Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
N   S M F
EVADA  TATE  EDICAID  RAUD 
 
C U :  
  ONTROL  NIT  
 
2012 O R  
  NSITE  EVIEW 
 
Stuart Wright  
Deputy Inspector General for 
Evaluation and Inspections 
 
September 2013 
OEI-09-12-00450   
   
NEVADA STATE MEDICAID FRAUD CONTROL UNIT:  
2012 ONSITE REVIEW 
OEI-09-12-00450 
 
WHY WE DID THIS STUDY 
The Office of Inspector General (OIG) oversees all State Medicaid Fraud Control Units 

(MFCU or Unit) with respect to Federal grant compliance.  As part of this oversight, 

OIG annually reviews and certifies all Units.  In addition, OIG conducts onsite reviews of 

selected States. These reviews assess Unit performance in accordance with the 12 MFCU 

performance standards and monitor Unit compliance with Federal grant requirements,
  
laws, and regulations. 

 
HOW WE DID THIS STUDY  
We analyzed data from seven sources:  (1) a review of documentation, policies, and 
procedures related to the Units operations, staffing, and caseload; (2) a review of 
financial documentation; (3) structured interviews with key stakeholders; (4) a survey of 
Unit staff; (5) structured interviews with the Units management and selected staff; (6) an 
onsite review of case files; and (7) an onsite review of Unit operations. 
 
WHAT WE FOUND 
From fiscal years 2009 through 2011, the Unit reported recoveries of $13.4 million, Unit 
convictions increased, and the Unit opened 262 cases.  All reviewed case files contained 
documentation indicating supervisory approval to open and close cases, and we found 
that almost all case files contained documentation indicating periodic supervisory 
reviews. Unit professional staff occasionally performed non-Unit duties, however.  In  
addition, the Units policies and procedures manual and its memorandum of 
understanding (MOU) with Nevadas State Medicaid agencythe Division of Health 
Care Financing and Policy (DHCFP)were not updated, and the Unit did not always 
comply with the MOU provisions.  The Unit maintained proper fiscal control of its 
resources, but incorrectly claimed indirect costs.  Except for the use of Unit professional 
staff for non-Unit duties, an MOU stipulation that the Unit assist DHCFP in obtaining 
funding for data requests, and the overclaiming of indirect costs, we found no evidence of 
noncompliance with applicable laws, regulations, and policy transmittals.  
 
WHAT WE RECOMMEND 
We recommend that the Nevada Unit (1) ensure that Unit professional staff exclusively 
perform Unit duties, (2) revise its policies and procedures manual, (3) revise its MOU 
with DHCFP, (4) comply with the MOU provisions, and (5) ensure that it correctly 
claims indirect costs.  In its written comments to our draft report, the Unit did not indicate 
whether it concurred with each of the recommendations.  However, the Unit described 
actions that it has taken, or plans to take, to address each of the recommendations  
 
 
 
 
   
TABLE OF CONTENTS 
Objective......................................................................................................1 

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

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

Findings........................................................................................................7 

From FY 2009 through FY 2011, the Unit reported recoveries       

of $13.4 million, Unit convictions increased, and the Unit     

opened 262 cases..............................................................................7 

All reviewed case files contained documentation indicating 

supervisory approval to open and close cases and almost all      

case files contained documentation indicating periodic     

supervisory reviews .........................................................................8 

Unit professional staff performed non-Unit duties and the 

associated costs were not subtracted from claimed Unit 

expenditures .....................................................................................9 

The Units policies and procedures manual was not updated,      

and the Units MOU with DHCFP did not reflect current law     

and practice ......................................................................................9 

The Unit did not always comply with the MOU provisions ..........11  

The Unit maintained proper fiscal control of its resources, but     

incorrectly claimed indirect costs ..................................................11
  
Other Observation:  Provider Outreach and Train the Trainer 

Programs ........................................................................................12 

Conclusion and Recommendations ............................................................13 

Unit Comments and Office of Inspector General Response ..........15 

Appendixes ................................................................................................16 

A: Performance Standards for Medicaid Fraud Control Units .....16 

B: Referrals of Provider Fraud and Patient Abuse and Neglect     

to the Nevada Medicaid Fraud Control Unit by Source, Fiscal    

Years 2009 Through 2011 ..............................................................21 

C: Investigations Opened and Closed by Provider Category       

and Case Type, Fiscal Years 2009 Through 2011 ..........................22 

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

Confidence Interval Estimates .......................................................24 

E: Unit Comments.........................................................................26 

Acknowledgments......................................................................................28 

 
 
   
   
 
OBJECTIVE 
To conduct an onsite review of the Nevada State Medicaid Fraud Control 
Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse and 
neglect under State law.1  Pursuant to Title XIX of the SSA, each State 
must maintain a certified Unit unless the Secretary of Health and Human 
Services (HHS) determines that operation of a Unit would not be 
cost-effective because (1) minimal Medicaid fraud exists in that State; and  
(2) the State has other, adequate safeguards to protect Medicaid 
beneficiaries from abuse and neglect.2   Currently, 49 States and the 
District of Columbia (States) have created such Units.3 In fiscal year 
(FY) 2012, combined Federal and State grant expenditures for the Units 
totaled $217.3 million, of which Federal funds represented 
$162.9 million.4   That year, the 50 Units employed 1,901 individuals.5  
Each Unit must employ an interdisciplinary staff that consists of at least an  
investigator, an auditor, and an attorney to carry out its duties and 
responsibilities in an effective and efficient manner.6  The staff reviews 
complaints provided by the State Medicaid agency and other sources and 
determines their potential for criminal prosecution and/or civil action.  
Collectively, in FY 2012, the 50 Units reported 1,337 convictions and 
823 civil settlements or judgments. That year, the Units reported 
recoveries of approximately $2.9 billion.7  
 
1 Social Security Act (SSA)  1903(q).  

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

responsibilities may include reviewing complaints of misappropriation of patients 

private funds in  residential health care facilities. 

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

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

4 All FY references in this report are based on the Federal FY (October 1  through 
 
September 30). 
 
