Department of Health and Human Services 
OFFICE OF 
 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
 
  C S M
OLORADO  TATE  EDICAID 
 
F  C U :  
RAUD  ONTROL  NIT   
 
 2016 O R  
  NSITE  EVIEW
 
(INI TIAL CAPS, SMALL CAPS) 
 
Suzanne Murrin 
Deputy Inspector General 
 
August 2017 
OEI-06-16-00520 
 
   
   
EXECUTIVE SUMMARY:  COLORADO STATE MEDICAID FRAUD CONTROL 
UNIT:  2016 ONSITE REVIEW  
OEI-06-16-00520 
 
WHY WE DID THIS STUDY  
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit 
(MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units 
performance in accordance with the requirements of the grant.  As part of this oversight, 
OIG conducts periodic reviews of all Units and prepares public reports based on these 
reviews.  These reviews assess the Units adherence to the 12 MFCU performance 
standards and compliance with applicable Federal statutes and regulations. 
 
HOW WE DID THIS STUDY 
We conducted an onsite review of the Colorado Unit in October 2016.  We based our 
review on an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; (2) financial 
documentation for fiscal years (FYs) 2013 through 2015; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Units 
management; (6) a sample of files for cases that were open in FYs 2013 through 2015; 
and (7) observation of Unit operations. 
 
WHAT WE FOUND 
Our review found that the Colorado Unit was generally in compliance with applicable 
laws, regulations, and policy transmittals.  For FYs 2013 through 2015, the Unit reported 
32 criminal convictions, 106 civil judgments and settlements, and combined criminal and 
civil recoveries of over $22 million.  However, we found four areas in which the Unit 
should improve.  First, the Unit investigated few patient abuse or neglect cases.  Second, 
the Unit did not report all convictions or adverse actions to Federal partners within the 
required timeframes.  Third, 46 percent of the Units case files lacked documentation of 
periodic supervisory reviews, although supervisors documented the opening and closing 
of all cases.  Finally, the Unit did not retain documentation for a recurring grant 
expenditure, as required by Federal regulation. 
 
WHAT WE RECOMMEND  
We recommend that the Colorado Unit:  (1) take steps to increase the number of 
investigations of patient abuse or neglect; (2) ensure that it consistently reports 
convictions and adverse actions to Federal partners within the required timeframes; 
(3) ensure that supervisory reviews of Unit case files are conducted and documented 
according to the Units policies and procedures; and (4) ensure that it retains expenditure 
documentation for the time period required by regulation.  The Unit concurred with our 
recommendations. 
 
 
   
   
TABLE OF CONTENTS 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................6 
For FYs 2013 through 2015, the Colorado Unit reported 
32 criminal convictions, 106 civil judgments and settlements, 
and combined criminal and civil recoveries of over $22 million ....6 
The Unit investigated few patient abuse or neglect cases ................7 
The Unit did not report all convictions or adverse actions to 
Federal partners within the required timeframes .............................8 
Forty-six percent of the Units case files lacked documentation of 
periodic supervisory reviews, although supervisors documented  
the opening and closing of all cases .................................................9 
The Unit did not retain documentation for a recurring grant 
expenditure, as required by Federal regulation ..............................10 
Conclusion and Recommendations ............................................................ 11 
            Unit Comments and Office of Inspector General Response ..........13 
Appendixes ................................................................................................14 
A:  2012 Performance Standards ...................................................14 
B:  Colorado MFCU Referrals by Referral Source for FYs 2013 
Through 2015 .................................................................................18 
C:  Point Estimates and 95-Percent Confidence Intervals Based 
on Reviews of Case Files ...............................................................19 
D:  Detailed Methodology .............................................................20 
E:  Unit Comments.........................................................................23 
Acknowledgments......................................................................................26 
 
 
   
OBJECTIVE 
To conduct an onsite review of the Colorado Medicaid Fraud Control Unit 
(MFCU or Unit). 
BACKGROUND  
The mission of MFCUs is to investigate and prosecute Medicaid provider 
fraud and patient abuse or neglect under State law.1  The Social Security 
Act (SSA) requires each State to operate a MFCU, unless the Secretary of 
Health and Human Services (HHS) determines that operation of a Unit 
would not be cost-effective because minimal Medicaid fraud exists in a 
particular State and that the State has other adequate safeguards to protect 
Medicaid beneficiaries from abuse and neglect.2  Currently, 49 States and 
the District of Columbia (States) have MFCUs.3   
Each Unit must employ an interdisciplinary staff that consists of at least an 
investigator, an auditor, and an attorney.4  Unit staff review referrals of 
provider fraud and patient abuse or neglect to determine their potential for 
criminal prosecution and/or civil action.  In fiscal year (FY) 2016 the 
50 Units collectively reported 1,564 convictions, 998 civil settlements and 
judgments, and approximately $1.9 billion in recoveries.5, 6 
Units must meet a number of requirements established by the SSA and 
Federal regulations.  For example, each Unit must: 
  be a single, identifiable entity of State government, distinct from 
the single State Medicaid agency; 7 
  develop a formal agreement, such as a memorandum of 
understanding (MOU), which describes the Units relationship 
with the State Medicaid agency;8 and   
                        ____________________________________________________________ 
1 SSA  1903(q).  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. 
2 SSA  1902(a)(61).   
3 North Dakota and the territories of American Samoa, Guam, the Northern Mariana 
Islands, Puerto Rico, and the U.S. Virgin Islands have not established Units. 
4 SSA  1903(q)(6); 42 CFR  1007.13. 
5 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2016. 
Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on February 28, 2017.   
6 All FY references in this report are based on the Federal FY (October 1 through     
September 30). 
7 SSA  1903(q)(2); 42 CFR  1007.5 and 1007.9(a). 
8 42 CFR  1007.9(d).  
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)                1    
   
