reviewing a case more than once between the cases opening and 
closing and documenting those reviews in the case file. 
29 Performance Standard  6(c)  does not  define periodically for the purpose of case file  
reviews.  Because Unit practice is to conduct supervisory reviews three times a year, we 
excluded case files that were open for less than 1 year.   
30 42 CFR   1007.11(f); OIG State Fraud Policy Transmittal 99-02, Public Disclosure 

Requests and Safeguarding  of  Privacy Rights (December 22, 1999). 

31 Ibid.  

 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   8 
   
   
However, we observed that some Unit case file boxes labeled with 
personally identifiable information were stored unlocked in public areas of 
the office. Although individuals must use a coded access card to enter the 
public areas of the Units office, non-Unit staff share this office space, and 
other non-Unit personnel (such as cleaning staff and information 
technology contractors) can gain access to areas where these unlocked 
case files are located. 
The Unit did not investigate 5 percent of cases before 
the statute of limitations expired  
According to Performance Standard 5(a), the Unit should take steps to 
maintain a continuous case flow and to complete cases in an appropriate 
timeframe based on the complexity of the cases.  However, five cases in  
our sample (5 percent) were closed because the Unit did not investigate 
them before the statute of limitations expired.  According to Unit 
management, these five cases were investigations of patient abuse and 
neglect that were considered to be lower priority because during their 
initial review, management determined that the cases were unlikely to 
have sufficient evidence for investigation and prosecution.32    
The Unit may not have enough investigators assigned 
to cases of patient abuse and neglect 
According to 2012 Performance Standard 2(c), the Unit should employ 
an appropriate mix and number of attorneys, auditors, investigators, and 
other 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.  At the time of our 
review, the Unit had seven investigators specializing in cases of patient 
abuse and neglect and seven investigators specializing in cases of provider 
fraud. However, in FY 2013, the Mississippi Unit received the 
third-highest number among the 50 Units of referrals of patient abuse and 
neglect and had the highest number of ongoing investigations of patient 
abuse and neglect.33   The Unit also had the highest proportion of cases of 
 
32 Unit management reported that because the Unit has a large caseload of cases of  patient  
abuse and neglect, the Chief Investigator assigns each incoming case a priority level.  
Any complaints involving the death or sexual assault of a patient are assigned the highest  
priority.  
33 In the fourth quarter of  FY 2013, the Mississippi Unit  had 611 ongoing investigations 
of patient abuse and neglect.   California had the second-highest  number of such  
investigations, with 439.   
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   9 
   
   
patient abuse and neglect to cases of fraud89 percent to 11 percentof 
the 50 Units.34  
Members of Unit management and staff reported that Mississippis  
mandatory reporting requirement for patient abuse and neglect created 
large caseloads that may have limited the Units ability to effectively 
investigate all of its cases.  Unit management reported that fraud 
investigators in the Unit each had caseloads of between 8 and 15 cases, 
whereas the Units investigators of patient abuse and neglect each had 
caseloads of between 60 and 80 cases.   Unit management reported that the 
ideal caseload would be 50 or fewer cases per investigator of patient abuse 
and neglect. According to one staff member, [W]ith around 
1,800 neglect/abuse and exploitation complaints fielded annually... the 
number of investigators is inadequate to handle the caseload.  Another 
staff member reported that the number of cases opened by our Unit seems 
to increase each year... I feel that our unit could use more manpower to 
handle the increased volume of cases.   
Unit management reported that the Unit is trying to get the caseload for 
each investigator of patient abuse and neglect down to a manageable 
level. Management reported that as part of this effort, the Unit 
implemented a new intake procedure that screens potential cases of patient 
abuse and neglect for sufficiency of evidence and consistency with the 
Units statutory functions. Management also reported that they have made 
an effort to close out unsubstantiated cases and have begun assigning 
teams of investigators to work on complex and/or high-priority cases.  For 
example, the Chief Investigator may ask all Unit investigators to conduct 
interviews for a single case of fraud or of patient abuse and neglect to 
ensure that it is completed in a timely manner.   
The Unit did not refer 11 sentenced individuals to OIG 
for program exclusion within an appropriate timeframe 
According to Performance Standard 8(d), when a convicted individual is  
sentenced, the Unit should send a referral letter to OIG within 30 days or  
other reasonable time period for the purpose of program exclusion.35, 36   
 
34 In the fourth quarter of  FY 2013, Alabama had the second-highest proportion  of cases 
of patient abuse and neglect to cases of  fraud63 percent  to 37  percent. 
 
35 Pursuant to section 1128(a) of the SSA, OIG excludes from participation in Federal 
 
health care programs any person or entity convicted of a criminal offense related to the 

delivery  of an item or service under the Medicaid program or to the neglect or abuse of
  
patients in residential health care facilities.  No payment may be made by  Medicaid, 
 
Medicare, or  other Federal  health care programs for an item or service provided,  ordered, 

or prescribed by an excluded individual or entity.  42 CFR  1001.1901.  