5  Office of  Inspector General (OIG),  State Medicaid Fraud Control Units  Fiscal Year 

2012  Grant Expenditures and Statistics. Accessed at http://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/  on March 19, 2013. 

6 SSA  1903(q)(6) and 42 CFR  1007.13. 
 
7 OIG,  State Medicaid Fraud Control Units  Fiscal Year 2012 Grant Expenditures and 

Statistics. Pursuant to  42 CFR  1007.17, Units report the total amount  of recovered 

funds in their annual reports to  OIG.  

Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  1  
   
   
Units are required to have either statewide authority to prosecute cases or 
formal procedures to refer suspected criminal violations to an office with 
such authority.8  In Nevada and 43 other States, the Units are located with  
offices of State Attorneys General that have this authority.  In the 
remaining six States, the Units are located in other State agencies;9  
generally, such Units must refer cases to offices with prosecutorial 
authority. Additionally, each Unit must be a single, identifiable entity of 
State government, distinct from the State Medicaid agency, and each Unit 
must develop a formal agreemente.g., a memorandum of understanding 
(MOU)that describes the Units relationship with that agency.10   
Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to both annually 
certify the Units and administer grant awards to reimburse States for a 
percentage of their costs of operating them.11 All Units are currently funded 
by the Federal Government on a 75-percent matching basis, with the States 
contributing the remaining 25 percent.12   To receive Federal reimbursement, 
each Unit must submit an initial application to OIG.13  OIG reviews the 
application and notifies the Unit if it is approved and the Unit is certified.  
Approval and certification are valid for a 1-year period; the Unit must be 
recertified each year thereafter.14    
Pursuant to Title XIX of the SSA, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.15   OIG 
developed and issued 12 performance standards to define the criteria that 
OIG applies in assessing whether a Unit is effectively carrying out statutory 
functions and meeting program requirements.16  Examples include 
maintaining an adequate caseload through referrals from several sources, 
maintaining an annual training plan for all three of the professional 
 
8  SSA  1903(q)(1). 
 
9 In States with  a Unit, the Unit shares responsibility for protecting the integrity of the 

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

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

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

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

Federal Financial Participation.  

12  SSA  1903(a)(6)(B). 
  
13 42 CFR   1007.15(a). 

14 42 CFR   1007.15(b) and  (c). 

15  SSA  1902(a)(61). 
 
16 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov  on 
 
November 22, 2011.  Prior to  the time of our onsite data collection (JulyAugust 2012), 

OIG  published a revision  of the performance standards, 77 Fed. Reg.  32645 

(June 1, 2012).  The performance standards referred to in this report are from 1994 and 

were in effect during the time of  our  review  period (FYs 2009 through 2011). 

Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  2  
   
   
disciplines (i.e., for auditors, investigators, and attorneys), and establishing  
policy and procedures manuals to reflect the Units operations.  See 
Appendix A for a complete list of the performance standards.  
Nevada Unit  
The Unit is an autonomous entity within the Bureau of Criminal Justice of 
the Nevada Office of the Attorney General and has the authority to 
prosecute Medicaid fraud and patient abuse and neglect cases.  At the time 
of our review, the Units 18 employees were divided between 2 offices.  
The Unit Director and 11 additional employees were located at the Units 
South office in Las Vegas. The Chief Investigator and five additional 
employees were located at the Units North office in the State capital of  
Carson City. The Unit Director directly supervises all South office 
employees, supervises the Chief Investigator, and acts as the Chief 
Attorney. The Chief Investigator directly supervises all North office 
employees. 
The Unit receives referrals of provider fraud from the State Medicaid 
agencythe Nevada Division of Health Care Financing and Policy 
(DHCFP)and from Federal agencies, such as OIG.  The Unit receives 
referrals of patient abuse and neglect from the Nevada Bureau of Health 
Care Quality and Compliance (BHQC) and the Nevada Aging and 
Disability Services Division.  In addition, the Unit receives referrals from  
other State and local agencies, from the public through a Medicaid Fraud 
Report hotline, and from an electronic form available on the Nevada 
Attorney Generals Web site. 17   For additional information on Unit 
referrals, see Appendix B. 
Upon receipt of a referral, Unit administrative assistants enter the referral 
and related information into the Units case file tracking system.  On a 
biweekly basis, the Units Director, Chief Investigator, and a Unit attorney  
screen these referrals and decide whether to proceed with the 
investigations or refer the cases to another agency.  For additional 
information on the Units opened and closed investigations, including a 
breakdown by case type and provider category, see Appendix C. 
The Unit Director assigns an investigator and attorney to cases that are 
accepted for investigation; the assigned investigator and attorney then 
meet to plan the case strategy.  The Unit may open a case and pursue it 
through a variety of actions, including criminal prosecution, civil action, 
or a combination of the two.  The Unit may close a case for a variety of 
reasons, including, but not limited to, resolving it through criminal and/or 
civil action or referring it to another agency.   
 
17 The Unit will occasionally open cases that were not formally referred by an outside 
source. For example, a case may be brought to the Units attention  by the media.  
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  3  
   
   
Previous Review  
In 2007, OIG conducted an onsite review of the Nevada Unit and found it 
to be in general compliance with all applicable Federal rules and 
regulations. However, the review identified a concern related to the use  
of MFCU grant funds to pay the salaries of two non-MFCU personnel.  
The Unit subsequently reimbursed the Federal government for the related 
unallowable costs.18    
METHODOLOGY 
We analyzed data from seven sources:  (1) a review of documentation, 
policies, and procedures related to the Units operations, staffing, and 
caseload for FYs 2009 through 2011; (2) a review of financial 
documentation for FYs 2009 through 2011; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with 
the Units management and selected staff; (6) an onsite review of case 
files that were open in FYs 2009 through 2011; and (7) an onsite review of 
Unit operations. 
We analyzed data from all seven sources to describe the caseload and 
assess the performance of the Unit.  We also analyzed the data to identify 
any opportunities for improvement and any instances in which the Unit 
did not meet the performance standards or was not operating in 
accordance with laws, regulations, and policy transmittals.19 In addition, 
we noted any practices that appeared  to benefit the Unit.  We based these 
observations on statements from Unit staff, data analysis, and our own 
judgment.  We did not independently verify the effectiveness of these 
practices, but included the information because it may be useful to other 
Units in their operations. 
We conducted the onsite review in JulyAugust 2012. 
Data Collection and Analysis 
Review of Unit Documentation.  We reviewed documentation, policies, 
and procedures related to the Units operations, staffing, and cases, 
including its annual reports, quarterly statistical reports, and responses to 
recertification questionnaires.  We reviewed this documentation to 
determine how the Unit investigates and prosecutes Medicaid cases.  Data 
collected included information such as the number of referrals received by 
the Unit and the number of investigations opened and closed.   
 
