U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
Idaho  
Medicaid Fraud 
Control Unit:  
2018 Onsite 
Inspection
 
 
OEI-12-18-00320  Suzanne Murrin 
August 2019  Deputy Inspector General  
  for Evaluation and Inspections 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
August 2019 
Office  of Inspector General 
OEI-12-18-00320 
 
 
Idaho Medicaid Fraud Control Unit: 2018 Onsite Inspection 
What OIG Found 
The Idaho Medicaid Fraud Control Unit (MFCU or Unit) reported 
13 indictments, 11 convictions, 28 civil settlements and judgments, and  Unit Case Outcomes 
nearly $5.3 million in recoveries for fiscal years (FYs) 20152017.  From  FYs 20152017 
the information we reviewed, we found that the Unit operated in 
  13 indictments 
accordance with applicable laws, regulations, and policy transmittals.  
  11 convictions  
However, we made three findings involving the Units adherence to the 
  28 civil settlements and 
MFCU performance standards.   
judgments 
1.  Although the Unit established a more frequent and robust    $5.3 million in recoveries 
practice for conducting periodic supervisory review of case files, 
it had not updated its policies and procedures manual to reflect  Unit Snapshot 
the updated practices.   The Unit is part of the Office of 
  Attorney Generals Criminal Law 
2.  Some of the Units cases had significant unexplained  Division  
investigative delays.  
9 MFCU staff2 attorneys, 4 
 
investigators, 1 auditor, and 2 support 
3.  Nearly a quarter of case files lacked documentation of periodic 
stafflocated in Boise   
supervisory review. 
Unit was founded in 2007 
In addition to the findings, we made a number of observations 
regarding Unit operations and practices, including two observations 
about barriers to pursuing certain cases as well as a beneficial practice that may be of interest to other MFCUs. 
  The Unit reported barriers that limited its ability to investigate and prosecute cases of patient abuse or neglect, 
including the Idaho statutes definition of vulnerable adults.    
 
  The Unit reported that Idahos civil recovery statute limited its ability to pursue civil cases.  
 
  In addition to reporting its own convictions to OIG, the Unit reported convictions of patient abuse or neglect 
obtained by local authorities for possible program exclusion.     
What OIG Recommends and How the Unit Responded 
To address the three findings, we recommend that the Unit: (1) update its policies and procedures manual to reflect current 
Unit practices for periodic supervisory case file review; (2) take steps to ensure that investigation delays are limited to 
situations imposed by resource constraints or other exigencies and that delays are documented in the case management 
system; and (3) ensure that the case management system includes documentation of supervisory oversight.  The Unit 
concurred with all three recommendations. 
 
 
Full report can be found at oig.hhs.gov/oei/reports/oei-12-18-00320.asp 
   
TABLE OF CONTENTS 
BACKGROUND  1 
PERFORMANCE ASSESSMENT  5 
Case Outcomes  5 
The Unit reported 13 indictments, 11 convictions, and 28 civil settlements and judgments 
from FYs 2015 through 2017 
The Unit reported total recoveries of nearly $5.3 million from FYs 2015 through 2017 
Performance Standard 1: Compliance with requirements  6 
From the information we reviewed, the Idaho Unit complied with applicable laws, 
regulations, and policy transmittals 
Performance Standard 2: Staffing   6 
The Unit was fully staffed at the time of our review but had vacancies during the review 
period 
Performance Standard 3: Policies and procedures  6 
Although the Unit had established a more frequent and robust practice for conducting 
periodic supervisory review of case files, it had not updated its policies and procedures 
manual to reflect the updated practices 
Performance Standard 4: Maintaining adequate referrals  7 
The Unit took steps to maintain an adequate volume and quality of referrals, but the total 
volume of referrals to the Unit dropped during the review period. 
Performance Standard 5: Maintaining a continuous case flow  7 
Some of the Units cases had significant unexplained investigative delays 
All case files contained documentation of supervisory approval to open and close cases, as 
appropriate 
Performance Standard 6: Case mix  8 
The Unit investigated many more cases of provider fraud than cases of patient abuse or 
neglect. 
The Unit reported barriers that limited its ability to investigate and prosecute cases of 
patient abuse or neglect, including the Idaho statutes definition of vulnerable adults    
The Unit reported that Idahos civil recovery statute limited its ability to pursue civil cases 
Performance Standard 7: Maintaining case information  10 
Nearly a quarter of case files lacked documentation of periodic supervisory review 
Performance Standard 8: Cooperation with Federal authorities on fraud cases  11 
   
The Unit reported all convictions and adverse actions during the review period to Federal 
partners within 30 days 
In addition to reporting its own convictions to OIG, the Unit reported convictions of 
patient abuse or neglect obtained by local authorities for possible program exclusion   
Performance Standard 9: Program recommendations   12 
The Unit made recommendations to the Medicaid agency  
Unit management drafted legislative proposals to improve the Units effectiveness.   
Performance Standard 10: Agreement with Medicaid agency    12 
The Units memorandum of understanding with the Medicaid agency reflected current 
practice, policy, and legal requirements 
Performance Standard 11: Fiscal control  13 
From our limited review, we identified no deficiencies in the Units fiscal control of its 
resources 
Performance Standard 12: Training  13 
The Units training plan included an in-house training program  
CONCLUSION AND RECOMMENDATIONS   
Update its policies and procedures manual to reflect current Unit practices for periodic  14 
supervisory case file review  
Take steps to ensure that investigation delays are limited to situations imposed by resource  14 
constraints or other exigencies and that delays are documented in the case management 
system      
Ensure that the case management system include documentation of supervisory oversight  14 
UNIT COMMENTS AND OIG RESPONSE  16 
APPENDICES   
A.  MFCU Performance Standards  17 
B.  Detailed Methodology  22 
C.  Unit Referrals by Source for Fiscal Years 2015 Through 2017  24 
D.  Point Estimates and 95-Percent Confidence Intervals of Case File Reviews  25 
E.  Unit Comments  26 
ACKNOWLEDGMENTS  30 
 