  have either statewide authority to prosecute cases or formal 
procedures to refer suspected criminal violations to an agency with 
such authority.9   
MFCU Funding 
Each MFCU is funded jointly by its State and the Federal government.  
Federal funding for the MFCUs is provided as part of the Federal 
Medicaid appropriation, but it is administered by OIG.10  Each Unit 
receives Federal financial participation equivalent to 75 percent of its total 
expenditures, with State funds contributing the remaining 25 percent.11  In 
FY 2016, combined Federal and State expenditures for the Units totaled 
nearly $258 million, $194 million of which represented Federal funds.12   
Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to administer the 
MFCU grant program.13  To receive Federal reimbursement, each Unit must 
submit an initial application to OIG for approval and be recertified each year 
thereafter.    
In annually recertifying the Units, OIG evaluates Unit compliance with 
Federal requirements and adherence to performance standards.  The Federal 
requirements for Units are contained in the SSA, regulations, and policy 
guidance.14  In addition, OIG has published 12 performance standards that it 
uses to assess whether a Unit is effectively performing its responsibilities.15  
The standards address topics such as staffing, maintaining adequate referrals, 
and cooperation with Federal authorities.  Appendix A contains the 
Performance Standards.     
OIG also performs periodic onsite reviews of the Units, such as this review 
of the Colorado MFCU.  During these onsite reviews, OIG evaluates Units 
compliance with laws, regulations, and policies, as well as adherence to the 
                        ____________________________________________________________ 
9 SSA  1903(q)(1). 
10 SSA  1903(a)(6)(B). 
11 Ibid.  
12 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2016. 
Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on February 28, 2017.   
13 The SSA authorizes the Secretary of HHS to award grants to the Units 
(SSA  1903(a)(6)); the Secretary delegated this authority to the OIG.   
14 On occasion, OIG issues policy transmittals to provide guidance and instructions to 
MFCUs.   
15 77 Fed. Reg. 32645 (June 1, 2012).  Accessed at 
https://oig.hhs.gov/authorities/docs/2012/PerformanceStandardsFinal060112.pdf on 
February 28, 2017.   
 
 
 
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  2
 
   
   
12 performance standards.  OIG also makes observations about best 
practices, provides recommendations to the Units, and monitors the 
implementation of the recommendations.  These evaluations differ from 
other OIG evaluations as they support OIGs direct administration of the 
MFCU grant program.  These evaluations are subject to the same internal 
quality controls as other OIG evaluations, including internal peer review. 
OIG provides additional oversight including the collection and dissemination 
of performance data, training, and technical assistance.  
Colorado MFCU 
The Colorado Unit, a division of the Colorado Office of the Attorney 
General, investigates and prosecutes cases of Medicaid fraud and patient 
abuse and neglect.  The Unit is located in Denver.  At the time of our 
October 2016 onsite review, the Unit employed 16 staff members, 
including 9 investigators, 3 attorneys, and 1 auditor.  The Units 
management was comprised of a director, a senior assistant attorney 
general, and a supervising investigator.16  The Colorado Unit had total 
expenditures of approximately $2.18 million in combined State and 
Federal funds in FY 2016.17   
Referrals.  The Unit receives fraud referrals from a variety of sources, 
including private citizens, the State Medicaid Agency, other law 
enforcement agencies, and OIG.  Appendix B depicts Unit referrals by 
source for FYs 2013 through 2015.  For patient abuse or neglect referrals, 
the Unit develops nearly all referrals by reviewing complaints in the 
Occurrences database maintained by the Health Facilities and Emergency 
Medical Services Division of the Colorado Department of Public Health 
and Environment.18  The Occurrences database stores complaints about 
harm to residents and patients of health care facilities in Colorado, ranging 
from verbal abuse to serious injury to death.  Unit staff search the 
Occurrences database for complaints that appear to warrant further 
investigation.  If staff identify such complaints, they are submitted to Unit 
                        ____________________________________________________________ 
16 The previous Unit director served during the review period of this report and left the 
position in February 2016.  The interim director served from February 2016 until 
September 2016, when the current director was hired. 
17 OIG, MFCU Statistical Data for Fiscal Year 2016.  Accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on February 22, 2017.   
18 Colorado Department of Public Health and Environment, Occurrences Reporting 
Manual.  Accessed at 
https://www.colorado.gov/pacific/sites/default/files/HF_Occurrence-Reporting-
Manual_0.pdf on May 6, 2017.   
 