18 This 2012  onsite review of the Unit found  no indication that this issue persisted.  
19 All relevant  regulations, statutes, and  policy transmittals are available online at 
http://oig.hhs.gov. 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  4  
   
   
Review of Financial Documentation. To evaluate internal controls of 
fiscal resources, OIG auditors reviewed policies and procedures related to 
the Units budgeting, accounting systems, cash management, procurement, 
property, and personnel. We obtained from the Unit its claimed grant 
expenditures for FYs 2009 through 2011 to (1) review final Federal Status 
Reports20 and supporting documentation, (2) select and review transactions 
within direct cost categories to determine if costs were allowable, and 
(3) verify that indirect costs were accurately computed using the approved 
indirect cost rate. Finally, we reviewed records in the HHS Payment 
Management System (PMS)21 and revenue accounts to identify any 
unreported program income.22    
Interviews With Key Stakeholders.  We conducted structured interviews 
with nine individual stakeholders among five agencies who were familiar 
with Unit operations. Specifically, we interviewed DHCFPs Surveillance  
Utilization Review System (SURS) Manager; the BHQCs Facilities 
Inspection Manager; the BHQCs Long-Term Care Ombudsman; two 
Assistant U.S. Attorneys based in Las Vegas; the Nevada Attorney 
Generals Chief of Staff; the Nevada Attorney Generals First Assistant;23  
an OIG Special Agent based in Las Vegas; and an OIG Assistant Special 
Agent in Charge for the State of Nevada. These interviews focused on the 
Units interaction with external agencies, Unit operations, opportunities 
for improvement, and any practices that appeared to benefit the Unit and 
that may be useful to other Units in their operations. 
Survey of Unit Staff. We conducted an electronic survey of Unit staff.24   
We requested and received responses from 15 nonmanagerial staff 
members, for a 100-percent response rate.25 Our questions focused on 
operations of the Unit, opportunities for improvement, and practices that 
appeared to benefit the Unit and that may be useful to other Units in their 
 
20 The Unit transmits financial status reports to OIGs Office of Management and Policy 
(OMP) on a quarterly and annual basis.  These reports detail Unit income and  
expenditures.  
21 The PMS is a grant payment system operated and maintained  by the HHS Program  
Support Center, Division  of Payment Management.  The PMS provides  disbursement, 
grant monitoring, reporting, and cash management services to awarding agencies and 
grant recipients, such as Units. 
22 Program income is defined as gross income received by the grantee or subgrantee 
directly generated by a grant supported activity, or earned only as a result of the grant 
agreement during the grant period.  45 CFR   92.25(b). 
23 The Attorney Generals Chief of  Staff and  First Assistant supervise the Unit Director. 
24 We did not survey one of the  Units nonmanagerial auditors because we interviewed 
that auditor onsite. 
25 This report uses the terms management and supervisors interchangeably.  Non-
management employees are  Unit staff members who have  no supervisory authority. 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  5  
   
   
operations. The survey also sought information about the Units 
compliance with applicable laws, regulations, and policy transmittals.   
Interviews With Unit Management and Selected Staff. We conducted 
structured interviews with the Units Director (Chief Attorney), Chief 
Investigator, and an auditor. We asked them to provide us with additional 
information necessary to better understand the Units operations, identify 
opportunities for improvement, identify practices that appeared to benefit 
the Unit and that may be useful to other Units in their operations, and 
clarify information obtained from other data sources.  
Onsite Review of Case Files.  We selected a simple random sample of 
80 case files from the 262 cases26  that were open at any point from  
FY 2009 through FY 2011. The design of this sample allowed us to 
estimate the percentage of all 262 cases with various characteristics at the 
95-percent confidence level. We reviewed these 80 sampled case files and 
the Units processes for monitoring the status and outcomes of cases.  
From these 80 case files, we selected another simple random sample of 
45 for a more in-depth review of potential issues.  This second-phase 
sample allowed us to conduct a more comprehensive review of case files 
to identify other potential issues from a qualitative perspective.  For 
population and sample size counts, as well as confidence interval 
estimates, see Appendix D. 
Onsite Review of Unit Operations. While onsite, we reviewed the Units 
operations. Specifically, we observed intake of referrals, data analysis 
operations, security of data and case files, and the general functioning of 
the Unit. 
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.27  
 
26 This  figure includes cases opened before FY  2009 that  remained open at some point  
during FYs 20092011. 

27 Full text  of these standards is available online at http://www.ignet.gov/pande/ 

standards/oeistds11.pdf. 

Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  6  
   
   
FINDINGS 
From FY 2009 through FY 2011, the Unit reported 
recoveries of $13.4 million, Unit convictions 
increased, and the Unit opened 262 cases 
From FY 2009 through FY 2011, the Unit reported total criminal and civil 
recoveries of $13.4 millionan annual average of $4.5 million (see 
Table 1). Of the $13.4 million in recoveries, the Unit attributed 
$12.6 million to civil recoveries and $766,000 to criminal recoveries.  
Global28 case judgments and settlements accounted for $10.7 million of 
the total civil recoveries and global cases accounted for 190 of the Units 
262 cases over the 3-year period. The Units annual average expenditures 
for FYs 2009 through 2011 were $1.6 million.29    
Table 1: Nevada Unit Reported Recovered Funds, FYs 2009 Through 2011  
3-Year  Annual  
FY 2009   FY 2010   FY 2011  
  Total   Average 
Reported Criminal 
$4,675   $119,814   $641,552   $766,041   $255,347  
Recoveries 
Global 
$5,557,737  $2,494,568   $2,619,011   $10,671,316   $3,557,105  
Recoveries 
Non-Global Civil 
$50,000   $1,226,788   $688,138   $1,964,926   $654,975  
Recoveries 
Total Reported  
$5,612,412  $3,841,170   $3,948,701   $13,402,283   $4,467,427  
Recoveries  
Total  
$1,549,762   $1,603,654   $1,721,663   $4,875,079   $1,625,026  
Expenditures 
Source:  Data provided by the Unit to OIG.  
 
 
From FY 2009 through FY 2011, Unit convictions increased  
From FY 2009 through FY 2011, the Unit obtained 27 convictions and 
reported 37 civil judgments and settlementsan annual average of 
9 convictions and 12.3 civil judgments and settlements (see Table 2).   
   
 
28 Unit-reported recoveries include funds recovered  from  multi-State, or global, civil 
false claims cases, both those  worked directly by the Unit and those worked  by staff from 
other Units.   
29 The figures presented in this  paragraph are rounded.  
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  7  
   
   
Table 2: Unit Convictions and Civil Judgments and/or Settlements, 
FYs 2009 Through 201130  
3-Year  Annual  
FY 2009   FY 2010   FY 2011  
  Total   Average 
Convictions  1  7  19  27  9 
Civil Judgments and/or Settlements  12  17  8  37  12.3 
Source:  Data provided by the Unit to OIG.  
 
The Units convictions increased during the review periodfrom 1 in 
FY 2009 to 19 in FY 2011. 
From FY 2009 through FY 2011, the Unit opened 262 cases  
From FYs 2009 through 2011, the Unit opened an average of 87 cases 
annually, with an average of 83 cases of provider fraud and 4 cases of 
patient abuse and neglect. From  FYs 2009 through 2011, the Unit closed 
an average of 55 cases annually, averaging 52 cases of provider fraud and 
3 cases of patient abuse and neglect.31  From FYs 2009 through 2011, the 
Unit received an average of 98 referrals annually, with an average of 
72 referrals of provider fraud and 26 referrals of patient abuse and neglect. 
All reviewed case files contained documentation 
indicating supervisory approval to open and close 
cases and almost all case files contained 
documentation indicating periodic supervisory 
reviews  
According to Performance Standard 6(b), Unit supervisors should approve 
the opening and closing of cases to ensure a continuous case flow and the 
timely completion of cases.  Supervisory approval to open and close cases 
demonstrates that Unit supervisors are monitoring the intake of cases and  
the timeliness of case resolutions.  Based on our review of 80 case files, 
the Unit documented supervisory approval to both open and close cases in 
all of the case files.  
According to Performance Standard 6(c), supervisory reviews should be 
conducted periodically and noted in the case file to ensure timely case 
completion.32  Based on our review of 80 case files, 98 percent of Unit 
case files contained documentation indicating periodic supervisory 
reviews. 
 
30 Civil Judgments and/or Settlements include those received from global cases.   

31 Closures include multiple cases opened before FY 2009. 

32 For the purposes of this report, supervisory approval to  open and close a case does not 
 
constitute a supervisory review.  Periodic supervisory review indicates that a supervisor  

reviewed a case more than once between the cases opening and closing. 

Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  8  
   
   
Unit professional staff performed non-Unit duties and 
the associated costs were not subtracted from  
claimed Unit expenditures 
According to Performance Standard 1(a), Unit professional staff must 
consist of permanent employees working full-time on Medicaid fraud and 
patient abuse matters.33  In addition, pursuant to Federal regulations,  a 
Unit may claim Federal reimbursement only for costs attributable to the 
establishment and operation of the Unit.34 During the review period, Unit 
professional staff occasionally served warrants for other Nevada Attorney 
General components.  In addition, Unit professional staff performed peace 
officer duties outside of the Unit for approximately one day per month.  
These activities were not attributable to the investigation and prosecution 
of Medicaid fraud or of patient abuse and neglect.  Costs not associated 
with the establishment or operation of the Unit are not subject to Federal 
reimbursement.  
The Units policies and procedures manual was not 
updated, and the Units  MOU with DHCFP did not 
reflect current law and practice 
The Units policies and procedures manual was last updated in 2006. This 
manual did not contain policies and procedures to address certain Unit 
operations or financial oversight. In addition, the Units June 2009 
MOU with DHCFP  includes a provision that may allow the Unit to be 
charged for data requests made to SURS.35 That MOU also was not 
updated to include a provision describing the referral process between the 
Unit and DHCFP for providers who are subject to a payment suspension 
on the basis of a credible allegation of fraud.36 
 
The Units policies and procedures manual was not updated to 
reflect current Unit operations 
 
33 Professional staff includes attorneys, investigators, auditors, and managers.  

OIG Policy Transmittal 89-1. 

34 42 CFR   1007.19(d). 

35  Memorandum  of Understanding between the Nevada Office of Attorney General and  
the Division  of  Health Care Financing and Policy of the Nevada  Department of  Health  
and Human Services,  1. 
36 The Affordable Care  Act,   6402(h)(2), requires State Medicaid programs, as a 
condition of receiving FFP, to suspend payments to providers for whom there is a 
credible allegation  of fraud, unless good cause exists to  not suspend payments.  One way  
to establish good cause is for the MFCU to inform the Medicaid agency that the 
suspension would compromise or  jeopardize its investigation of the provider.  CMS and  
OIG implemented this provision in  revisions to 42 CFR   455.23 and 1007.9(e) 
effective March 25, 2011 (76 Fed.  Reg. 5862). 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  9  
   