 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   10 
   
   
The Unit reported 174 total convictions within the review period, but did 
not refer 11 of those sentenced individuals to OIG for program exclusion 
within an appropriate timeframe.  Each of these 11 individuals had been 
sentenced at least 4 months prior to our onsite review.  However, they were  
referred to OIG more than 60 days after their sentencing dates, including 
two individuals who were referred more than 180 days after their sentencing 
dates. 
The Units policies and procedures manual did not 
reflect current Unit operations 
According to 2012 Performance Standard 3(a), the Unit should have 
written guidelines or manuals that contain current policies and procedures 
for its operations that are consistent with the performance standards.  The 
Units policies and procedures manual was finalized approximately 
3 years prior to our onsite review, and management reported that the 
manual is continually updated.  However, the manual did not address 
procedures for supervisory approval to open and close cases or for 
documenting periodic supervisory reviews in the Units case files.   
 
36 According to  2012 Performance Standard  8(f), all referrals for exclusion should be  
transmitted to  OIG within 30  days.  Unlike its 1994 counterpart, the 2012 standard does 
not include an  additional option for transmitting such referrals within an unspecified  
other reasonable time period.  
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   11 
   
   
CONCLUSION AND RECOMMENDATIONS 
From FY 2011 through FY 2013, the Unit reported recoveries of  
$52 million, 174 convictions, and 37 civil judgments and settlements.  A  
Unit supervisor approved the opening and closing of most case files.  
Opportunities for Unit improvement  exist.  Unit case files did not 
consistently contain documentation of periodic supervisory reviews, and 
the Unit did not adequately safeguard some of its case files.  The Unit did 
not investigate 5 percent of cases before the statute of limitations expired 
and may not have enough investigators assigned to patient abuse and 
neglect cases. In addition, the Unit also did not refer all sentenced 
individuals to OIG for program exclusion within an appropriate 
timeframe.  Finally, the Units policies and procedures manual did not 
reflect current Unit operations.  Other than with regard to case file 
security, we found no evidence of noncompliance with applicable laws, 
regulations, or policy transmittals.  
We recommend that the Mississippi Unit: 
Ensure that supervisors approve the opening and closing of 
cases and that periodic supervisory reviews are conducted 
and documented in Unit case files 
The Unit should ensure that supervisors are approving the opening and 
closing of cases and periodically reviewing case files, and these periodic 
supervisory reviews should be documented in the case files. 
Ensure that case files are secure 
The Unit should store its case files and other documentation containing 
personally identifiable information in a locked room or in locked storage 
cabinets when not in use. 
Ensure that all cases are investigated or closed, as 
appropriate, before the statute of limitations expires  
The Unit should establish policies and procedures to track open cases to 
ensure that they are investigated or closed, as appropriate, before the 
statute of limitations expires. 
Assess the allocation of existing staff levels and take 
appropriate action 
The Unit should assess whether existing staff levels are efficiently allocated 
between cases of provider fraud and cases of patient abuse and neglect.  The 
Unit should also assess whether existing staff allocations are sufficient to 
respond to the volume of referrals and to investigate and prosecute the Units  
cases in a timely manner. The Unit should take appropriate action on the 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   12 
   
   
basis of these assessments.  For example, if appropriate, the Unit could hire 
additional staff.  
Ensure that letters referring providers for exclusion are 
submitted to OIG within an appropriate timeframe 
The Unit should ensure that letters referring individuals and entities for 
exclusion are sent within 30 days of defendant sentencing, consistent with 
Standard 8(f) of the 2012 Performance Standards.   
Revise its policies and procedures manual to reflect current 
Unit operations 
The Unit should revise its policies and procedures manual to include 
current Unit procedures.  Specifically, to be consistent with the current 
performance standards, the Unit should revise its policies and procedures 
manual to include procedures for supervisory approval to open and close 
cases and for documenting periodic supervisory reviews in the Units case 
files.   
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   13 
   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Unit concurred with the six report recommendations. 
Regarding the first recommendation, the Unit reported that it has 
implemented new procedures to ensure that the case files include 
documentation of supervisory approval to open and close cases and of 
supervisory reviews. 
Regarding the second recommendation, the Unit reported that it will 
ensure that files are not left unattended in the areas of the office that are 
open to non-Unit staff. 
Regarding the third recommendation, the Unit reported that each case is 
assigned a priority level upon initial review and that the cases mentioned 
in the third recommendation did not have sufficient evidence for 
investigation or prosecution. 
Regarding the fourth recommendation, the Unit reported that it has 
requested additional investigators for FY 2015 and that these investigators 
will be assigned to cases of patient abuse and neglect.  
Regarding the fifth recommendation, the Unit reported that it has 
implemented new procedures to ensure that all sentenced individuals are 
reported to OIG within an appropriate timeframe.  
Regarding the sixth recommendation, the Unit reported that it is in the 
process of updating its policies and procedures manual to reflect current 
operations. 
The full text of the Units comments is provided in Appendix G. 
 