   
   
BACKGROUND 
Objective 
To examine the performance and operations of the Idaho Medicaid 
Fraud Control Unit  
Medicaid Fraud Control Units (MFCUs or Units) investigate (1) Medicaid 
Medicaid Fraud 
provider fraud and (2) patient abuse or neglect in facility settings, and 
Control Units 
prosecute those cases under State law or refer them to other prosecuting 
offices.1, 2  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.3  Each State must operate a MFCU or receive a waiver.4  
Currently, 49 States, the District of Columbia, Puerto Rico, and the 
U.S. Virgin Islands operate MFCUs.5  Each Unit receives a Federal grant 
award equivalent to 90 percent of total expenditures for new Units and 
75 percent for all other Units.6  In Federal fiscal year (FY) 2018, combined 
Federal and State expenditures for the Units totaled approximately 
$294 million.7   
 
 
 
 
1 SSA  1903(q)(3).  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 References to State in this report refer to the States, the District of Columbia, and the 
U.S. territories. 
3 SSA  1903(q). 
4 SSA  1902(a)(61). 
5 North Dakota and the territories of American Samoa, Guam, and the Northern Marianas 
Islands have not established Units. 
6 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. 
7 OIG analysis of MFCU annual statistical reporting data for FY 2018.  The Federal FY 2018 was 
from October 1, 2017 through September 30, 2018. 
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The Office of Inspector General (OIG) administers the grant award to each 
OIG Grant 
Unit and provides oversight of Units.8, 9  As part of its oversight, OIG reviews 
Administration 
and recertifies each Unit annually and conducts periodic onsite reviews or 
and Oversight  inspections, such as this inspection.   
of MFCUs  In its recertification review, OIG examines the Units reapplication, 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;10 the Units 
compliance with applicable laws, regulations, and OIG policy transmittals;11 
and the Units case outcomes.  (See Appendix A for MFCU performance 
standards, including performance indicators for each standard.)   
OIG further assesses Unit performance by conducting onsite Unit reviews 
that may identify findings and make recommendations for improvement.  
During an onsite review, OIG also makes observations regarding Unit 
operations and practices, and may identify beneficial practices that may be 
useful to share with other Units.  Finally, OIG provides training and technical 
assistance to Units while onsite, as appropriate, and on an ongoing basis.  
The Idaho MFCU is located in Boise and is part of the Office of Attorney 
Idaho 
Generals Criminal Law Division.  At the time of our July 2018 review, the 
MFCU 
Unit employed two attorneys (one of whom is the director), four 
investigators (one of whom is the lead investigator), an investigative auditor, 
a legal secretary, and an administrative assistant.  The lead investigator 
supervises the investigators, and the Unit director supervises the rest of the 
staff.  During our review period of FYs 2015-2017, the Unit spent $2,508,162, 
with a State share of $627,017. 
Referrals.  The Unit receives fraud referrals from a number of sources, 
including the State Medicaid agency and private citizens.  A key source of 
referrals of patient abuse and neglect is Idahos survey and certification 
agency, known as Bureau of Facility Standards (BFS) which is part of the 
Idaho Department of Health and Welfare (DHW).  When the Unit receives a 
referral, the lead investigator reviews and makes a recommendation to the 
 
8 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. 
9 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. 
10 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). 
11 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.  
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director.  The director decides whether to open or decline an investigation 
or refer the matter to another agency. 
Investigations and Prosecutions.  After the Unit opens an investigation, the 
director assigns an investigator and/or an investigative auditor and an 
attorney.  The assigned investigator or investigative auditor completes a 
checklist containing anticipated investigative steps.  The Unit stores case 
recordsincluding opening documentation, investigative activity reports, 
emails, and case closing memoranda requestsin the Units case 
management system.  If the assigned attorney determines that charges 
should be filed, she or he prepares a charging memorandum and provides 
it to the director.  If the director agrees that charges should be filed, he 
forwards the charging memorandum to the Chief of the Criminal Law 
Division for approval.   
Idaho Department of Health and Welfare, Division of Medicaid.  The Idaho 
Idaho 
Department of Health and Welfare includes the Division of Medicaid.  
Medicaid 
Medicaid participants have access to benefits through different benefit 
Program  plans, depending on individual health needs.  The Idaho Medicaid program 
relies upon managed care organizations to provide dental services, medical 
transportation, and outpatient behavioral health, as well as comprehensive 
managed care for persons dually eligible for Medicaid and Medicare.  
Enrollment in the Medicaid program averaged 300,838 participants per 
month during State FY 2017.12  In Federal FY 2018, total Medicaid 
expenditures were just over $2.0 billion.13  
OIG conducted a previous onsite review of the Idaho Unit in 2012.14  In that 
Prior OIG 
review, OIG found that the Unit: (1) lacked adequate safeguards to secure 
Report  case files; (2) had not updated its policies and procedures manual to reflect 
current operations; and (3) had not updated its Memorandum of 
Understanding (MOU) with DHW to reflect current law and practice.  OIG 
recommended that the Unit: (1) ensure that its case files are secure; (2) 
revise its policies and procedures manual to reflect current Unit operations; 
and (3) revise its MOU with DHW to reflect current law and practices.  In 
response to the recommendations, the Unit secured its case files, updated 
its internal policies and procedures, and revised its MOU with DHW.  
 