 
 
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  3
 
   
   
management for acceptance as a referral.  If Unit management accepts the 
complaint as a referral, it subsequently opens an investigation.   
Investigations.  Once the Unit decides to open a case, the supervising 
investigator and the director assign one or more investigators and attorneys 
to the case.  Per Unit policy, the assigned investigator(s) are responsible for 
all investigative activity conducted for the case, under the direction of the 
supervising investigator.  The supervising investigator conducts reviews of 
each open case every 90 days.19  Unit policy requires that the Unit maintain 
documentation of each supervisory review in the case file.   
Previous Onsite Review 
In 2010, OIG issued a report regarding its onsite review of the 
Colorado Unit.  The review found that the Unit did not fully comply with  
2 of the 12 MFCU performance standards.  First, the review found that a 
Colorado MFCU investigator worked on a non-Medicaid matter.  OIG 
determined that the non-Medicaid related activity was minimal and did not 
require a reimbursement adjustment to the grant.  Second, the review found 
that the MOU between the Unit and the State Medicaid agency did not 
address cross-training with the fraud detection staff of the State Medicaid 
agency, as required at the time.20  
METHODOLOGY 
Data Collection and Analysis 
We conducted the onsite review in October 2016.  We based our review on 
an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; 
(2) financial documentation for FYs 2013 through 2015; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
interviews with the Units management; (6) a sample of files for cases that 
were open in FYs 2013 through 2015; and (7) observation of Unit 
operations.  Appendix E provides details of our methodology.   
                        ____________________________________________________________ 
19 The Unit changed its supervisory review policy during our review period from every 
90 days to 912 times per year.  For the purposes on this evaluation, we used the 90 days 
threshold.   
20 59 Fed. Reg. 49080 (Sept. 26, 1994).  Performance Standards adopted in FY 2012 and 
after the earlier review no longer require the MOU to address cross-training between the 
Unit and the State Medicaid agency. 77 Fed. Reg. 32645 (June 1, 2012).  Accessed at 
https://oig.hhs.gov/authorities/docs/2012/PerformanceStandardsFinal060112.pdf on 
February 28, 2017. 
 
 
 
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  4
 
   
   
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. 
   
 
 
 
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  5
 
   
   
FINDINGS 
Our review of the Colorado Unit found that it was generally in compliance 
with applicable laws, regulations, and policy transmittals.  The Unit 
reported over $22 million in combined criminal and civil recoveries and 
32 criminal and civil convictions during the review period.  However, the 
Unit investigated few patient abuse or neglect cases.  Further, the Unit did 
not report all convictions or adverse actions to Federal partners within the 
required timeframes, and some case files lacked documentation of at least 
one required supervisory review.  Additionally, the Unit did not retain 
documentation for a recurring grant expenditure, as required by regulation. 
For FYs 2013 through 2015, the Colorado Unit reported 
32 criminal convictions, 106 civil judgments and 
settlements, and combined criminal and civil 
recoveries of over $22 million 
For FYs 2013 through 2015, the Unit reported 32 criminal convictions and 
106 civil judgments and settlements.  Exhibit 1 provides details of the 
Units yearly convictions and civil judgments and settlements.  Of the 
Units 32 convictions over the 3-year period, 31 involved provider fraud, 
and 1 involved patient abuse or neglect.   
Exhibit 1:  Colorado MFCU Criminal Convictions and Civil 
Judgments and Settlements, FYs 20132015 
3-Year 
Outcomes  FY 2013  FY 2014  FY 2015  Total 
Criminal Convictions (fraud)  13   9  9  31 
Criminal Convictions (abuse or neglect)  0  1  0  1 
Civil Judgments and Settlements  36  26  44  106 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
The Unit reported criminal and civil recoveries of over $22 million for 
FYs 2013 through 2015ranging from $4.7 million to nearly $10 million 
over the 3 years (shown in Exhibit 2).  During the 3-year period, global 
recoveries accounted for over 90 percent of the Units total recoveries.  
 
 
 
 
 
 
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Exhibit 2:  Colorado MFCU Recoveries and Expenditures,  
FYs 20132015 
Type of 
FY 2013  FY 2014  FY 2015  3Year Total 
Recovery 
Global Civil  $7,605,983  $9,607,840  $3,739,443  $20,953,266 
Nonglobal Civil  $317,966  $308,015  $307,040  $933,021 
Criminal  $226,252  $84,118  $660,651  $971,021 
Total 
$8,150,201  $9,999,973  $4,707,134  $22,857,308 
Recoveries 
Total 
$2,046,627  $1,615,525  $1,651,018  $5,313,170 
Expenditures 
 
Source:  OIG analysis of Unit-submitted documentation, 2016.
The Unit investigated few patient abuse or neglect 
cases  
The Unit opened and investigated few patient abuse or neglect cases during 
the review period.  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.  Of the 673 cases that were open at 
any time during the review period, less than 4 percent (25 cases) were 
patient abuse or neglect cases.  Moreover, the number of abuse or neglect 
referrals that the Unit processed declined each year during our review 
period from 11 in 2013 to 8 in 2014 to only 1 referral in 2015.   
According to Unit staff, the previous management did not prioritize abuse 
or neglect cases.  Staff reported that the previous director and supervising 
investigator declined to develop nearly all abuse or neglect complaints into 
referrals and investigations.21  Several Unit staff reported that, since the 
appointment of an interim director and now under the current permanent 
director, the Unit increased its focus on abuse and neglect cases.   
                        ____________________________________________________________ 
21 As explained in the background, Unit staff search the Occurrences database for abuse or 
neglect complaints that appear to warrant further investigation.  Unit staff then submit these 
complaints to Unit management for acceptance as a referral, from which an investigation 
may be opened. 
 