   
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   14 
   
   
APPENDIX A 
Performance Standards for MFCUs (Units)37   
1. 	A Unit will be in conformance with all applicable statutes, 
regulations, and policy transmittals. In meeting this standard, the 
Unit must meet, but is not limited to, the following requirements:  
a. 	  The Unit professional staff must consist of permanent employees 
working full-time on Medicaid fraud and patient abuse matters. 
b.	   The Unit must be separate and distinct from the single State 
Medicaid agency. 
c. 	  The Unit must have prosecutorial authority or an approved formal 
procedure for referring cases to a prosecutor. 
d. 	  The Unit must submit annual reports, with appropriate 

certifications, on a timely basis. 
 
e. 	  The Unit must submit quarterly reports on a timely basis. 
f. 	  The Unit must comply with the Americans with Disabilities Act, 
the Equal Employment opportunity requirements, the Drug Free 
workplace requirements, Federal lobbying restrictions, and other 
such rules that are made conditions of the grant. 
2. 	A Unit should maintain staff levels in accordance with staffing 
allocations approved in its budget. In meeting this standard, the 
following performance indicators will be considered: 
a. 	  Does the Unit employ the number of staff that was included in the 
Unit's budget as approved by the Office of Inspector General 
(OIG)? 
b. 	  Does the Unit employ the number of attorneys, auditors, and 
investigators that were approved in the Unit's budget? 
c. 	  Does the Unit employ a reasonable size of professional staff in 
relation to the States total Medicaid program expenditures?   
d. 	  Are the Unit office locations established on a rational basis and are 
such locations appropriately staffed? 
3. 	A Unit should establish policies and procedures for its operations, 
and maintain appropriate systems for case management and case 
tracking.  In meeting this standard, the following performance 
indicators will be considered: 
 
37 59 Fed. Reg. 49080  (Sept. 26, 1994).  These performance standards were in effect 
during most of our review  period and precede the performance standards published in 
June 2012. 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   15 
   
   
a. 	  Does the Unit have policy and procedure manuals? 
b. 	  Is an adequate, computerized case management and tracking 
system in place? 
4. A Unit should take steps to ensure that it maintains an adequate 
workload through referrals from the single State agency and other 
sources.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit work with the single State Medicaid agency to 
ensure adequate fraud referrals? 
b. 	  Does the Unit work with other agencies to encourage fraud 

referrals? 

c. 	  Does the Unit generate any of its own fraud cases? 
d. 	  Does the Unit ensure that adequate referrals of patient abuse 
complaints are received from all sources? 
5. 	A Units case mix, when possibl e, should cover all significant 
provider types. In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit seek to have a mix of cases among all types of 
providers in the State? 
b. 	  Does the Unit seek to have a mix of Medicaid fraud and Medicaid 
patient abuse cases? 
c. 	  Does the Unit seek to have a mix of cases that reflect the 

proportion of Medicaid expenditures for particular provider 

groups? 

d. 	  Are there any special Unit initiatives targeting specific provider 
types that affect case mix? 
e. 	  Does the Unit consider civil and administrative remedies when  
appropriate? 
6. 	A Unit should have a continuous case flow, and cases should be 
completed in a reasonable time. In meeting this standard, the 
following performance indicators will be considered:  
a. 	  Is each stage of an investigation and prosecution completed in an 
appropriate time frame?  
b. 	  Are supervisors approving the opening and closing of 

investigations?
   
c. 	  Are supervisory reviews conducted periodically and noted in the 
case file? 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   16 
   
   
7. A Unit should have a process for monitoring the outcome of cases.  
In meeting this standard, the following performance indicators will be 
considered:  
a. 	  The number, age, and type of cases in inventory. 
b. 	  The number of referrals to other agencies for prosecution. 
c. 	  The number of arrests and indictments. 
d. 	  The number of convictions. 
e. 	  The amount of overpayments identified. 
f. 	  The amount of fines and restitution ordered. 
g. 	  The amount of civil recoveries. 
h. 	  The numbers of administrative sanctions imposed. 
8. 	 A Unit will cooperate with the OIG and other federal agencies, 
whenever appropriate and consistent with its mission, in the 
investigation and prosecution of health care fraud.  In meeting this 
standard, the following performance indicators will be considered: 
a. 	  Does the Unit communicate effectively with the OIG and other 
Federal agencies in investigating or prosecuting health care fraud 
in their State? 
b. 	  Does the Unit provide OIG regional management, and other 
Federal agencies, where appropriate, with timely information 
concerning significant actions in all cases being pursued by the 
Unit? 
c. 	  Does the Unit have an effective procedure for referring cases,  
when appropriate, to Federal agencies for investigation and other 
action?  
d.	   Does the Unit transmit to the OIG, for purposes of program  
exclusions under section 1128 of the Social Security Act, reports 
of convictions, and copies of Judgment and Sentence or other 
acceptable documentation within 30 days or other reasonable time 
period? 
9. 	A Unit should make statutor y or programmatic recommendations, 
when necessary, to the State government. In meeting this standard, 
the following performance indicators will be considered:  
a. 	  Does the Unit recommend amendments to the enforcement 
provisions of the State's statutes when necessary and appropriate to 
do so? 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   17 
   
