Use of Funds Appropriated  
to the Office of Inspector General 
for Medicaid-Related Program Integrity Activities 
 
 
March 2009 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
U.S. Department of Health and Human Services 
Office of Inspector General 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities    Fiscal Year 2008   
Use of Funds Appropriated  
to the Office of Inspector General 
for Medicaid-Related Program Integrity Activities 
 
 
Table of Contents 
 
INTRODUCTION..........................................................................................................................1 
BACKGROUND............................................................................................................................1 
Office of Inspector General Mission and Organization..............................................................1 
Office of Inspector General Resources.......................................................................................1 
Funding Sources......................................................................................................................1 
Statutory Funding Streams......................................................................................................2 
OVERSIGHT DURING FISCAL YEAR 2008..............................................................................3 
Medicaid-Related Audits and Evaluations..................................................................................4 
Generic Drug Price Increases..................................................................................................4 
Unit of Measure Inconsistencies in the Medicaid Prescription Drug Program......................4 
Medicaid Outpatient Prescription Drug Expenditures............................................................5 
Hurricane Katrina Uncompensated Care Costs Claimed by Two Mississippi Medical 
Facilities..................................................................................................................................5 
States Medicaid Claims for Hurricane Katrina Evacuees.....................................................6 
Medicaid Targeted Case Management Services Provided by Several States.........................7 
Tennessee Home- and Community-Based Mental Retardation Services...............................9 
Medicaid School-Based Services in Utah...............................................................................9 
State Medicaid Agency Referrals to the Office of Inspector General Exclusions Program...9 
External Quality Review in Medicaid Managed Care..........................................................10 
New Jersey Medicaid Contingency Fee Contract Payments................................................10 
Californias Medicaid Management Information System Expenditures..............................10 
Medicaid Information Technology Audit Resolution Process..............................................10 
Indiana Medicaid Disproportionate Share Hospital Eligibility............................................11 
Texas Medicaid Upper Payment Limit for Hospitals...........................................................11 
Substance Abuse Treatment Facilities..................................................................................11 
Kansass Medicaid Claims for the Child Welfare Services and Family Preservation 
Programs...............................................................................................................................12 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility 
in Two States.........................................................................................................................12 
Medicaid Buy-In Payments in North Carolina.....................................................................13 
Rhode Island Medicaid Transportation Claims....................................................................13 
Separate State Childrens Health Insurance Program Enrollees Eligibility for Medicaid 
in 2006..................................................................................................................................13 
Fee-for-Service Payments for Services Covered by Capitated Medicaid Managed Care....14 
Investigations and Legal Services.............................................................................................15 
Criminal and Civil Enforcement...............................................................................................15 
Pharmaceutical Manufacturers and Distributors...................................................................16 
Hospitals...............................................................................................................................18 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities    Fiscal Year 2008  Practitioners..........................................................................................................................18 
Clinics...................................................................................................................................19 
Transportation Providers.......................................................................................................19 
Individuals.............................................................................................................................19 
Joint Investigations With State Medicaid Fraud Control Units............................................19 
Oversight of Federal Grants to Medicaid Fraud Control Units................................................21 
Administrative Sanctions..........................................................................................................22 
Program Exclusions..................................................................................................................22 
Civil Monetary Penalties...........................................................................................................23 
Outreach and External Activities..............................................................................................24 
Advisory Opinions to Outside Parties.......................................................................................24 
Provider Self-Disclosure Protocol............................................................................................25 
Medicaid Integrity Program Conferences.................................................................................26 
Collaboration With Medicaid Integrity Group.........................................................................27 
Government-Industry Roundtable............................................................................................27 
Collaboration With Department of Justice on Litigation..........................................................27 
OVERSIGHT IN FISCAL YEAR 2009 AND BEYOND............................................................28 
CONCLUSION.............................................................................................................................28 
APPENDIX A:   DEFICIT REDUCTION ACT REQUIREMENTS..........................................29 
Section 6001:  Federal Upper Payment Limit for Multiple Source Drugs and Other Drug 
Payment Provisions...................................................................................................................29 
Section 6031:  Encouraging the Enactment of State False Claims Acts...................................30 
Section 6034:  Medicaid Integrity Program..............................................................................30 
APPENDIX B:   AUDIT AND EVALUATION REVIEWS COMPLETED IN 
FISCAL YEAR 2008....................................................................................................................31 
Medicaid Hospitals...................................................................................................................31 
Medicaid Home, Community, and Nursing Home Care...........................................................31 
Medicaid Prescription Drugs....................................................................................................32 
Other Medicaid Services...........................................................................................................34 
Medicaid Administration..........................................................................................................35 
Medicaid Information Systems and Data Security...................................................................37 
Medicaid and State Childrens Health Insurance Program.......................................................38 
APPENDIX C:   WORK IN PROGRESS AND NEW STARTS.................................................39 
Medicaid Hospitals...................................................................................................................39 
Medicaid Home, Community, and Nursing Home Care...........................................................39 
Medicaid Prescription Drugs....................................................................................................41 
Other Medicaid Services...........................................................................................................42 
Medicaid Administration..........................................................................................................43 
Medicare and Medicaid Information Systems and Data Security............................................44 
Medicaid and State Childrens Health Insurance Program.......................................................45 
APPENDIX D:  ACRONYMS AND ABBREVIATIONS..........................................................46 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities    Fiscal Year 2008   
Use of Funds Appropriated to the Office of Inspector General 
for Medicaid-Related Oversight and Program Integrity Activities 
 