12 Idaho Department of Health and Welfare, Facts, Figures, and Trends: 2017-2018, pages 81-
85.  Accessed at 
https://healthandwelfare.idaho.gov/Portals/0/AboutUs/Publications/FFT2017_2018.pdf on 
September 28, 2018.  The State fiscal year is July 1June 30. 
13 OIG, MFCU Statistical Data for FY 2018.  Accessed at https://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/expenditures_statistics/fy2018-statistical-chart.pdf on April 19, 2019.   
14 Office of Inspector General, Idaho State Medicaid Fraud Control Unit: 2012 Onsite Review.  
Accessed at https://oig.hhs.gov/oei/reports/oei-09-12-00220.asp on June 20, 2019. 
 
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Methodology  OIG conducted the onsite inspection of the Idaho MFCU in July 2018.  Our 
review covered the 3-year period of FYs 2015-2017.  We based our 
inspection on an analysis of data and information from seven sources: (1) 
Unit documentation; (2) financial documentation; (3) structured interviews 
with key stakeholders; (4) structured interviews with the Units managers 
and selected staff; (5) a review of a random sample of 68 case files that were 
open at some 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) observation of Unit operations.  (See Appendix B for a detailed 
methodology.)  In examining the Units operations and performance, we 
applied the published performance standards in Appendix A, 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 other OIG 
evaluations, including internal and external peer review.   
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PERFORMANCE ASSESSMENT 
Below are the results of OIGs assessment of the performance and 
operations of the Idaho Unit.  OIG identified the Units case outcomes, 
found that the Unit complied with legal and policy requirements, and, for 
each of the performance standards, offered either a finding or 
observation(s), including highlighting a beneficial practice.   
CASE OUTCOMES   
 
Observations  The Unit reported 13 indictments, 11 convictions, and 28 civil 
settlements and judgments from FYs 2015 through 2017.  From the 
11 convictions, 9 convictions involved provider fraud and 2 involved patient 
 
abuse or neglect. 
The Unit reported total recoveries of nearly $5.3 million from FYs 2015 
through 2017.  (See Exhibit 1 for the sources of those recoveries.)  
  Exhibit 1: The Unit reported combined civil and criminal recoveries 
of nearly $5.3 million (FYs 20152017). 
 
Source: OIG analysis of Unit statistical data FYs 20152017. 
Note: Global civil recoveries derive from civil settlements or judgments involving the U.S. Department 
of Justice and a group of State MFCUs and are facilitated by the National Association of Medicaid Fraud 
Control Units.   
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STANDARD 1  A Unit conforms with all applicable statutes, regulations, and policy 
  directives. 
 
Observation  From the information we reviewed, the Idaho Unit complied with 
applicable laws, regulations, and policy transmittals.  We did not identify 
any legal or compliance concerns related to Unit operations. 
 
STANDARD 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. 
 
Observation  The Unit was fully staffed at the time of our review but had vacancies 
during the review period.  During the review period, the Unit was 
approved by OIG for nine staff.  At the time of our review and during FY 
2015, the Unit was staffed in accordance with the staffing allocations 
approved by OIG.  However, the Unit experienced vacancies during FY 2016 
(two vacancies) and FY 2017 (one vacancy).   
 
STANDARD 3  A Unit establishes written policies and procedures for its operations 
  and ensures that staff are familiar with, and adhere to, policies and 
procedures. 
 
Finding 
Although the Unit established a more frequent and robust practice for 
conducting periodic supervisory review of case files, it had not updated 
its policies and procedures manual to reflect the updated practices.  
Performance Standard 3(a) states that a Unit have written guidelines or 
manuals that contain current policies and procedures.  The Unit used an 
Operations Manual for general operations and for investigating cases.  We 
found that the Units Operations Manual contained a policy that required a 
quarterly supervisory review of each investigators top 3 cases.  However, 
Unit management reported that, during the review period, the Unit began 
reviewing all cases on a quarterly basis and had phased out reviews of only 
the top 3 cases.  In addition, the Unit director reported establishing 
another new practice for conducting supervisory reviews in February 2018 
(after the end of the review period).  This new practice involved a monthly 
meeting in which all staff (including supervisors) reviewed a case list 
organized by the age of the case, discussed investigative steps taken in the 
prior month on each case, and established relative priorities for all cases.  
The Operations Manual had not been updated to include procedures for 
conducting and documenting this more frequent and robust review of all 
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open cases.  See also Performance Standard 7 for a related finding on 
documentation of periodic supervisory reviews (page 10). 
STANDARD 4  A Unit takes steps to maintain an adequate volume and quality of 
  referrals from the State Medicaid agency and other sources. 
 
Observation  The Unit took steps to maintain an adequate volume and quality of 
referrals, but the total volume of referrals to the Unit dropped during 
the review period.  The Unit director met monthly with the Medicaid 
agencys program integrity unit director to discuss fraud referrals and 
provided yearly training to the program integrity unit on the elements of a 
quality referral.  The Unit director also attended a quarterly meeting with the 
Bureau of Facility Standards chief to discuss potential referrals of patient 
abuse or neglect.  In addition, the Unit conducted regular outreach to local 
law enforcement, offices of prosecuting attorneys, and provider groups to 
inform them of the existence of the Unit and its mission.  For example, the 
Unit sent outreach materials to all sheriffs departments and gave a 
presentation to the Boise State University nursing program. 
 
Notwithstanding these efforts, the total number of fraud referrals to the Unit 
dropped during the review period.  The Unit received similar totals of fraud 
referrals in FY 2015 (69) and FY 2016 (68), but fraud referrals declined in 
FY 2017 (50).   
The total number of referrals of patient abuse or neglect also declined over 
the review period, from 20 in FY 2015 to 15 in FY 2016 to 8 in FY 2017, 
including referrals from the Bureau of Facility Standards, the Units primary 
source of these referrals.  
See Appendix C for all sources of fraud and patient abuse or neglect 
referrals during FYs 2015-2017.   
STANDARD 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. 
 