   
b. 	  Does the Unit provide program recommendations to single State 
agency when appropriate? 
c. 	  Does the Unit monitor actions taken by State legislature or State 
Medicaid agency in response to recommendations? 
10. 	A Unit should periodica lly review its memorandum of 
understanding (MOU) with the single State Medicaid agency and 
seek amendments, as necessary, to ensure it reflects current law  
and practice.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Is the MOU more than 5 years old? 
b. 	  Does the MOU meet Federal legal requirements? 
c. 	  Does the MOU address cross-training with the fraud detection staff  
of the State Medicaid agency? 
d. 	  Does the MOU address the Units responsibility to make program  
recommendations to the Medicaid agency and monitor actions  
taken by the Medicaid agency concerning those recommendations? 
11. The Unit director should exercise proper fiscal control over the 
Unit resources.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit director receive on a timely basis copies of all fiscal 
and administrative reports concerning Unit expenditures from the 
State parent agency? 
b. 	  Does the Unit maintain an equipment inventory?  
c. 	  Does the Unit apply generally accepted accounting principles in its 
control of Unit funding? 
12. A Unit should maintain an annual training plan for all 
professional disciplines.  In meeting this standard, the following 
performance indicators will be considered:  
a. 	  Does the Unit have a training plan in place and funds available to 
fully implement the plan? 
b. 	  Does the Unit have a minimum number of hours training 
requirement for each professional discipline, and does the staff 
comply with the requirement? 
c. 	  Are continuing education standards met for professional staff? 
d. 	  Does the training undertaken by staff aid to the mission of the 
Unit? 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   18 
   
   
APPENDIX B 
Revised 2012 Performance Standards for MFCUs38   
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 
 
38  77  Fed.  Reg. 32645 (June 1, 2012). 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   19 
   
   
staffed, commensurate with the volume of case referrals and 
workload for each location. 
3. 	A Unit establishes written policies and procedures for its 
operations and ensures that staff are familiar with, and adhere to, 
policies and procedures.  
a. 	  The Unit has written guidelines or manuals that contain current 
policies and procedures, consistent with these performance 
standards, for the investigation and (for those Units with 
prosecutorial authority) prosecution of Medicaid fraud and patient 
abuse and neglect. 
b. 	  The Unit adheres to current policies and procedures in its 

operations. 

c. 	  Procedures include a process for referring cases, when appropriate, 
to Federal and State agencies. Referrals to State agencies, 
including the State Medicaid agency, should identify whether 
further investigation or other administrative action is warranted, 
such as the collection of overpayments or suspension of payments. 
d. 	  Written guidelines and manuals are readily available to all Unit 
staff, either online or in hard copy. 
e. 	  Policies and procedures address training standards for Unit 

employees. 

4. 	A Unit takes steps to maintain an adequate volume and quality of 
referrals from the State Medicaid agency and other sources. 
a. 	  The Unit takes steps, such as the development of operational 
protocols, to ensure that the State Medicaid agency, managed care 
organizations, and other agencies refer to the Unit all suspected 
provider fraud cases. Consistent with 42 CFR 1007.9(g), the Unit 
provides timely written notice to the State Medicaid agency when 
referred cases are accepted or declined for investigation.  
b. 	  The Unit provides periodic feedback to the State Medicaid agency 
and other referral sources on the adequacy of both the volume and 
quality of its referrals.  
c. 	  The Unit provides timely information to the State Medicaid or 
other agency when the Medicaid or other agency requests 
information on the status of MFCU investigations, including when 
the Medicaid agency requests quarterly certification pursuant to  
42 CFR 455.23(d)(3)(ii). 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   20 
   
   
d. 	  For those States in which the Unit has original jurisdiction to 
investigate or prosecute patient abuse and neglect cases, the Unit 
takes steps, such as the development of operational protocols, to 
ensure that pertinent agencies refer such cases to the Unit, 
consistent with patient confidentiality and consent.  Pertinent 
agencies vary by State but may include licensing and certification 
agencies, the State Long Term Care Ombudsman, and adult 
protective services offices. 
e. 	  The Unit provides timely information, when requested, to those 
agencies identified in (D) above regarding the status of referrals. 
f. 	  The Unit takes steps, through public outreach or other means, to 
encourage the public to refer cases to the Unit.  
5. 	A Unit takes steps to maintain a continuous case flow and to 
complete cases in an appropriate timeframe based on the 
complexity of the cases.  
a. 	  Each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
b. 	  Supervisors approve the opening and closing of all investigations 
and review the progress of cases and take action as necessary to 
ensure that each stage of an investigation and prosecution is 
completed in an appropriate timeframe. 
c. 	  Delays to investigations and prosecutions are limited to situations 
imposed by resource constraints or other exigencies. 
6. 	A Units case mix, as practicabl e, covers all significant provider 
types and includes a balance of fraud and, where appropriate, 
patient abuse and neglect cases.  
a. 	  The Unit seeks to have a mix of cases from all significant provider 
types in the State.  
b. 	  For those States that rely substantially on managed care entities for 
the provision of Medicaid services, the Unit includes a 
commensurate number of managed care cases in its mix of cases. 
c. 	  The Unit seeks to allocate resources among provider types based 
on levels of Medicaid expenditures or other risk factors.  Special 
Unit initiatives may focus on specific provider types. 
d. 	  As part of its case mix, the Unit maintains a balance of fraud and 
patient abuse and neglect cases for those States in which the Unit 
has original jurisdiction to investigate or prosecute patient abuse 
and neglect cases.  
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   21 
   