 
 
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The Unit did not report all convictions or adverse 
actions to Federal partners within the required 
timeframes 
The Unit did not report all convictions or adverse actions to OIG and the 
National Practitioner Data Bank (NPDB) within the timeframes required 
by these entities.  Performance Standard 8(f) states that the Unit should 
transmit to OIG reports of all convictions for the purpose of exclusion 
from Federal health care programs within 30 days of sentencing.  Federal 
regulations require that Units report any adverse actions resulting from 
investigations or prosecution of healthcare providers to the 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     
The Unit did not report more than half of its convictions to OIG 
within the required timeframe 
The Unit did not report 59 percent of its convictions (19 of 32) to OIG 
within 30 days of sentencing.  Exhibit 3 illustrates the number of days after 
sentencing that the Unit reported these convictions to OIG.  Unit managers 
and staff explained that late reporting of convictions to OIG was primarily 
due to the Units case management system lacking the functionality to 
automate monitoring of case progress.  In December 2016, the Unit 
reported that it began exploring options for a more comprehensive case 
management system, to replace its current system.  Late reporting of 
convictions to OIG delays the initiation of the program exclusion process, 
which may result in improper payments to providers by Medicare or other 
Federal health care programs or possible harm to beneficiaries.   
                        ____________________________________________________________ 
22 45 CFR  60.5 
23 Performance Standard 8(g) states that the Unit should report qualifying cases to the 
Healthcare Integrity & Protection Databank [HIPDB], the National Practitioner Data 
Bank, or successor data bases.  The HIPDB and the NPDB were merged during our 
review period (FYs 2013 through 2015); therefore, we reviewed the reporting of adverse 
actions under the NPDB requirements.  See 78 Fed. Reg. 20473 (April 5, 2013).  
Examples of final adverse actions include, but are not limited to, convictions, civil 
judgments (but not civil settlements), and program exclusions.  See 45 CFR  60.3. 
 
 
 
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Exhibit 3:  Number of Convictions and Adverse Actions Reported After Required Timeframe 
Convictions or  Convictions or  Convictions  or 
Total Convictions  
Federal Partner  Adverse Actions  Adverse Actions  Adverse Actions 
or Adverse Actions  
Reported To  Reported 130   Reported 31-60  Reported More Than 
Reported Late  
Days Late  Days Late  60 Days Late 
OIG (Convictions)  10  6  3  19 
NPDB (Adverse Actions)  12  6  42  60 
Source:  OIG analysis of Unit convictions and dates reported to OIG and the NPDB, 2016. 
The Unit did not report 72 percent of adverse actions to the 
NPDB within the required timeframe 
The Unit did not report 60 of its 83 adverse actions (72 percent) to the 
NPDB within 30 days of the adverse action, as required.  Exhibit 3 
illustrates the number of days after the adverse actions that the Unit reported 
them to the NPDB.  Similar to late reporting of convictions to OIG, the Unit 
stated that late reporting to the NPDB was due to the Units inadequate case 
management system.  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.  If a Unit fails to report adverse actions to the NPDB, 
individuals may find new healthcare employment with an organization that 
is not aware of the adverse actions.   
Forty-six percent of the Units case files lacked 
documentation of periodic supervisory reviews, 
although supervisors documented the opening and 
closing of all cases 
Of the Units 71 case files that were open longer than 90 days and required 
review, 33 cases (46 percent) lacked documentation of supervisory reviews, 
as required by Unit policy.24  Performance Standards 5(b) and 7(a) state that 
supervisors should periodically review the progress of cases, consistent with 
Unit policies and procedures, ensure that each stage of the investigation and 
prosecution is completed in an appropriate timeframe, and note in the case 
file that the reviews took place.  Unit policy for supervisory reviews states 
that the supervising investigator is to meet at least quarterly with 
investigators to review progress of cases.  
                        ____________________________________________________________ 
24 Appendix C contains the point estimates and 95-percent confidence intervals. 
 