 
Finding  Some of the Units cases had significant unexplained investigative 
delays.  Our review found that 10 percent of investigations had significant 
delays that were not explained in the case file.  Performance Standard 5(c) 
states that delays in investigation and prosecution should be limited to 
situations imposed by resource constraints or other exigencies.  Of the 
8 (of 68) cases in our sample that had unexplained delays, 4 had delays of 
approximately 2 years and 3 had delays of at least 1 year. 
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All case files contained documentation of supervisory approval to 
Observation 
open and close cases, as appropriate.  All cases contained 
documentation of supervisory approval to open them.  All of the cases that 
were closed at the time of our review (68 percent) contained 
documentation of supervisory approval to close them.  
 
STANDARD 6  A Units case mix, as practicable, covers all significant provider types 
  and includes a balance of fraud and, where appropriate, patient 
abuse and neglect cases. 
 
The Unit investigated many more cases of provider fraud than cases of 
Observations 
patient abuse or neglect.  Of the 277 cases that were open during our 
review period, 92 percent (254 cases) involved provider fraud and 8 percent 
(23 cases) involved patient abuse or neglect.  According to Performance 
Standard 6, the Units case mix should cover all significant provider types 
and include a balance of fraud and patient abuse or neglect cases.   
The Unit reported barriers that limited its ability to investigate and 
prosecute cases of patient abuse or neglect, including the Idaho 
statutes definition of vulnerable adults.  The Unit director reported to us 
that the Idaho statutes definition of a vulnerable adult presented a barrier 
to its ability to prosecute patient abuse or neglect.  Specifically, the Idaho 
criminal code offense of Abuse, Exploitation, or Neglect of a Vulnerable 
Adults defines a vulnerable adult as an adult unable to protect himself 
from abuse, neglect or exploitation due to physical or mental impairment 
which affects the persons judgment or behavior. . . .15  The Unit director 
stated that because of this definition, the prosecution must prove that a 
victim has a sufficient level of physical or mental impairment to convict a 
criminal defendant on a charge of abuse, neglect, or exploitation.  The Unit 
director had drafted a legislative amendment that would permit the MFCU 
to pursue a charge of abuse, exploitation or neglect without specifically 
demonstrating that the victim has such a physical or mental impairment.  
The proposed amendment had not yet been introduced to the Idaho 
legislature as of April 2019. 
Unit management identified a second barrier to investigating cases of 
patient abuse or neglect that involved the untimely receipt of referrals.  The 
Bureau of Facility Standards, which enforces State and Federal regulations in 
health care facilities and identifies alleged complaints of patient abuse and 
 
15 Idaho Code  18-1505. Accessed at 
https://legislature.idaho.gov/statutesrules/idstat/Title18/T18CH15/SECT18-1505/ on October 
17, 2018. 
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neglect, has a policy of referring complaints of patient abuse or neglect to 
local law enforcement and to local prosecutors.16  While the Bureau of 
Facility Standards can make concurrent referrals to the Unit, it does not, 
despite requests from the Unit.  It typically notified the Unit about cases six 
months to a year after making the referral to local law enforcement.  In 
most cases, by the time the Bureau of Facility Standards notified the Unit, 
local law enforcement had completed most of its investigation and the case 
had already been reviewed by the local county prosecuting attorney.   
In addition to the untimely notice of cases to the MFCU, Unit management 
reported that the Unit will not get involved in cases handled by local law 
enforcement unless asked.  Nevertheless, Unit management reported that 
when made aware of cases, even from media sources, the Unit offered 
assistance to the local agencies whenever possible.  The Unit had also 
begun educating local law enforcement on assistance the Unit could 
provide on these cases and planned more such outreach.   
As a final barrier identified by Unit management, officials in the Office of the 
Attorney General (OAG) had expressed concerns relating to the practice in 
Idaho of the State operating most long term care facilities.  OAG officials 
expressed that the Units prosecution of some cases of patient abuse or 
neglect presented a potential conflict of interest since attorneys in other 
OAG divisions represented the Department of Health and Welfare in these 
cases.  Unit management reported that the OAG is exploring remedies to 
address the potential conflict. 
The Unit reported that Idahos civil recovery statute limited its ability to 
pursue civil cases.  From FY 2015 to FY 2017, the Unit had just two civil 
cases open that were not global cases.17  Performance Standard 6(e) states 
that as part of its case mix, a Unit seek to maintain, consistent with legal 
authorities, a balance of criminal and civil fraud cases.   
The Unit director reported that Idahos civil recovery statute required the 
Unit to prove civil cases with a standard of criminal intent, thus severely 
limiting the Units ability to pursue civil cases.18  The Unit director had 
drafted a State civil recovery statute for false Medicaid claims, modeled after 
 
16 The Units explanation for this protocol was that Idaho law provides primary jurisdiction to 
local law enforcement and prosecutors for all criminal offenses in the State.  Idaho Code  31-
2227.  Accessed at https://legislature.idaho.gov/statutesrules/idstat/Title31/T31CH22/SECT31-
2227/ on February 13, 2019.   
17 Global cases are civil false claims actions that involve the U.S. Department of Justice and a 
group of State MFCUs.  The Idaho MFCU participated in 126 global cases during the review 
period. 
18 Idaho Code  56-227B 
https://legislature.idaho.gov/statutesrules/idstat/Title56/T56CH2/SECT56-227B/ accessed on 
December 5, 2018.  
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the Federal civil False Claims Act.19  However, this draft legislation had not 
been introduced to the Idaho legislature as of April 2019. 
 
STANDARD 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. 
 