   
e. 	  As part of its case mix, the Unit seeks to maintain, consistent with 
its legal authorities, a balance of criminal and civil fraud cases. 
7. 	A Unit maintains case files in an effective manner and develops a 
case management system that allows efficient access to case 
information and other performance data. 
a. 	  Reviews by supervisors are conducted periodically, consistent with 
MFCU policies and procedures, and are noted in the case file.  
b. 	  Case files include all relevant facts and information and justify the 
opening and closing of the cases. 
c. 	  Significant documents, such as charging documents and settlement 
agreements, are included in the file.  
d. 	  Interview summaries are written promptly, as defined by the Units 
policies and procedures. 
e. 	  The Unit has an information management system that manages and 
tracks case information from initiation to resolution. 
f. 	  The Unit has an information management system that allows for 
the monitoring and reporting of case information, including the 
following: 
1. 	  The number of cases opened and closed and the reason that  
cases are closed. 
2. 	  The length of time taken to determine whether to open a 
case referred by the State Medicaid agency or other 
referring source. 
3. 	  The number, age, and types of cases in the Units 
inventory/docket. 
4. 	  The number of referrals received by the Unit and the 
number of referrals by the Unit to other agencies. 
5. 	  The dollar amount of overpayments identified. 
6. 	  The number of cases criminally prosecuted by the Unit or 
referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending 
prosecutions. 
7. 	  The number of criminal convictions and the number of civil 
judgments. 
8. 	  The dollar amount of fines, penalties, and restitution 
ordered in a criminal case and the dollar amount of 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   22 
   
   
recoveries and the types of relief obtained through civil 
judgments or prefiling settlements. 
8. 	A Unit cooperates with OIG and other Federal agencies in the 
investigation and prosecution of Medicaid and other health care 
fraud.  
a. 	  The Unit communicates on a regular basis with OIG and other 
Federal agencies investigating or prosecuting health care fraud in 
the State.  
b.	   The Unit cooperates and, as appropriate, coordinates with OIGs 
Office of Investigations and other Federal agencies on cases being 
pursued jointly, cases involving the same suspects or allegations, 
and cases that have been referred to the Unit by OIG or another 
Federal agency. 
c. 	  The Unit makes available, to the extent authorized by law and 
upon request by Federal investigators and prosecutors, all 
information in its possession concerning provider fraud or fraud in 
the administration of the Medicaid program. 
d.	   For cases that require the granting of extended jurisdiction to 
investigate Medicare or other Federal health care fraud, the Unit 
seeks permission from OIG or other relevant agencies under 
procedures as set by those agencies.  
e. 	  For cases that have civil fraud potential, the Unit investigates and 
prosecutes such cases under State authority or refers such cases to 
OIG or the U.S. Department of Justice. 
f. 	  The Unit transmits to OIG, for purposes of program exclusions 
under section 1128 of the Social Security Act, all pertinent 
information on MFCU convictions within 30 days of sentencing, 
including charging documents, plea agreements, and sentencing 
orders. 
g. 	  The Unit reports qualifying cases to the Healthcare Integrity & 
Protection Databank, the National Practitioner Data Bank, or 
successor data bases.  
9. 	 A Unit makes statutory or programmatic recommendations, when 
warranted, to the State government. 
a. 	  The Unit, when warranted and appropriate, makes statutory 
recommendations to the State legislature to improve the operation 
of the Unit, including amendments to the enforcement provisions 
of the State code. 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   23 
   
   
b. 	  The Unit, when warranted and appropriate, makes other regulatory 
or administrative recommendations regarding program integrity 
issues to the State Medicaid agency and to other agencies 
responsible for Medicaid operations or funding.  The Unit monitors 
actions taken by the State legislature and the State Medicaid or 
other agencies in response to recommendations. 
10. 	A Unit periodically reviews  its Memorandum of Understanding 
(MOU) with the State Medicaid agency to ensure that it reflects 
current practice, policy, and legal requirements. 
a. 	  The MFCU documents that it has reviewed the MOU at least every 
5 years, and has renegotiated the MOU as necessary, to ensure that 
it reflects current practice, policy, and legal requirements. 
b.	   The MOU meets current Federal legal requirements as contained in 
law or regulation, including 42 CFR 455.21, Cooperation with 
State Medicaid fraud control units, and 42 CFR 455.23, 
Suspension of payments in cases of fraud. 
c. 	  The MOU is consistent with current Federal and State policy, 
including any policies issued by OIG or the Centers for Medicare 
& Medicaid Services (CMS). 
d.	   Consistent with Performance Standard 4, the MOU establishes a 
process to ensure the receipt of an adequate volume and quality of  
referrals to the Unit from the State Medicaid agency. 
e. 	  The MOU incorporates by reference the CMS Performance 
Standard for Referrals of Suspected Fraud from a State Agency to 
a Medicaid Fraud Control Unit. 
11. 	A Unit exercises proper fiscal  control over Unit resources.  
a. 	  The Unit promptly submits to OIG its preliminary budget 
estimates, proposed budget, and Federal financial expenditure 
reports. 
b.	   The Unit maintains an equipment inventory that is updated 

regularly to reflect all property under the Units control. 

c. 	  The Unit maintains an effective time and attendance system and 
personnel activity records. 
d.	   The Unit applies generally accepted accounting principles in its 
control of Unit funding. 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   24 
   
   
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. 
  
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   25 
   
   
APPENDIX C 
Referrals of Provider Fraud and Patient Abuse and Neglect to  
the Mississippi MFCU by  Source, FYs 2011 Through 2013 
Table C-1: Total MFCU Referrals of Fraud and Abuse and Annual Average 
Annual  
  Case Type   FY 2011   FY 2012   FY 2013   3-Year Total  
Average*  
Patient Abuse and Neglect  1,930   1,806   1,920   5,656   1,885  
 
Provider Fraud   49  32  42  123  41 
 
  Total   1,979   1,838   1,962   5,779   1,926  
 
Source:  Unit response to OIG data request. 
 