 
 
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  9
 
   
   
Still, all of the Units case files contained documentation of supervisory 
approval to open and close the cases.  Performance Standard 5(b) states that 
Unit supervisors should approve the opening and closing of cases.  The 
Units policy also requires opening and closing memorandums to document 
the opening and closing of cases.  Supervisory approval to open cases 
indicates that Unit supervisors are monitoring the intake of cases, thereby 
facilitating progress in the investigation.  Supervisory approval to close 
cases helps ensure the timely completion and resolution of cases.  
The Unit did not retain documentation for a recurring 
grant expenditure, as required by Federal regulation  
The Unit was unable to provide supporting documentation for a monthly 
expenditure incurred during FY 2013, selected as part of OIGs sample.  
The Unit explained that it could not provide documentation of the monthly 
expenditure from this time period because the documentation was purged 
from a system no longer used by the Colorado Office of Attorney 
General.25  Federal regulations require grantees to retain all financial 
records and supporting documents pertinent to a Federal award for a 
period of three years, from the date of submission of the last expenditure 
report.26   
 
 
 
 
 
 
 
 
 
                        ____________________________________________________________ 
25 The FY 2013 expenditure, of $780 ($585 Federal share), was a monthly expense for 
leased phones that was centrally billed by another State agency to the Office of Attorney 
General.   
26 45 CFR  92.42.  Beginning in FY 2016, the applicable requirement is found at 
45 CFR  75.361. 
 
 
 
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CONCLUSION AND RECOMMENDATIONS 
Our review of the Colorado Unit found that it was generally in compliance 
with applicable laws, regulations, and policy transmittals.  For FYs 2013 
through 2015, the Unit reported 32 criminal convictions, 106 civil 
judgments and settlements, and combined criminal and civil recoveries of 
over $22 million.   
However, we found four areas in which the Unit should improve.  First, 
the Unit investigated few patient abuse or neglect cases.  Second, the Unit 
did not report all convictions or adverse actions to Federal partners within 
the required timeframes.  Third, some case files lacked documentation of 
at least one required supervisory review.  Finally, the Unit did not retain 
documentation for a recurring grant expenditure, as required by Federal 
regulation. 
We recommend that the Colorado Unit:  
Take steps to increase the number of investigations of patient 
abuse or neglect 
The Unit should, as appropriate, increase the number of investigations it 
opens from complaints in the Occurrences database.  The Unit could also 
work with new and existing stakeholders to increase the number of 
referrals.   
Ensure that it consistently reports convictions and adverse 
actions to Federal partners within the required timeframes 
The Unit should develop procedures to ensure that it consistently reports 
convictions to OIG and adverse actions to the NPDB within 30 days of 
sentencing or following the adverse action.  The Unit should also continue 
to explore implementing a new case management system that will make it 
easier to monitor case progress.   
Ensure that supervisory reviews of Unit case files are 
conducted and documented according to the Units policies 
and procedures 
Unit management should ensure that supervisors adhere to the Units 
written policy for conducting and documenting reviews of case files. 
 
 
 
 
 
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Ensure that it retains expenditure documentation for the time 
period required by regulation 
The Unit should ensure that the MFCU and other State offices can provide 
supporting documentation for all expenditures, in accordance with Federal 
regulations. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Colorado Unit concurred with our recommendations. 
Regarding the first recommendation, the Unit stated it has taken steps to 
increase the number of referrals of abuse and neglect by meeting with 
stakeholders beginning in October 2016, completing negotiations for 
a new MOU with the Colorado Department of Public Health and Finance, 
and increasing the number of cases it opens after reviewing the 
Occurrences database. 
Regarding the second recommendation, the Unit reported that the 
Colorado Department of Law is evaluating options for a case management 
system that would consolidate the Units multiple tracking systems.  In 
addition, the Unit now requires that closing forms contain all sentencing 
information, which will help to ensure timely reporting to Federal 
partners.   
Regarding the third recommendation, the Unit stated that it has taken steps 
to ensure that the lack of review and lack of documentation to show 
review do not occur going forward.  These steps include conducting 
monthly meetings between the supervising investigator and investigators 
about open cases and requiring that attendees sign an electronic 
case-review form after each meeting. 
Regarding the fourth recommendation, the Unit stated that it is taking 
steps to ensure that it retains all supporting documentation for all 
expenditures in accordance with Federal regulations.   
The full text of the Units comments is provided in Appendix E. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX A 
2012 Performance Standards27  
1.  A UNIT CONFORMS WITH ALL APPLICABLE STATUTES, REGULATIONS, AND POLICY DIRECTIVES, 
INCLUDING: 
A.  Section 1903(q) of the Social Security Act, containing the basic requirements for operation of a MFCU; 
B.  Regulations for operation of a MFCU contained in 42 CFR part 1007; 
C.  Grant administration requirements at 45 CFR part 92 and Federal cost principles at 2 CFR part 225; 
D.  OIG policy transmittals as maintained on the OIG Web site; and  
E.  Terms and conditions of the notice of the grant award. 
2.  A UNIT MAINTAINS REASONABLE STAFF LEVELS AND OFFICE LOCATIONS IN RELATION TO THE 
STATES MEDICAID PROGRAM EXPENDITURES AND IN ACCORDANCE WITH STAFFING 
ALLOCATIONS APPROVED IN ITS BUDGET.   
A.  The Unit employs the number of staff that is included in the Units budget estimate as approved by OIG. 
B.  The Unit employs a total number of professional staff that is commensurate with the States total Medicaid 
program expenditures and that enables the Unit to effectively investigate and prosecute (or refer for 
prosecution) an appropriate volume of case referrals and workload for both Medicaid fraud and patient abuse 
and neglect. 
C.  The Unit employs an appropriate mix and number of attorneys, auditors, investigators, and other 
professional staff that is both commensurate with the States total Medicaid program expenditures and that 
allows the Unit to effectively investigate and prosecute (or refer for prosecution) an appropriate volume of case 
referrals and workload for both Medicaid fraud and patient abuse and neglect. 
D.  The Unit employs a number of support staff in relation to its overall size that allows the Unit to operate 
effectively. 
E.  To the extent that a Unit maintains multiple office locations, such locations are distributed throughout the 
State, and are adequately staffed, commensurate with the volume of case referrals and workload for each 
location. 
3.  A UNIT ESTABLISHES WRITTEN POLICIES AND PROCEDURES FOR ITS OPERATIONS AND 
ENSURES THAT STAFF ARE FAMILIAR WITH, AND ADHERE TO, POLICIES AND PROCEDURES.   
A.  The Unit has written guidelines or manuals that contain current policies and procedures, consistent with 
these performance standards, for the investigation and (for those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect.  
B.  The Unit adheres to current policies and procedures in its operations. 
C.  Procedures include a process for referring cases, when appropriate, to Federal and State agencies.  
Referrals to State agencies, including the State Medicaid agency, should identify whether further investigation 
or other administrative action is warranted, such as the collection of overpayments or suspension of payments. 
D.  Written guidelines and manuals are readily available to all Unit staff, either online or in hard copy. 
E.  Policies and procedures address training standards for Unit employees. 
4.  A UNIT TAKES STEPS TO MAINTAIN AN ADEQUATE VOLUME AND QUALITY OF REFERRALS FROM 
THE STATE MEDICAID AGENCY AND OTHER SOURCES.   
                        ____________________________________________________________ 
27 77 Fed. Reg. 32645, June 1, 2012. 
 