Observation  Nearly a quarter of case files lacked documentation of periodic 
Finding 
supervisory reviews.  Performance Standard 7(a) states that supervisory 
reviews should be conducted periodically, consistent with MFCU policies 
and procedures, and noted in the case file.  As found under Performance 
Standard 3 (page 6), the Units written policy required a quarterly review of 
each investigators top 3 cases, but Unit management reported that 
during the review period, the Unit began reviewing all cases on a quarterly 
basis.  In our review of the case files, we applied the Units practice of 
reviewing all case files on a quarterly basis.  Our review found that 
24 percent of case files that were open more than 90 days contained either 
no documentation of periodic supervisory reviews or contained some 
documentation, but less than quarterly documentation of supervisory 
reviews.  Specifically, 14 percent of case files contained no documentation of 
periodic supervisory review.  An additional 11 percent of case files contained 
some documentation of periodic review, but did not reflect the Units 
written policy of quarterly reviews.20  Of the case files in our sample that had 
some documentation of supervisory reviews but not of quarterly reviews, 
gaps between periodic reviews ranged from 8 months to 2 years.   
As also found under Performance Standard 3 (page 6), in February 2018, the 
Unit director established a new practice for supervisory reviews involving a 
review of the status and priority of all open cases at a monthly Unit staff 
meeting, using an aged case list.  The Unit director reported that the Unit 
maintained a record of the monthly meeting which included the aged case 
list with status updates for each case.  The Unit first maintained hard copies 
of the list in binders and then, beginning in May 2018, electronically in a 
separate file in the Units case management system.21   
Whether quarterly or monthly, periodic supervisory review of cases is 
important to help ensure the timely completion of cases.  Moreover, 
 
19 31 U.S.C.  37293733 
20 Because of rounding, percentages do not sum precisely.  See Appendix D for further 
details on point estimates. 
21 During our review of case files in July 2018, we did not assess whether the record of this 
new monthly meeting was documented in the case management system. 
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documenting those reviews in the case management system is important to 
ensure that cases are properly managed. 
 
STANDARD 8  A Unit cooperates with OIG and other Federal agencies in the 
  investigation and prosecution of Medicaid and other health care fraud. 
 
The Unit reported all convictions and adverse actions during the review 
Observations 
period to Federal partners within 30 days.  Performance Standard 8(f) 
  states that the Unit should transmit information on convictions to OIG within 
30 days of sentencing for exclusion from Federal health care programs.  The 
Unit reported all 11 convictions within 30 days.  Additionally, Federal 
regulations require that Units report any adverse actions resulting from 
investigations or prosecution of healthcare providers to the National 
Practitioner Data Bank (NPDB) within 30 calendar days of the date of the 
final adverse action.22  Performance Standard 8(g) also states that the Unit 
should report qualifying cases to the NPDB.23  During our review period, the 
Unit reported 19 adverse actions; all were reported within 30 days of the 
qualifying action.   
 
In addition to reporting its own convictions to OIG, the Unit reported 
Beneficial Practice 
convictions of patient abuse or neglect obtained by local authorities for 
possible program exclusion.  The Units legal secretary monitored local 
news sources for convictions of patient abuse or neglect in which the Unit 
had no involvement in the investigation or prosecution.  When the legal 
secretary identified a conviction, she obtained the police reports and court 
documents related to the conviction.  The Unit director reviewed these 
documents and court proceedings.  Upon approval from the Unit director, 
the legal secretary submitted the documents to OIG, whereby OIG 
determined whether it had a basis to exclude the parties from participation 
in Federal health care programs.  Since 2013, seven individuals had been 
excluded from Federal health care programs because of the Units efforts.  
 
 
 
 
 
 
22 45 CFR  60.5.  Examples of adverse actions include but are not limited to convictions, civil 
judgments (but not civil settlements), and program exclusions.  See SSA  1128E(a) and (g)(1). 
23 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. 
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STANDARD 9  A Unit makes statutory or programmatic recommendations, when 
  warranted, to the State government. 
 
Observations  The Unit made recommendations to the Medicaid agency.  Performance 
Standard 9(b) states that the Unit, when warranted and appropriate, make 
recommendations regarding program integrity issues to the Medicaid 
agency.  The Unit informed DHW of potential program integrity deficiencies 
identified through the Units investigations.  For example, during the review 
period, the Unit sent a letter to DHW with recommendations to improve the 
definitions and coding of one-on-one services provided to Medicaid 
beneficiaries by community support workers.  In response, DHW reported it 
will develop policies to address the recommendations.  As another example 
of a Unit recommendation, the Unit proposed amendments to a managed 
care contract that was under consideration, some of which DHW 
incorporated into the contract.  
Unit management drafted legislative proposals to improve the Units 
effectiveness.  Performance Standard 9(a) states that the Unit, when 
warranted and appropriate, make recommendations to the State legislature 
to improve the operation of the Unit.  The Unit director drafted both a 
legislative amendment that would expand the definition of vulnerable adults 
and an amendment to the State civil recovery statute, as also discussed 
under Performance Standard 6 (pages 8-10).  In addition, the Unit director 
drafted a State anti-kickback statute as well as a State health care fraud 
statute modeled on the Federal health care fraud statutes.  As of April 2019, 
the four legislative proposals had not yet been introduced to the State 
legislature. 
STANDARD 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. 
 
Observation  The Units MOU with the Medicaid agency reflected current practice, 
policy, and legal requirements.  The Office of the Attorney General and 
the Idaho Department of Health and Welfare had a current MOU, 
 
amended on February 20, 2018.  The MOU reflected all policy and legal 
requirements as well as the current practices between the parties. 
 
 
 
 
 
 
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STANDARD 11  A Unit exercises proper fiscal control over its resources. 
 
 
From our limited review, we identified no deficiencies in the Units fiscal 
Observation 
control of its resources.  From the responses to a detailed fiscal-controls 
questionnaire and interviews with fiscal staff, we identified no issues related 
to the Units budget process, accounting system, cash management, 
procurement, electronic data security, property, or personnel.  In our 
inventory review, we located 30 of the 30 sampled inventory items.  
 