*Averages in  this  table are rounded. 
 
Table C-2: MFCU Referrals, by Referral Source  
 
 
FY 2011   FY 2012   FY 2013  
   
Abuse  Abuse  Abuse  Percentage 
Referral 
Fraud   and  Fraud   and  Fraud   and  Total   of All 
Source  
Neglect   Neglect   Neglect   Referrals*  
Providers  5  1,929   1  1,806   4  1,920  
5,665   98.0%  
Private  14  1  14  0  9  0 
Citizens  38  0.7%  
13  0  5  0  16  0 
Other  
34  0.6%  
Medicaid  7  0  4  0  12  0 
Agency  
SUR/S39   23  0.4%  
Law   4  0  3  0  0  0 
Enforcement   7  0.1%  
Licensing  3  0  1  0  1  0 
Board   5  0.1%  
2  0  3  0  0  0 
OIG  
5  0.1%  
State Survey   0  0  1  0  0  0 
and 
Certification  1  0.0%  
1  0  0  0  0  0 
Prosecutors 
1  0.0%  
Total   49  1,930   32  1,806   42  1,920   5,779   100%  
Annual  
1,979   1,838   1,962    
Total    
Annual  
1,926    
Average*    
Source:  Unit response to OIG data request. 
*These figures  are rounded. 
 
 
39 SUR/S refers to the Surveillance and Utilization Review Subsystem division  of the 
State Medicaid agency. 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   26 
   
   
APPENDIX D 
Investigations Opened and Closed by the Mississippi MFCU, 
by Provider Category and Case Type, FYs 2011 Through 2013 
 
Table D-1: Total Annual Opened and Closed Investigations  
 
  Annual   
 Case Type   FY 2011   FY 2012   FY 2013   3-Year Total   Average*  
 Opened   175  223  344  742  247 
Patient Abuse and 
  126  184  310  620  207 
Neglect 
  Provider Fraud   49  39  34  122  41 
Closed  344  433  614  1,389   463 
 
Patient Abuse and 
320  416  589  1,325   442 
  Neglect 
Provider Fraud   22  17  25  64  21 
 
S ource:  Unit response to OIG data request. 
*Averages in  this  column are rounded. 
   
 
Table D-2: Patient Abuse and Neglect Investigations  
 
Provider Category   FY 2011   FY 2012   FY 2013  
        
Opened  Closed  Opened  Closed  Opened  Closed 
Home Health Aides  0  0  1  2  1  86 
Nondirect Care   2  14  1  8  0  9 
Nurses/Doctors Assistants  48  87  94  131  112  253 
Nursing Facilities   12  70  17  113  26  111 
Other Long-Term  Care 
15  40  24  68  22  64 
Facilities  
Other   49  109  47  94  40  66 
Total   126  320  184  416  201  589 
Source:  Unit response to OIG data request. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   27 
   
   
Table D-3: Provider Fraud Investigations  
 
Provider Category   FY 2011   FY 2012   FY 2013  
Facilities   Opened  Closed   Opened  Closed   Opened  Closed  
Hospitals  1  0  2  0  1  1 
Other  Facilities   2  3  0  0  7  0 
  Subtotal   3  3  2  0  8  1 
Practitioners   Opened  Closed  Opened  Closed  Opened  Closed 
Counselors/ 
5  0  2  2  2  0 
Psychologists 
Dentists  2  1  4  2  3  3 
Doctors of Medicine or 
9  0  5  1  2  3 
Osteopathy  
Optometrists/Opticians  1  0  0  0  1  0 
Podiatrists  0  0  0  0  1  1 
  Subtotal   17  1  11  5  9  7 
Medical Support  Opened  Closed   Opened  Closed   Opened  Closed  
Durable Medical 
3  0  4  0  0  0 
Equipment Suppliers 
Home Health Care 
2  0  1  0  0  1 
Agencies 
Home Health Care Aides  5  3  0  4  3  0 
Nurses/Doctors 
2  2  2  0  2  3 
Assistants  
Pharmaceutical 
12  12  9  8  9  10 
Manufacturers 
Pharmacies  0  0  2  0  1  1 
Transportation Services  0  1  0  0  0  0 
Other Medical Support   5  0  7  0  2  1 
  Subtotal   29  18  25  12  17  16 
Program  Related   Opened  Closed  Opened  Closed  Opened  Closed 
Billing Company  0  0  1  0  0  1 
  Subtotal   0  0  1  0  0  1 
  Total   49  22  39  17  34  25 
 
Source:  Unit response to OIG data request. 
 