 
 
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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 PROVIDER TYPES AND 
INCLUDES A BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.   
A.  The Unit seeks to have a mix of cases from all significant provider types in the State. 
B.  For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
D.  As part of its case mix, the Unit maintains a balance of fraud and patient abuse and neglect cases for those 
States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and neglect cases. 
C.  The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors.  Special Unit initiatives may focus on specific provider types. 
E.  As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7.  A UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER AND DEVELOPS A CASE 
MANAGEMENT SYSTEM THAT ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.   
A.  Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B.  Case files include all relevant facts and information and justify the opening and closing of the cases. 
C.  Significant documents, such as charging documents and settlement agreements, are included in the file.  
D.  Interview summaries are written promptly, as defined by the Units policies and procedures. 
E.  The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
 
 
 
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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 number of cases criminally prosecuted by the Unit or referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending prosecutions. 
6.  The number of criminal convictions and the number of civil judgments. 
7.  The dollar amount of overpayments identified. 
8.  The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil judgments or prefiling settlements. 
8.  A UNIT COOPERATES WITH OIG AND OTHER FEDERAL AGENCIES IN THE INVESTIGATION AND 
PROSECUTION OF MEDICAID AND OTHER HEALTH CARE FRAUD.   
A.  The Unit communicates on a regular basis with OIG and other Federal agencies investigating or prosecuting 
health care fraud in the State. 
B.  The Unit cooperates and, as appropriate, coordinates with OIGs Office of Investigations and other Federal 
agencies on cases being pursued jointly, cases involving the same suspects or allegations, and cases that have 
been referred to the Unit by OIG or another Federal agency.  
C.  The Unit makes available, to the extent authorized by law and upon request by Federal investigators and 
prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the 
Medicaid program. 
D.  For cases that require the granting of extended jurisdiction to investigate Medicare or other Federal health 
care fraud, the Unit seeks permission from OIG or other relevant agencies under procedures as set by those 
agencies.  
E.  For cases that have civil fraud potential, the Unit investigates and prosecutes such cases under State 
authority or refers such cases to OIG or the U.S. Department of Justice. 
F.  The Unit transmits to OIG, for purposes of program exclusions under section 1128 of the Social Security Act, 
all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
G.  The Unit reports qualifying cases to the Healthcare Integrity & Protection Databank, the National Practitioner 
Data Bank, or successor data bases. 
9.  A UNIT MAKES STATUTORY OR PROGRAMMATIC RECOMMENDATIONS, WHEN WARRANTED, TO 
THE STATE GOVERNMENT.   
A.  The Unit, when warranted and appropriate, makes statutory recommendations to the State legislature to 
improve the operation of the Unit, including amendments to the enforcement provisions of the State code. 
B.  The Unit, when warranted and appropriate, makes other regulatory or administrative recommendations 
regarding program integrity issues to the State Medicaid agency and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State legislature and the State Medicaid or other 
agencies in response to recommendations.  
10.  A UNIT PERIODICALLY REVIEWS ITS MEMORANDUM OF UNDERSTANDING (MOU) WITH THE 
STATE MEDICAID AGENCY TO ENSURE THAT IT REFLECTS CURRENT PRACTICE, POLICY, AND 
LEGAL REQUIREMENTS.   
A.  The MFCU documents that it has reviewed the MOU at least every 5 years, and has renegotiated the MOU 
as necessary, to ensure that it reflects current practice, policy, and legal requirements. 
 