STANDARD 12  A Unit conducts training that aids in the mission of the Unit. 
 
 
Observation  The Units training plan included an in-house training program.  The 
 
Unit had a training plan for attorneys, investigators, and auditors, 
pursuant to Performance Standard 12(a), which states that the Unit 
maintain a training plan that includes an annual minimum number of 
training hours and is at least as stringent as required for professional 
certification.  As part of basic training, the Unit offered an in-house 
orientation program that addressed a variety of topics, including a 
Medicaid overview, MFCU jurisdiction and venue, the MFCU Operations 
Manual, the case management system, patient abuse and neglect 
investigations, Medicaid managed care, and Medicaid information 
systems.  In addition, the in-house orientation program included the 
shadowing of a Unit professional staff member for up to a year. 
   
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CONCLUSION AND RECOMMENDATIONS 
From the information we reviewed, we found that the Idaho Unit complied 
with applicable legal requirements and generally adhered to performance 
standards, but we identified three areas in which the Unit should improve its 
adherence to standards.  We found that although the Unit established a 
more frequent and robust practice for conducting periodic supervisory 
review of case files, it had not updated its policies and procedures manual 
to reflect the updated practices.  We also found that nearly one quarter of 
case files did not contain documented periodic supervisory review.  We also 
found that some of the Units cases had significant unexplained investigative 
delays.   
Additionally, the Unit reported barriers that limited its ability to investigate 
and prosecute cases of patient abuse or neglect and civil cases.  OIG 
encourages and supports the Units efforts to remove any barriers that 
prevent the Unit from investigating and prosecuting all cases within their 
authority, as appropriate.  The Unit drafted amendments to provisions of 
the Idaho code that may warrant consideration for introduction to the Idaho 
Legislature. 
To address the three findings, we recommend that the Idaho Unit: 
Update its policies and procedures manual to reflect current 
Unit practices for periodic supervisory case file review   
The Unit should update its Operations Manual to include its current 
procedures for periodic supervisory reviews that involve a monthly review of 
all cases during a staff meeting and for documenting these reviews in the 
Units case management system. 
 
Take steps to ensure that investigation delays are limited to 
situations imposed by resource constraints or other exigencies 
and that delays are documented in the case management 
system    
Except for delays imposed by resource constraints or other exigencies, the 
Unit should avoid extended delays to investigations.  To demonstrate that 
extended delays were imposed by resource constraints or other exigencies, 
the Unit should document such occurrences in the case management 
system.  
Ensure that the case management system includes 
documentation of supervisory oversight 
After the Unit revises its Operations Manual to include procedures for 
documenting periodic supervisory review (as recommended in the first 
recommendation), the Unit should take steps to ensure that periodic 
Idaho Medicaid Fraud Control Unit: 2018 Onsite Inspection  14 
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supervisory reviews of cases are consistently documented in the case 
management system.  This may include a master listing, such as the Units 
aged case list, that includes such information, as long as that list is readily 
accessible in the case management system.   
     
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UNIT COMMENTS AND OIG RESPONSE 
The Idaho Unit concurred with all three of our recommendations. 
First, the Unit concurred with our recommendation to update its policies 
and procedures manual to reflect current Unit practices for periodic 
supervisory case file review.  The Unit stated that it will update its 
Operations Manual with procedures for its monthly meeting during which 
all Unit staff, including the Unit director and investigations supervisor, review 
all individual cases.  The Unit also explained that it will update its Operations 
Manual to include a procedure for saving the aged case list, which serves 
as the documentary product of [the] . . .  monthly reviews, in the case 
management system.   
Second, the Unit concurred with our recommendation to take steps to 
ensure that investigation delays are limited to situations imposed by 
resource constraints or other exigencies and that delays are documented in 
the case management system.  The Unit stated its belief that this objective is 
now being addressed with the monthly review process (introduced after the 
review period) and is documented on the aged case list, which includes 
recent investigative steps, the level of investigative activity, as well as 
reasons for any delays in case progression.  We will assess the adequacy of 
these steps to limit investigative delays in our follow-up to the 
recommendation. 
Finally, the Unit concurred with our recommendation to ensure that the case 
management system includes documentation of supervisory oversight.  As 
stated in response to our first recommendation, the Unit will document its 
monthly review of cases by retaining the aged case list in the case 
management system.  We will assess the accessibility of this list in the case 
management system in our follow-up to the recommendation.  
For the full text of the Units comments, see Appendix E. 
 
 
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APPENDIX A: MFCU Performance Standards24 
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; 25 
D)  OIG policy transmittals as maintained on the OIG website; 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 Unite employs an appropriate mix and number of attorneys, auditors, 
investigators, and other professional staff that is both commensurate with 
the States total Medicaid program expenditures and that allows the Unit to 
effectively investigate and prosecute (or refer for prosecution) an 
appropriate volume of case referrals and workload for both Medicaid fraud 
and patient abuse and neglect. 
D)  The Unit employs a number of support staff in relation to its overall size 
that allows the Unit to operate effectively. 
E)  To the extent that a Unit maintains multiple office locations, such locations 
are distributed throughout the State, and are adequately staffed, 
commensurate with the volume of case referrals and workload for each 
location. 
3)  A Unit establishes written policies and procedures for its operations and 
ensures that staff are familiar with, and adhere to, policies and 
procedures. 
A)  The Unit has written guidelines or manuals that contain current policies and 
procedures, consistent with these performance standards, for the 
investigation and (for those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect. 
B)  The Unit adheres to current policies and procedures in its operations. 
C)  Procedures include a process for referring cases, when appropriate, to 
Federal and State agencies.  Referrals to State agencies, including the State 
 