 
 
 
 
 
 
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   28 
   
   
APPENDIX E 
Methodology  
We analyzed data from seven sources to describe the caseload and assess 
the performance of the Unit.  We also analyzed the data to identify any 
opportunities for improvement and any instances in which the Unit did not 
meet the performance standards or was not operating in accordance with 
laws, regulations, and/or policy transmittals.40 In addition, we noted 
practices that appeared to benefit the Unit.  We based these observations 
on statements from Unit staff and an analysis of collected data.   
Data Collection and Analysis 
Review of Unit Documentation.  We collected and reviewed (1) Unit 
documentation, including policies and procedures related to the Units 
operations, staffing, and cases; (2) the Units annual reports and quarterly 
statistical reports; and (3) the Units responses to recertification 
questionnaires. The documentation also included data such as the number 
of referrals received by the Unit and the number of investigations opened 
and closed. We reviewed the documentation to determine how the Unit 
investigates and prosecutes Medicaid cases.  Additionally, we confirmed 
with the Unit Director that the documentation we had was current at the 
time of our review and requested any additional data or clarification, as 
needed.  The data we collected from the Unit was current as of January 27, 
2014. Subsequent changes to the data would therefore not be included in 
our analyses.  
Review of Financial Documentation. We reviewed Unit financial 
practices to determine compliance with applicable laws and regulations 
and to determine the need for additional internal controls.  Prior to the 
onsite review, we reviewed the Units financial policies and procedures; 
its response to an internal control questionnaire; and MFCU grant-related 
documents, such as financial status reports.  During the onsite review, we 
reviewed a sample of the Units purchase and travel transactions.  In 
addition, we reviewed vehicle records, the equipment inventory, and a 
sample of time and effort records.    
Structured Interviews With Key Stakeholders. We conducted structured 
interviews with six individual stakeholders among five agencies who were 
familiar with Unit operations.  Specifically, we interviewed the 
Mississippi Division of Medicaids Bureau of Program Integrity Director, 
two Assistant U.S. Attorneys, a Mississippi Deputy Attorney General,41 an 
 
40 All relevant  regulations, statutes, and  policy transmittals are available online at 

http://oig.hhs.gov. 

41 The Deputy Attorney General supervises the Unit Director. 

 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   29 
   
   
OIG Special Agent based in Mississippi, and an FBI Special Agent.  These 
interviews focused on the Units interaction with external agencies, Unit 
operations, opportunities for improvement, and any practices that appeared 
to benefit the Unit and that may be useful to other Units in their 
operations. 
Survey of Unit Staff. We conducted an online survey of Unit staff.42  We  
requested responses from 30 staff members and received responses from 
29 staff members, a 97percent response rate.  Our questions focused on 
Unit operations, opportunities for improvement, and practices that 
appeared to benefit the Unit and that may be useful to other Units in their 
operations. The survey also sought information about the Units 
compliance with applicable laws, regulations, and policy transmittals.   
Structured Interviews With Unit Management and Selected Staff.  We  
conducted structured interviews with the Units Director, Chief 
Investigator, Fraud Supervisor, and Analyst.  We asked them to provide us 
with additional information to help us better understand the Units 
operations, identify opportunities for improvement, identify practices that 
appeared to benefit the Unit and that may be useful to other Units in their 
operations, and to clarify information obtained from other data sources.  
Onsite Review of Case Files.  We selected a simple random sample of 
100 case files from the 2,086 cases43  that were open at any point from  
FY 2011 through FY 2013. The design of this sample allowed us to 
estimate the percentage of all 2,086 cases with various characteristics at 
the 95-percent confidence level. We reviewed these 100 sampled case 
files and the Units processes for monitoring the status and outcomes of 
cases. From the 100 case files in the initial sample, we selected another 
simple random sample of 50 files for a more comprehensive review to 
identify any potential issues from a qualitative perspective.  We consulted 
Unit staff to address any apparent issues with individual case files, such as  
missing documentation.   
Onsite Review of Unit Operations. While onsite, we reviewed the Units 
operations. Specifically, we observed the intake of referrals, security of 
data and case files, and the general functioning of the Unit.  We also 
 
42 We did not survey the Unit Director or Chief Investigator. 
43 This  figure includes cases opened before FY  2011 that  remained open at some point  
during  FYs 20112013.  This figure does not include 35 multi-State (global) civil  
false-claims cases, which consist of both those worked  directly by the Unit and those 
worked by staff from the Federal government or  other Units.  For the purposes of our  
case file review, the Units global cases were not included  as part of the Units case file 
population.   Including  global  cases, the total  number of Unit cases open  during the review  
period was 2,121. 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   30 
   
   
checked to ensure that the Unit referred sentenced individuals to OIG for 
program exclusion and that the Unit reported adverse actions to the 
National Practitioner Data Bank (NPDB).44, 45  
 
 
 
44 The NPDB  was established by the Department of Health and Human Services as a  
national  health care fraud and abuse data collection program ... for the reporting of 
certain final adverse actions ... against health  care providers, suppliers, or practitioners.  
SSA  1128E(a) and 45 CFR   61.1(2012).   This  portion of the NDPB  used to be a 
separate databank  called  the Healthcare Integrity and Protection  Databank  (HIPDB).  The 
HIPDB and the NPDB  were  merged into one databank in  May 2013.  78  Fed. Reg. 
20473 (April 5, 2013). 
45 Examples of adverse actions  include criminal convictions; civil judgments (but  not 
civil settlements); exclusions; and other negative actions or findings, including any  
action or finding that under the States law is publicly available information, and  
rendered  by a licensing  or certification authority, including  but  not limited to, limitations  
on the scope of practice, liquidations, injunctions and forfeitures.  SSA   1128E(g)(1)  
and 45 CFR  61.3 (2012).  We  reviewed the reporting  of adverse actions under  HIPDB 
requirements because the HIPDB and the NPDB had not yet been merged during the 
period of  our  review  (FYs  2010 through 2012).  Current Unit requirements for  reporting 
to the merged  NPDB are in  45 CFR pt. 60. 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   31 
   