   
According to Performance Standard 3, a Unit should establish policies and  
procedures for its operations, which should be included in a manual.  
However, the Units manual was not updated to include policies and 
procedures for various current Unit operations, such as provider training 
and field projects.37  In addition, the Unit did not have policies and 
procedures for ensuring that indirect costs are claimed accurately.   
Since our onsite review, the Unit provided OIG with a draft of a revised 
policies and procedure manual that comprehensively addresses Unit 
operations, including provider training and field projects.  
The Units MOU with DHCFP did not reflect current law and 
practice 
According to Performance Standard 10, Units should periodically review  
their MOUs with the State Medicaid agency to ensure that the MOUs reflect 
current law and practice.  As required by Federal regulations, 38 the Unit had 
an MOU with DHCFP.  In the MOU, DHCFP must agree to comply with 
42 CFR  455.21, which includes a requirement to provide the Unit with 
access to, and free copies of, any records or information kept by the agency 
or its contractors.39  However, the MOU includes a provision that the 
MFCU agrees to assist SURS in obtaining any additional funding that may 
be necessary to comply with requests from [the] MFCU.40   This provision 
could allow the Unit to be charged for data requests made to SURS, which 
would be inconsistent with Federal regulations.  However, the Unit Director 
reported that the Unit has never been asked by SURS to assist in obtaining 
additional funding for data requests.  
 
In addition, the MOU that was in effect during the review period was  not  
updated to include a provision describing the referral process between the 
Unit and DHCFP for providers who are subject to a payment suspension 
on the basis of a credible allegation of  fraud.  During our onsite review, we  
received an updated MOU from the Unit Director that includes provisions 
for suspending provider payments based on a credible allegation of fraud.  
The updated MOU was dated March 2012.    
 
 
 
37 The term field projects refers to a variety of informal actions taken by  Unit 
 
investigators to gather information on providers that may be useful at a later date. 
 
38  42 CFR  1007.9(d).  

39 42 CFR   455.21(a)(2)(i) and 1007.9(d). 

40  Memorandum  of Understanding between the Nevada Office of Attorney General and  
the Division  of  Health Care Financing and Policy of the Nevada  Department of  Health  
and Human Services,  1. 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  10  
   
   
The Unit did not always comply with the MOU 
provisions  
Pursuant to the Units MOU with DHCFP, the Unit will, on a monthly 
basis, inform SURS of all providers it has under investigation, all cases it 
has settled or closed, and [provide] copies of all supporting documentation 
of any settlement agreements reached and/or money collected.41 Pursuant 
to Federal regulations, State Medicaid agencies must report this 
information to HHS at prescribed intervals. 42  The DHCFPs MOU with 
the Unit was structured to ensure that SURS received the pertinent Unit 
case information monthly for this reporting purpose.  However, DHCFP 
staff indicated that the Unit did not always comply with the provisions 
during the review period. Consequently, DHCFP was unable to provide 
the required Unit case information to HHS in a timely manner.   
The Unit maintained proper fiscal control of its 
resources, but incorrectly claimed indirect costs 
According to Performance Standard 11, the Unit Director should exercise 
proper fiscal control over the Units resources.  Control includes 
maintaining an equipment inventory, using generally accepted accounting 
principles, properly reporting program income, and conducting proper 
reporting between the Unit and its State parent agency.  From  
FY 2009 through FY 2011, the Unit reported program income in 
accordance with applicable Federal requirements and maintained adequate 
internal controls related to accounting, budgeting, personnel, procurement, 
property, and equipment.  In addition, most of the expenditures that the 
Unit claimed represented allowable costs in accordance with applicable 
Federal requirements.   
Although the Unit maintained proper fiscal control of its resources, it 
incorrectly claimed its indirect costs.  The Unit claimed indirect costs that 
differed from the amounts approved in the States cost allocation plans.   
Specifically, the Unit either omitted or added a fiscal quarter of approved 
costs during each year of the review period.  As a result, the Unit 
underclaimed indirect costs in FY 2009 and FY 2010, but overclaimed 
indirect costs in FY 2011. 
Units claim indirect costs to fund general operations, such as 
administration; these costs are not attributable to specific purchases or to 
other direct costs. Pursuant to Federal regulations,43 a cost allocation 
 
41  Memorandum  of Understanding between the Nevada Office of Attorney General and  
the Division  of  Health Care Financing and Policy of the Nevada  Department of  Health  
and Human Services,  11. 
42 42 CFR   455.17. 
43 2 CFR pt. 225, Appendixes A and C. 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  11  
   
   
plan identifies and allocates billing rates based on allowable costs of  
services provided by, or for, State agencies, such as Units.  Each State 
must submit an approved cost allocation plan to HHS for each year in 
which it claims such costs under Federal awards.  These costs are 
reimbursed by the Federal government to its benefitting State agencies.  
Costs omitted from these plans are not reimbursable.44  
Other Observation:  Provider Outreach and Train the 
Trainer Programs 
According to Performance Standard 4, a Unit should take steps to ensure 
that it maintains an adequate workload through referrals from the single 
State agency and other sources.  The Units outreach program consists of  
educational classes taught by Unit presenters to describe the various types 
of fraud and abuse/neglect, discuss Federal and State laws regarding fraud 
and abuse/neglect, and provide Unit contact information for the reporting 
of Medicaid-related crime.  
Unit management and staff highlighted the Units Train the Trainer 
program as being instrumental to the success of the provider outreach 
program.  Train the Trainer is a PowerPoint presentation given to Unit 
investigators who are scheduled to teach the provider education classes.  
This presentation helps to ensure that the classes are uniformly taught, that 
all pertinent information is imparted to providers, and that Unit 
investigators become skilled presenters.  
 