24 77 Fed. Reg. 32645 (June 1, 2012). 
25 For FYs 2016 and later, grant administration requirements are found at 45 CFR pt. 75. 
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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). 
D)  For those States in which the Unit has original jurisdiction to investigate or 
prosecute patient abuse and neglect cases, the Unit takes steps, such as the 
development of operational protocols, to ensure that pertinent agencies 
refer such cases to the Unit, consistent with patient confidentiality and 
consent.  Pertinent agencies vary by State but may include licensing and 
certification agencies, the State Long Term Care Ombudsman, and adult 
protective services offices. 
E)  The Unit provides timely information, when requested, to those agencies 
identified in (D) above regarding the status of referrals. 
F)  The Unit takes steps, through public outreach or other means, to 
encourage the public to refer cases to the Unit. 
5)  A Unit takes steps to maintain a continuous case flow and to complete 
cases in an appropriate timeframe based on the complexity of the cases. 
A)  Each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
B)  Supervisors approve the opening and closing of all investigations and 
review the progress of cases and take action as necessary to ensure that 
each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
C)  Delays to investigations and prosecutions are limited to situations imposed 
by resource constraints or other exigencies. 
6)  A Units case mix, as practicable, covers all significant providers 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. 
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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. 
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 recoveries and the 
types of relief obtained through civil judgments or prefiling 
settlements. 
 
 
 
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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, 
case involving the same suspects or allegations, and cases that have been 
referred to the Unit by OIG or another Federal agency. 
C)  The Unit makes available, to the extent authorized by law and upon request 
by Federal investigators and prosecutors, all information in its possession 
concerning provider fraud or fraud in the administration of the Medicaid 
program. 
D)  For cases that require the granting of extended jurisdiction to investigate 
Medicare or other Federal health care fraud, the Unit seeks permission 
from OIG or other relevant agencies under procedures as set by those 
agencies. 
E)  For cases that have civil fraud potential, the Unit investigates and 
prosecutes such cases under State authority or refers such cases to OIG or 
the U.S. Department of Justice. 
F)  The Unit transmits to OIG, for purposes of program exclusions under 
section 1128 of the Social Security Act, all pertinent information on MFCU 
convictions within 30 days of sentencing, including charging documents, 
plea agreements, and sentencing orders. 
G)  The Unit reports qualifying cases to the Healthcare Integrity & Protection 
Databank, the National Practitioner Data Bank, or successor data bases. 
9)  A Unit makes statutory or programmatic recommendations, when 
warranted, to the State government. 
A)  The Unit, when warranted and appropriate, makes statutory 
recommendations to the State legislature to improve the operation of the 
Unit, including amendments to the enforcement provisions of the State 
code. 
B)  The Unit, when warranted and appropriate, makes other regulatory or 
administrative recommendations regarding program integrity issues to the 
State Medicaid agency and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State 
legislature and the State Medicaid or other agencies in response to 
recommendations. 
10)  A Unit periodically reviews its Memorandum of Understanding (MOU) 
with the State Medicaid agency to ensure that it reflects current 
practice, policy, and legal requirements. 
A)  The MFCU documents that it has reviewed the MOU at least every 5 years, 
and has renegotiated the MOU as necessary, to ensure that it reflects 
current practice, policy, and legal requirements. 
B)  The MOU meets current Federal legal requirements as contained in law or 
regulation, including 42 CFR 455.21, Cooperation with State Medicaid 
fraud control units, and 42 CFR 455.23, Suspension of payments in cases 
of fraud. 
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C)  The MOU is consistent with current Federal and State policy, including any 
policies issued by OIG or the Centers for Medicare & Medicaid Services 
(CMS). 
D)  Consistent with Performance Standard 4, the MOU establishes a process to 
ensure the receipt of an adequate volume and quality of referrals to the 
Unit from the State Medicaid agency. 
E)  The MOU incorporates by reference the CMS Performance Standard for 
Referrals of Suspected Fraud From a State Agency to a Medicaid Fraud 
Control Unit. 
11)  A Unit exercises proper fiscal control over Unit resources. 
A)  The Unit promptly submits to OIG its preliminary budget estimates, 
proposed budget, and Federal financial expenditure reports. 
B)  The Unit maintains an equipment inventory that is updated regularly to 
reflect all property under the Units control. 
C)  The Unit maintains an effective time and attendance system and personnel 
activity records. 
D)  The Unit applies generally accepted accounting principles in its control of 
Unit funding. 
E)  The Unit employs a financial system in compliance with the standards for 
financial management systems contained in 45 CFR 92.20. 
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. 
 
   
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APPENDIX B: Detailed Methodology 
Data Collection and Analysis 
We collected and analyzed data from the seven sources below to identify 
any opportunities for improvement and instances in which the Unit did not 
adhere to the performance standards or was not operating in accordance 
with laws, regulations, or policy transmittals.26  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.  Prior to the onsite inspection, we reviewed 
the recertification analysis for FYs 20152017, which involved examining the 
Units recertification materials, including (1) the annual reports, (2) the Unit 
Directors recertification questionnaires, (3) the Units memorandum of 
understanding with the State Medicaid agency, (4) the Program Integrity 
Directors questionnaires, and (5) 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 20152017.  We examined the 
recommendations from the 2012 OIG onsite review 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.  Prior to the onsite review, we 
analyzed the Units response to an internal controls questionnaire and 
conducted a desk review of the Units financial status reports.  While onsite, 
we followed up with Office of Attorney General and Unit officials to clarify 
issues identified in the internal controls questionnaire.  We also selected a 
purposive sample of 30 items from the list of current inventory list of 
116 items maintained in the Units office and verified those items onsite. 
Interviews With Key Stakeholders.  In June 2018, we interviewed key 
stakeholders, including officials in the Idaho Department of Health and 
Welfare, the Idaho Bureau of Facility Standards, and the U.S. Attorneys 
Office.  We also interviewed the agents from OIGs Office of Investigations 
who work regularly with the Unit.  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. 
 