 
 
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B.  The MOU meets current Federal legal requirements as contained in law or regulation, including 42 CFR  
455.21, Cooperation with State Medicaid fraud control units, and 42 CFR  455.23, Suspension of payments 
in cases of fraud. 
C.  The MOU is consistent with current Federal and State policy, including any policies issued by OIG or the 
Centers for Medicare & Medicaid Services (CMS). 
D.  Consistent with Performance Standard 4, the MOU establishes a process to ensure the receipt of an 
adequate volume and quality of referrals to the Unit from the State Medicaid agency. 
E.  The MOU incorporates by reference the CMS Performance Standard for Referrals of Suspected Fraud from 
a State Agency to a Medicaid Fraud Control Unit. 
11.  A UNIT EXERCISES PROPER FISCAL CONTROL OVER UNIT RESOURCES.   
A.  The Unit promptly submits to OIG its preliminary budget estimates, proposed budget, and Federal financial 
expenditure reports.   
B.  The Unit maintains an equipment inventory that is updated regularly to reflect all property under the Units 
control. 
C.  The Unit maintains an effective time and attendance system and personnel activity records. 
D.  The Unit applies generally accepted accounting principles in its control of Unit funding. 
E.  The Unit employs a financial system in compliance with the standards for financial management systems 
contained in 45 CFR 92.20. 
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 
Colorado MFCU Referrals by Referral Source for FYs 2013 
Through 2015 
 
FY 2013  FY 2014  FY 2015 
Referral  Abuse &  Abuse &  Abuse & 
Fraud  Fraud  Fraud 
Source  Neglect1  Neglect  Neglect 
Medicaid 
agency    5  0  13  0  6  0 
PI/SURS2 
Medicaid 
20  0  2  0  3  0 
agency  other 
Managed care 
0  0    0  0  0 
organizations 
State survey 
and certification  0  6  1  1  6  0 
agency 
Other State 
5  0  0  0  2  0 
agencies 
Licensing board  0  0  0  0  0  0 
Law 
10  0  0  0  1  1 
enforcement 
Office of 
Inspector  3  1  1  0  9  0 
General 
Prosecutors  0  0  1  0  1  0 
Providers  6  0  1  0  0  0 
Provider 
0  0  0  0  0  0 
associations 
Private health 
0  0  0  0  0  0 
insurer 
Long-term-care 
0  0  0  0  0  0 
ombudsman 
Adult protective 
0  1  0  0  0  0 
services 
Private citizens  57  1  76  0  82  0 
MFCU hotline  0  0  0  0  0  0 
Self-generated  0  0  0  0  0  0 
Other  19  2  18  7  4  0 
   Total  125  11  113  8  114  1 
   Annual Total  136  121  115 
Source:  OIG analysis of Unit Quarterly and Annual Statistical Reports, FYs 2013-2015. 
1 The category of abuse & neglect referrals includes patient funds referrals. 
2 The abbreviation PI stands for program integrity; the abbreviation SURS stands for Surveillance and Utilization 
Review Subsystem. 
 
 
 
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APPENDIX C 
Point Estimates and 95-Percent Confidence Intervals Based on 
Reviews of Case Files 
95-Percent Confidence 
Sample  Point  Interval  
Estimate 
Size   Estimate 
Lower  Upper 
Percentage of cases open longer than 90 days 
that required periodic supervisory review but  71  46.5%28  35.7  57.7 
lacked documentation of such review 
Percentage of cases that contained 
99  100.0%  96.7%  100.0% 
documentation of supervisory approval to open  
Percentage of cases that contained 
89  100.0%  96.4%  100.0% 
documentation of supervisory approval to close 
Source:  OIG analysis of Colorado MFCU case files, 2016. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                        ____________________________________________________________ 
28 The actual percentage is 46.479, which rounds to 46 percent as a whole number and 
to 46.5 percent when rounding to one decimal place. 
 
 
 
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APPENDIX D 
Detailed Methodology 
Data collected from the seven sources below was used to describe the 
caseload and assess the performance of the Colorado MFCU. 
Data Collection  
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information regarding the Units investigation of Medicaid cases, 
including information about the number of referrals the Unit received, the 
number of investigations the Unit opened and closed, the outcomes of 
those investigations, and the Units case mix.  We also collected and 
analyzed information about the number of cases that the Unit referred for 
prosecution and the outcomes of those prosecutions.   
We gathered this information from several sources, including the Units 
quarterly statistical reports, annual reports, recertification questionnaire, 
policy and procedures manuals, and MOU with the State Medicaid agency.  
We requested any additional data or clarification from the Unit as 
necessary. 
Review of Unit Financial Documentation.  We reviewed the Units control 
over its fiscal resources to identify any issues involving internal controls 
or the use of resources.  Prior to the onsite review, we reviewed the Units 
financial policies and procedures; its response to an internal control 
questionnaire; and documents (such as financial status reports) related to 
MFCU grants. 
We reviewed three purposive samples to assess the Units internal control 
of fiscal resources.  All three samples were limited to the review period of 
FYs 2013 through FY 2015.  The three samples included the following: 
1.  To assess the Units expenditures, we selected a purposive sample 
of 24 items from the Units 1,585 non-payroll expenditure 
transactions.  We selected routine and nonroutine transactions 
representing a variety of budget categories and payment amounts. 
2.  To assess the Units travel expenditures, we selected a purposive 
sample of 24 items from the Units 228 travel transactions.  We 
selected a variety of travel expenditure categories related to both 
in-State and out-of-State travel, such as hotel stays, airfare, and 
conference expenses.   
3.  To assess employees time and efforti.e., their work hours 
spent on various MFCU taskswe selected a sample of three pay 
periods, one from each fiscal year.  We then requested and 
 