44 Pursuant to Federal  regulations, a grantee (such as a Unit)  should charge only those  
costs incurred during the specific funding period.  45 CFR   92.23(a).  
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  12  
   
   
CONCLUSION AND RECOMMENDATIONS 
From FY 2009 through FY 2011, the Unit reported recoveries of 
$13.4 million, and opened 262 cases.  Unit convictions increased during 
the review period. All reviewed case files contained documentation 
indicating supervisory approval to open and close cases and almost all 
case files contained documentation indicating periodic supervisory 
reviews. The Unit also exercised proper fiscal control over its resources. 
Finally, the Unit took steps to educate providers about fraud through a 
provider outreach programs.    
Additional opportunities for improvement exist.  Specifically, Unit 
professional staff performed non-Unit duties, contrary to Federal 
regulations. The Units policies and procedures manual had not been 
updated to reflect current Unit operations.  The Units MOU with DHCFP 
allowed for the Unit to be charged by DHCFP for data requests, contrary 
to Federal regulations. The Unit also did not always comply with the 
MOU terms.  Finally, the Unit incorrectly claimed indirect costs.  With the 
exceptions of the use of Unit professional staff for non-Unit duties and an 
MOU stipulation that the Unit agreed to help DHCFP obtain funding for 
data requests, we found no evidence of noncompliance with applicable 
laws, regulations, and policy transmittals. 
We recommend that the Nevada Unit: 
Ensure That Unit Professional Staff Perform Duties Exclusively 
Related to Unit Operations 
The Unit should ensure that professional staff are full-time employees who 
work on duties exclusively related to the operation of the Unit.  In 
addition, the Unit should work with OIGs Office of Management and 
Policy (OMP) to determine the extent to which the Unit should reimburse 
OIG the Federal share of unallowable personnel costs related to non-Unit 
duties.  
Revise Its Policies and Procedures Manual To Reflect Current 
Unit Operations  
The Unit should regularly update its policies and procedures manual to 
reflect current Unit operations. The Unit should develop and incorporate a 
procedure for ensuring that indirect costs are claimed correctly.  
Revise Its MOU With DHCFP To Reflect Current Law and 
Practice 
The Unit should revise its MOU with DHCFP to remove the stipulation 
that the Unit agrees to assist DHCFP in obtaining funding for data 
requests.  
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  13  
   
   
 
Ensure That DHCFP Consistently Receives Unit Case 
Information in a Timely Manner 
The Unit should provide case information to DHCFP on a monthly basis 
so that DHCFP can fulfill its reporting requirements to HHS. 
Ensure That Indirect Costs Are Claimed Correctly  
The Unit should work with OMP to ensure that it correctly claims indirect 
costs on its cost allocation plan assessments.  The Unit should also work 
with OMP to determine whether it should reimburse indirect costs that 
were incorrectly claimed during the review period. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  14  
   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
In written comments to our draft report, the Unit did not indicate whether 
it concurred with each of the recommendations.  However, the Units  
comments described the following actions that it has taken, or plans to 
take, to address each of the recommendations.  In its final management 
letter, the Unit should clarify whether it concurs with the 
recommendations.  
Regarding our first recommendation, the Unit has ceased the 
once-a-month rotational desk duty that is unrelated to MFCU operations 
and is working with the OIG OMP to determine the extent to which the 
Unit should reimburse OIG for unallowable personnel costs.  The Unit did 
not comment specifically on the other activity identified in our finding, 
relating to the execution of search warrants. 
Regarding our second recommendation, the Unit will periodically review 
its policies and procedures manual to ensure that it reflects current Unit 
operations. 
Regarding our third recommendation, the Unit is working with DHCFP to 
revise its MOU to reflect current law and practice.  
Regarding our fourth recommendation, the Unit has incorporated 
measures to ensure that DHCFP receives Unit case information in a 
timely manner.  
Regarding our fifth recommendation, the Unit is working with OMP to 
ensure that indirect costs are claimed accurately and to determine whether 
the Unit should reimburse indirect costs that were incorrectly claimed 
during the review period. 
The full text of the Units comments is provided in Appendix E.  We did 
not make any changes to the report as a result of the Units comments. 
 
 
 
 
 
 
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  15  
   
   
 
 
APPENDIX A 
Performance Standards for Medicaid Fraud Control Units 
(Unit)45   
1. 	A Unit will be in conformance with all applicable statutes, 
regulations and policy transmittals.  In meeting this standard, the 
Unit must meet, but is not limited to, the following requirements:  
a. 	  The Unit professional staff must consist of permanent employees 
working full-time on Medicaid fraud and patient abuse matters. 
b. 	  The Unit must be separate and distinct from the single State 
Medicaid agency. 
c. 	  The Unit must have prosecutorial authority or an approved formal 
procedure for referring cases to a prosecutor. 
d. 	  The Unit must submit annual reports, with appropriate 

certifications, on a timely basis. 
 
e. 	  The Unit must submit quarterly reports on a timely basis. 
f. 	  The Unit must comply with the Americans with Disabilities Act, 
the Equal Employment opportunity requirements, the Drug Free 
workplace requirements, Federal lobbying restrictions, and other 
such rules that are made conditions of the grant. 
2. 	A Unit should maintain staff levels in accordance with staffing 
allocations approved in its budget. In meeting this standard, the 
following performance indicators will be considered: 
a. 	  Does the Unit employ the number of staff that was included in the 
Unit's budget as approved by the Office of Inspector General 
(OIG)? 
b. 	  Does the Unit employ the number of attorneys, auditors, and 
investigators that were approved in the Unit's budget? 
c. 	  Does the Unit employ a reasonable size of professional staff in 
relation to the State's total Medicaid program expenditures?   
d. 	  Are the Unit office locations established on a rational basis and are 
such locations appropriately staffed? 
 
45 59 Fed. Reg. 49080  (Sept. 26, 1994).  These performance standards were in effect 
during the time of  our review  period and precede the performance standards published in  
June 2012.  
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  16  
   
   
3. 	A Unit should establish policies and procedures for its operations, 
and maintain appropriate systems for case management and case 
tracking.  In meeting this standard, the following performance 
indicators will be considered: 
a. 	  Does the Unit have policy and procedure manuals? 
b.	   Is an adequate, computerized case management and tracking 
system in place? 
4. A Unit should take steps to ensure that it maintains an adequate 
workload through referrals from the single State agency and other 
sources.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit work with the single State Medicaid agency to 
ensure adequate fraud referrals? 
b. 	  Does the Unit work with other agencies to encourage fraud 

referrals? 