26 All relevant regulations, statutes, and policy transmittals are available online at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.  
 
 
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Onsite Interviews With Unit Management and Selected Staff.  We 
conducted structured onsite interviews with the Units management and 
selected staff in July 2018.  We interviewed the Unit director, the attorney, 
the lead investigator, the auditor, one current and one former Unit 
investigator, and the legal secretary.  In addition, we interviewed the 
supervisors of the Unitthe section chief and the division chief of the 
Criminal Division.  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 2015 through 2017 and to include the status of the case; whether the 
case was criminal, civil, or global; and the date on which the case was 
opened and closed, if applicable.  The total number of cases was 277.   
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 126 global cases, leaving 151 case files.   
We then selected a simple random sample of 68 cases from the population 
of 151 cases.  This sample allowed us to make estimates of the overall 
percentage of case files with various characteristics with an absolute 
precision of +/- 10 percent at the 95-percent confidence level.  We reviewed 
the 68 case files for adherence to the relevant performance standards and 
compliance with statute, regulation, and policy transmittals.  During the 
onsite review of the sampled cases, we consulted MFCU staff to address any 
apparent issues with individual case files, such as missing documentation.  
Review of Unit Submissions to OIG and NPDB.  We also reviewed all 
convictions submitted to OIG for program exclusion during the review 
period (11), and all adverse actions submitted to the National Practitioner 
Data Bank (NPDB) during the review period (19).  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 
20152017.  We also assessed the timeliness of the submissions to OIG and 
the NPDB.   
Onsite Review of Unit Operations.  During the onsite inspection, we 
observed the Units workspace and operations of the Units office in Boise.  
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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APPENDIX C: Unit Referrals by Source for Fiscal 
Years 2015 Through 2017 
  FY 2015  FY 2016  FY 2017  Grand Totals  
Fraud  Abuse or  Fraud  Abuse or  Fraud  Abuse or  Fraud  Abuse or 
Referral Source 
Neglect  Neglect  Neglect  Neglect 
Adult protective 
0  0  0  2  0  0  0  2 
services 
Anonymous  4  1  4  0  2  0  10  1 
HHS-OIG  0  1  1  0  2  2  3  3 
Law enforcement
0  3  0  1  0  1  0  5 
other  
Licensing board  0  0  1  0  0  0  1  0 
Local prosecutor  1  0  0  0  0  0  1  0 
Long-term-care 
0  0  0  1  0  0  0  1 
ombudsman 
Medicaid agency
4  0  18  0  6  0  28  0 
PI/SURS1 
Medicaid agency
0  0  2  0  0  0  2  0 
other 
Private citizen  24  2  12  5  13  0  49  7 
Private health 
0  0  0  0  1  0  1  0 
insurer 
Provider  6  2  1  0  4  0  11  2 
State agency
0  0  3  0  1  0  4  0 
other 
State survey and 
certification agency 
1  11  0  6  0  5  1  22 
(Bureau of Facility 
StandardsBFS) 
Other2  29  0  26  0  21  0  76  0 
     Total  69  20  68  15  50  8  187  43 
     Annual Total  89  83  58  230 
Source:  OIG analysis of Unit Annual Statistical Reports, FYs 2015-2017. 
1 The abbreviation PI stands for program integrity; the abbreviation SURS stands for Surveillance and Utilization Review Subsystem. 
2 Most Other referrals (64 of 76) are global cases from the National Association of Medicaid Fraud Control Units. 
   
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APPENDIX D: Point Estimates and 95-Percent 
Confidence Intervals of Case File Reviews 
 
95-Percent Confidence 
Point 
 Estimate Description  Sample Size   Interval 
Estimate 
Lower  Upper 
Percentage of All Cases with Investigative 
68  10.3%  5.3%  17.9% 
Delays 
Percentage Of All Cases Closed At The Time 
68  67.6%  57.6%  76.2% 
Of Our Review 
Percentage of All Cases That Had 
68  100%  95.4%  100% 
Supervisory Approval To Open 
Percentage of All Closed Cases That Had 
46  100%  94.1%  100% 
Supervisory Approval To Close  
Percentage of All Cases Opened Longer 
68  97.1%  91.4%  98.7% 
Than 90 Days 
Percentage of All Case Files Opened Longer 
Than 90 Days and Lacked Periodic  66  24.2%  16.3%  34.0% 
Supervisory Review 
Percentage of All Case Files Opened Longer 
Than 90 Days and Contained No Periodic  66  13.6%  7.5%  21.8% 
Review  
Percentage of All Case Files Opened Longer 
Than 90 Days and Contained Some Periodic  66  10.6%  5.4%  18.4% 
Review, But Not Quarterly Review 
Supervisory Review 
Source: OIG analysis of Idaho MFCU case files, 2018. 
   
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APPENDIX E: Unit Comments
 
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Idaho Medicaid Fraud Control Unit: 2018 Onsite Inspection  27 
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Idaho Medicaid Fraud Control Unit: 2018 Onsite Inspection  28 
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ACKNOWLEDGMENTS 
Susan Burbach of the Medicaid Fraud Policy and Oversight Division served 
as the team leader for this inspection.  Two agents from the Office of 
Investigations also participated in the inspection.  Office of Evaluation and 
Inspections staff who provided support include Christina Lester and Kevin 
Farber.   
This report was prepared under the direction of Richard Stern, Director of 
the Medicaid Fraud Policy and Oversight Division.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov
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ABOUT THE OFFICE OF INSPECTOR GENERAL 
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  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
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  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
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  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
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 Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
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.