   
APPENDIX F 
Case File Review Population, Sample Size Counts, and 
Confidence Interval Estimates 
Table F-1 shows population and sample counts and percentages by case 
type. Note that both samples have percentages of case types similar to the 
general population, though sample counts for some case types are very 
small.  Because of these small sample sizes, we cannot reliably generalize 
what we found in our sample review to each case type in the population, 
and only our overall estimates project to the population of all case files.  
We estimated the 4 population values for all 2,086 nonglobal case files 
from the results of our review of the case files selected in our simple 
random samples.  Table F-2 includes the estimate descriptions, sample 
sizes, point estimates, and 95-percent confidence intervals for these four  
estimates.  
 
Table F-1:  Population and Sample Size Counts for Case Types 
Population Count  Sample Count*    Sample Count* 
Case Type  
and (%)  n=2,086   and (%)  n=100   and (%)  n=50  
Closed  1,491 (71%)   73 (73%)   33 (66%)  
Open   595 (29%)   27 (27%)   17 (34%)  
       
Civil (Nonglobal)  6 (0%)   1 (1%)   0 (0%)  
Criminal  2,080 (100%)   99 (99%)   50 (100%)  
       
Patient Abuse/Neglect  1,979 (95%)   97 (97%)   50 (100%)  
Provider Fraud  
107 (5%)   3 (3%)   0 (0%)  
(Nonglobal)  
Source: The Mississippi Unit provided a list of all  case  files open during FYs 2011 through 2013. 
* OIG generated  this random sample. 
 
 
 
 
 
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   32 
   
   
 
Table F-2:  Confidence Intervals for Key Case File Review  Data  
Point  95-Percent Confidence 
Estimate Description  Sample Size 
Estimate  Interval  
Case Files With No 
Documented Supervisory   100   7%   2.913.8%  
Approval for Opening  
Case Files With No 
Documented Supervisory   78  11.5%   5.520.6%  
Approval for Closing  
Case Files With No 
Documentation of 
100   44%   34.354.1%  
Periodic Supervisory  
Reviews  
Cases That Were Not 
Investigated Before the 
100  5%   1.711.1%  
Statute of Limitations 
Expired 
 
 
 
 
 
 
 
 
 
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   33 
   
   
APPENDIX G 
Unit Comments 
 
 
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)  34 
  Recommendaucn 3  Ensure that all cases are irl\'estlgatuc! or c!osec!. as 

approptHJ/IJ. before the s1Hiuti3 uf iuntlattons expires. 

Response:  We concur with !h1s recornrnendat1on.  Upon initial 
rev1ew. each case 1s ass1gned a prionty level  However. I would 
like to point out that the cases mentioned 111 the rev1ew d1cl not 
have suff1c1ent evidence for 1nvesligat1on and prosecution. 
tr.erefore. tt1e cases were not pursued and were not closed untii 
after the statute of limitations. 
F<ecommoJJOa/mn 4  Assess 111o al!oc:alton of ex1sling staff levels 
Response  We concur w1!h thrs recornrnendation  We have 
requestel1 addrtJonal mvestigC!tors for t11e next fiscal yea1.  These 
awe$tigators wiil be assigned to abuse. neglect. and expiortatiOn 
cases, 
Rowmmen<1at10n 5  Ensure that it reiers all sentenced individuals for exciusion 
to OIG within an rpproprrate time frame 
Response.  We concur w1tl1 this recommondallon. The Unrt 
has implemented new procedures to ensure that all sentenced 
individuals are reponed with1n an appropnate time frame 
Rewmmf'ndalion 6  Revise its nolicies and proceclures manual to ret/eel cunent 
opemtions 
Response  We concur ,v,th this recommendation.  The Unit is 
in the process of upda!rng the policies and procedures manual to 
reflect current operations and to reflect the implementation of the 
recommendations from the on-site review. 
The Missrss1pp1 MFCU would again lrke to express our appreciation of the rev;ew leam an<! \herr 
profesSIOiiahsm exhibited during the rev1ew process  We also appreciate the opportunity to 
discuss Hnd n?spond to this report  We look forward to continue to work with you to continue to 
combat fri)Ud rn healthcare programs. 
Sincerely 
Treasure R  Tyson 
Special Assistant t1ttorney General 
Medicaid Frauo Control Unit Director 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review (OEI-09-13-00700)  35   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy S. Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry,  Deputy Regional Inspector General.  
Rosemary Rawlins served as the lead  analyst for this study.  Other Office 
of Evaluation and Inspections staff who provided support from the San 
Francisco regional office include Matthew DeFraga.  Central office staff 
who provided support include Susan Burbach, Kevin Farber, 
Christine Moritz, Andrew VanLandingham, and Sherri Weinstein.  Office 
of Investigations staff who provided support include Ian Ives.   
 
 
Mississippi State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-09-13-00700)   36 
   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office  of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations  
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office  of Counsel to  the Inspector  General  
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.