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

proportion of Medicaid expenditures for particular provider 

groups? 

d.	   Are there any special Unit initiatives targeting specific provider 
types that affect case mix? 
e. 	  Does the Unit consider civil and administrative remedies when  
appropriate? 
6. 	A Unit should have a continuous case flow, and cases should be 
completed in a reasonable time. In meeting this standard, the 
following performance indicators will be considered:  
a. 	  Is each stage of an investigation and prosecution completed in an 
appropriate time frame?  
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  17  
   
   
b. 	  Are supervisors approving the opening and closing of 

investigations?
   
c. 	  Are supervisory reviews conducted periodically and noted in the 
case file? 
7. A Unit should have a process for monitoring the outcome of cases.  
In meeting this standard, the following performance indicators will be 
considered:  
a. 	  The number, age, and type of cases in inventory. 
b. 	  The number of referrals to other agencies for prosecution. 
c. 	  The number of arrests and indictments. 
d. 	  The number of convictions. 
e. 	  The amount of overpayments identified. 
f. 	  The amount of fines and restitution ordered. 
g. 	  The amount of civil recoveries. 
h. 	  The numbers of administrative sanctions imposed. 
8. 	 A Unit will cooperate with the OIG and other federal agencies, 
whenever appropriate and consistent with its mission, in the 
investigation and prosecution of health care fraud.  In meeting this 
standard, the following performance indicators will be considered: 
a. 	  Does the Unit communicate effectively with the OIG and other 
Federal agencies in investigating or prosecuting health care fraud 
in their State? 
b. 	  Does the Unit provide OIG regional management, and other 
Federal agencies, where appropriate, with timely information 
concerning significant actions in all cases being pursued by the 
Unit? 
c. 	  Does the Unit have an effective procedure for referring cases,  
when appropriate, to Federal agencies for investigation and other 
action?  
d.	   Does the Unit transmit to the OIG, for purposes of program  
exclusions under section 1128 of the Social Security Act, reports 
of convictions, and copies of Judgment and Sentence or other 
acceptable documentation within 30 days or other reasonable time 
period? 
9. 	A Unit should make statutor y or programmatic recommendations, 
when necessary, to the State government. In meeting this standard, 
the following performance indicators will be considered:  
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  18  
   
   
a. 	  Does the Unit recommend amendments to the enforcement 
provisions of the State's statutes when necessary and appropriate to 
do so? 
b.	   Does the Unit provide program recommendations to single State 
agency when appropriate? 
c. 	  Does the Unit monitor actions taken by State legislature or State 
Medicaid agency in response to recommendations? 
10. 	A Unit should periodica lly review its memorandum of 
understanding (MOU) with the single State Medicaid agency and 
seek amendments, as necessary, to ensure it reflects current law  
and practice.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Is the MOU more than 5 years old? 
b.	   Does the MOU meet Federal legal requirements? 
c. 	  Does the MOU address cross-training with the fraud detection staff  
of the State Medicaid agency? 
d.	   Does the MOU address the Units responsibility to make program  
recommendations to the Medicaid agency and monitor actions  
taken by the Medicaid agency concerning those recommendations? 
11. The Unit director should exercise proper fiscal control over the 
Unit resources.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  Does the Unit director receive on a timely basis copies of all fiscal 
and administrative reports concerning Unit expenditures from the 
State parent agency? 
b.	   Does the Unit maintain an equipment inventory?  
c. 	  Does the Unit apply generally accepted accounting principles in its 
control of Unit funding? 
12. A Unit should maintain an annual training plan for all 
professional disciplines.  In meeting this standard, the following 
performance indicators will be considered:  
a. 	  Does the Unit have a training plan in place and funds available to 
fully implement the plan? 
b.	   Does the Unit have a minimum number of hours training 
requirement for each professional discipline, and does the staff 
comply with the requirement? 
c. 	  Are continuing education standards met for professional staff? 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  19  
   
   
d.   Does the training undertaken by staff aid to the mission of the 
Unit? 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  20  
   
   
 APPENDIX B 
Referrals of Provider Fraud and Patient Abuse and Neglect to  
the Nevada Medicaid Fraud Control Unit by Source, Fiscal 
Years 2009 Through 2011 
Table B-1: Total Medicaid Fraud Control Unit Fraud and Abuse Referrals 
and Annual Average 
Annual  
  Case Type   FY 2009   FY 2010   FY 2011   3-Year Total  
Average 
Patient Abuse and Neglect  37  16  24  77  26 
 
Provider Fraud   51  92  74  217  72 
 
  Total  88  108  98  294  98 
 
Source:  Office of  Inspector General (OIG) analysis of Nevada Fraud Control Unit (Unit) Quarterly Statistical  
 
Reports, fiscal years (FY) 2009 through 2011. 
 
Table B-2: Unit Referrals, by Referral Source 
 
 
FY 2009   FY 2010   FY 2011  
   
Abuse  Abuse  Abuse  Percentage 
Referral 
Fraud   &  Fraud   &  Fraud   &  Total   of All 
Source  
Neglect   Neglect   Neglect   Referrals  
Private 
20  2  30  3  31  2  88  29.9 
Citizens*  
Providers  11  1  13  0  8  2  35  11.9 
Other   6  2  17  1  7  2  35  11.9 
Long-Term 
Care  2  28  1  3  0  0  34  11.6 
Ombudsman  
Single State 
Medicaid  5  0  16  0  12  0  33  11.2 
Agency 
Law  
1  2  2  6  1  10  22  7.5 
Enforcement  
OIG  1  0  12  0  5  0  18  6.1 
Other State 
5  0  1  0  5  0  11  3.7 
Agencies 
State Survey  
and 
0  2  0  2  2  1  7  2.4 
Certification 
Agency 
Adult 
Protective  0  0  0  0  2  4  6  2.1 
Services  
Licensing 
0  0  0  1  1  3  5  1.7 
Board  
Total   51  37  92  16  74  24  294  100 
Annual    
88  108  98 
Total    
Annual    
98 
Average   
Source:  OIG analysis of Unit  Quarterly Statistical Reports, FYs 2009  through 2011. 
*Includes phone  calls to the Units main number, emails to  the Unit, electronic fraud report 
submissions, and walk-in referrals. 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  21 
   