 
 
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reviewed documentation to support the time and effort of the 
MFCU staff during the selected pay periods. 
We also reviewed a purposive sample of the Units equipment inventory.  
For this review, we selected and verified a purposive sample of 25 items 
from the current inventory list of 95 items maintained in the Units office.  
Interviews with Key Stakeholders.  In September and October 2016, we 
interviewed key stakeholders, including officials in the U.S. Attorneys 
Office and State agencies that interact with the Unit, including the Colorado 
Department of Health and Environment and Medicaid Program Integrity.  
We also interviewed supervisors from OIGs Region VII office who work 
regularly with the Unit.  We focused these interviews on the Units 
relationship and interaction with OIG and other Federal and State 
authorities, and we identified opportunities for improvement.  We used the 
information collected from these interviews to develop subsequent interview 
questions for Unit management. 
Survey of Unit Staff.  In September 2016, we conducted an online survey 
of all 11 nonmanagerial Unit staff within each professional discipline 
(i.e., investigators, auditors, attorneys, analysts, and nurse investigators) as 
well as support staff.  Our questions focused on Unit operations, 
opportunities for improvement, and practices that contributed to the 
effectiveness and efficiency of Unit operations and/or performance.  The 
survey also sought information about the Units compliance with 
applicable laws and regulations.   
Onsite Interviews with Unit Management.  We conducted structured onsite 
interviews with the Units management in October 2016.  We interviewed 
the Unit Director, Supervising Investigator, two Assistant Attorneys 
General, Audit Manager, Nurse Analyst, and Administrative Manager.  We 
also interviewed the Chief Section Counsel who supervises the Unit 
director.  The Chief Section Counsel served as interim Unit director for 
approximately 7 months until the new director was hired in September 
2016.  We asked these individuals to provide information 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, and  
(4) clarification regarding information obtained from other data sources. 
Onsite Review of Case Files and Other Documentation.  We requested that 
the Unit provide us with a list of cases that were open at any time during 
FYs 2013 through 2015.  We requested data on the 673 cases that 
included, but was not limited to, the current status of the case; whether the 
 
 
 
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case was criminal, civil, or global; and the date on which the case was 
opened.  Because global cases are civil false claims actions that typically 
involve multiple agencies, such as the U.S. Department of Justice and a 
group of State MFCUs, we excluded all of those cases from our review of 
a Units case files.  Therefore, we excluded 342 cases categorized as 
global from the list of cases.  The remaining number of case files was 
331.   
We then selected a simple random sample of 100 cases from the 
population of 331 cases.  From this initial sample of 100 case files, we 
selected a further simple random sample of 50 files for a more in-depth, 
qualitative review of selected issues, such as the timeliness of 
investigations and case development.  While onsite, we consulted MFCU 
staff to address any apparent issues with individual case files, such as 
missing documentation.  We did not estimate any population or 
subpopulation proportions from this additional sample of 50 case files.   
Onsite Review of Unit Operations.  During our October 2016 onsite visit, 
we reviewed the Units workspace and operations.  To conduct this 
review, we visited the Unit headquarters in Denver, Colorado.  While 
onsite, we observed the Units offices and meeting spaces, security of data 
and case files, location of select equipment, and the general functioning of 
the Unit. 
Data Analysis 
We analyzed data to identify any opportunities for improvement and 
instances in which the Unit did not fully meet the performance standards 
or was not operating in accordance with laws, regulations, or policy 
transmittals.29 
                        ____________________________________________________________ 
29 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
 
 
 
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APPENDIX E 
Unit Comments  
 
 
 
 
 
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Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  24
 
   
   
   
 
 
 
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ACKNOWLEDGMENTS 
Ben Gaddis served as the team leader for this study.  Office of Evaluation 
and Inspections staff who conducted the review include 
Anthony Soto McGrath.  Medicaid Fraud Policy and Oversight Division 
staff who participated in the review include Susan Burbach.  Office of 
Investigations staff also participated in the review.  Central office staff 
who contributed to this review include Kevin Farber and Christine Moritz.   
This report was prepared under the direction of Ruth Ann Dorrill, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office, and Deputy Regional Inspectors General, Amy Ashcraft 
and Petra Nealy; and in consultation with Richard Stern, Director of the 
Medicaid Fraud Policy and Oversight Division.  
 
 
 
 
 
 
 
Colorado State Medicaid Fraud Control Unit:  2016 Onsite Review (OEI-06-16-00520)  26
 
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.