   
APPENDIX C 
Investigations Opened and Closed by Provider Category and 
Case Type, Fiscal Years 2009 Through 2011 
Table C-1: Total Annual Opened and Closed Investigations  
 
  Annual   
 Case Type   FY 2009   FY 2010   FY 2011   3-Year Total   Average*  
 Opened  49  99  114  262  87 
Patient Abuse and 
  3  5  5  13  4 
Neglect 
  Provider Fraud   46  94  109  249  83 
           
 
Closed  37  63  66  166  55 
 
Patient Abuse and 
3  3  4  10  3 
  Neglect 
Provider Fraud   34  60  62  156  52 
Source:  Unit response to OIG data request. 
*Averages in  this  table are rounded. 
 
Table C-2: Total Investigations, by Case Type 
FY 2009   FY 2010   FY 2011  
Case Type  
Opened  Closed  Opened  Closed  Opened  Closed 
Patient Abuse and Neglect  3  3  5  3  5  4 
Provider Fraud   46  34  94  60  109  62 
Total   49  37  99  63  114  66 
Source:  Unit response to OIG data request. 
 
Table C-3: Patient Abuse and Neglect Investigations  
 
Provider Category   FY 2009   FY 2010   FY 2011  
        
Opened  Closed  Opened  Closed  Opened  Closed 
Home Health Aides  0  0  1  0  1  0 
Nursing Facilities   0  0  0  0  1  0 
Other Long-Term  Care 
2  3  3  2  1  4 
Facilities  
Other   1  0  1  1  2  0 
Total   3  3  5  3  5  4 
Source:  Unit response to OIG data request. 
 
 
 
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  22  
   
   
Table C-4: Provider Fraud Investigations  
 
Provider Category   FY 2009   FY 2010   FY 2011  
Facilities   Opened  Closed   Opened  Closed   Opened  Closed  
Hospitals  1  0  3  2  3  0 
Other   0  1  1  0  0  1 
Practitioners   Opened  Closed  Opened  Closed  Opened  Closed 
Counselors/Psychologists  0  0  10  0  9  5 
Dentists  2  1  1  3  0  2 
Doctors of Medicine or 
1  2  0  2  2  1 
Osteopathy  
Other   0  2  1  0  0  1 
Medical Support  Opened  Closed   Opened  Closed   Opened  Closed  
Durable Medical 
3  6  7  3  6  4 
Equipment Suppliers 
Home Health Care 
1  3  2  2  0  2 
Agencies 
Home Health Care Aides  7  6  8  14  7  12 
Laboratories  0  0  3  1  1  2 
Pharmaceutical 
23  11  53  33  78  27 
Manufacturers 
Pharmacies  6  0  2  0  0  1 
Transportation Services  0  1  0  0  0  0 
Other   0  1  1  0  1  1 
Program  Related   Opened  Closed  Opened  Closed  Opened  Closed 
Billing Companies  1  0  0  0  0  1 
Managed Care   0  0  0  0  0  1 
Other   1  0  2  0  2  1 
Total   46  34  94  60  109  62 
 
Source:  Unit response to OIG data request. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  23  
   
   
APPENDIX D 
Case File Review Population, Sample Size Counts, and 
Confidence Interval Estimates 
Table D-1 shows population and sample counts and percentages by case 
type. Note that both samples have percentages of case types similar to the 
general population, though sample counts for some case types are very 
small.  Because of these small sample sizes, we cannot reliably generalize 
what we found in our sample review to each case type in the population, 
and only our overall estimates project to the population of all case files.  
We estimated the 4 population values for all 262 case files from the results 
of our review of the case files selected in our simple random samples.  
Table D-2 includes the estimate descriptions, sample sizes, point 
estimates, and 95-percent confidence intervals for these four estimates.  
 
Table D-1: Population and Sample Size Counts for Case Types 
Population Count  Sample Count*    Sample Count* 
Case Type  
and (%)  n=262   and (%)  n=80   and (%)  n=45  
Closed  88 (34%)   30 (38%)   14 (31%)  
Open   174 (66%)   50 (62%)   31 (69%)  
       
Civil  199 (76%)   55 (69%)   32 (71%)  
Criminal  63 (24%)   25 (31%)   13 (29%)  
       
Global  190 (72%)   54 (67%)   32 (71%)  
Patient Abuse/Neglect  13 (5%)   6 (8%)   2 (5%)  
Provider Fraud   59 (23%)   20 (25%)   11 (24%)  
Source: The Nevada Unit provided a list of all  case files open during FYs 2009 through 2011. 
*OIG generated this random sample. 
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  24  
   
   
Table D-2: Confidence Intervals for Key Case File Review  Data  
Point  95-Percent Confidence 
Estimate Description  Sample Size 
Estimate  Interval  
Case Files With 
Documented Supervisory   80  100.0%   96.2100.0%  
Approval for Opening  
Case Files With 
Documented Supervisory   30  100.0%   89.8100.0%  
Approval for Closing  
Case Files With 
Documentation Indicating  
80  97.5%   92.099.2%  
at Least One Supervisory  
Review  
Case Files With 
Documentation Indicating  
80  97.5%   92.099.2%  
Periodic Supervisory  
Review  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  25  
   
   
APPENDIX E 
Unit Comments 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  26  
   
   
 
 
 
 
 
 
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  27  
   
   
 
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy S. Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry,  Deputy Regional Inspector General.  
Matthew DeFraga served as the lead analyst for this study.  Central office 
staff who provided support include Thomas Brannon, Kevin Farber, and 
Sherri Weinstein.  Office of Audit Services staff who provided support 
include Gupa Goha, Ryan Moul, and Clarissa Yu.  Office of Investigations 
staff who provided support include Ken Benson.   
Nevada State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00450)  28  
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office  of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations  
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office  of Counsel to  the Inspector  General  
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.