 
INTRODUCTION 
 
This document summarizes Medicaid-related oversight and program integrity activities of the 
Department of Health and Human Services (HHS), Office of Inspector General (OIG) during 
fiscal year (FY) 2008 and includes an overview of Medicaid-related work that OIG anticipates 
undertaking during FY 2009 and beyond.   
 
 
BACKGROUND  
 
Office of Inspector General Mission and Organization 
 
OIGs operational mission is to protect program integrity and the well-being of program 
beneficiaries by detecting and preventing waste, fraud, and abuse; identifying opportunities to 
improve program economy, efficiency, and effectiveness; and holding accountable those who 
do not meet program requirements or who violate Federal laws.  OIG carries out its mission by 
conducting audits, evaluations, and investigations; providing guidance to industry; and, when 
appropriate, imposing civil monetary penalties (CMP), assessments, and administrative 
sanctions.  OIG works closely with HHS and its Operating and Staff Divisions; the Department 
of Justice (DOJ); and other agencies in the executive branch, Congress, and States to bring about 
systemic changes, successful prosecutions, negotiated settlements, and recovery of funds. 
 
OIG is organized into six components, which carry out OIGs mission and support functions:  the 
Office of Audit Services, Office of Investigations, Office of Evaluation and Inspections, Office 
of Counsel to the Inspector General, Office of Management and Policy, and Immediate Office of 
the Inspector General.  OIG is headquartered in Washington, DC, and has a nationwide network 
of approximately 90 regional and field offices with almost 80 percent of its staff working outside 
Washington, DC. 
 
Office of Inspector General Resources 
 
Funding Sources.  Funding for OIG derives from multiple sources, including a single 
discretionary appropriation1 and multiple statutory funding streams provided through other 
legislation.  The discretionary appropriation represents approximately 20 percent of OIGs total 
annual funding, while separate statutory funding streams that are mandated for OIGs oversight 
of Medicare and Medicaid provide approximately 80 percent.  Accordingly, OIGs annual budget 
is devoted largely to oversight of Medicare and Medicaid because of statutory mandates.   
                                                 
1 OIG refers to its annual appropriation, made as part of the overall appropriation for HHS, as its discretionary 
appropriation.  This is distinguished from the permanent appropriation for the Health Care Fraud and Abuse 
Control Program (HCFAC) contained in section 1817(k) of the Social Security Act (our HCFAC funds) and other 
funds appropriated by Congress in other legislation for specified purposes.    
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  1  Fiscal Year 2008     
Statutory Funding Streams.  The separate statutory funding streams generally mirror HHSs 
budget; for FY 2009, funds for Medicare and Medicaid are estimated to constitute about 85 
percent2 of HHSs total outlays.  In FY 2008, OIGs statutory funding streams provided 
approximately $195 million3 for overseeing the integrity of an estimated $595 billion4 in 
Medicare and Medicaid mandatory program outlays.  For FY 2008, the two statutory funding 
streams were the HCFAC program created by the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA) and the Medicaid Integrity Program (MIP) created by the 
Deficit Reduction Act of 2005 (DRA).     
 
  Heath Care Fraud and Abuse Control Program.  The HCFAC program was established 
by the HIPAA to be under the joint direction of the Attorney General and the Secretary of 
HHS, acting through the HHS Inspector General.  Monies are appropriated from the 
Medicare Trust Fund in amounts that the Secretary of HHS and Attorney General jointly 
certify as necessary to finance antifraud activities, up to ceilings fixed by the legislation.  
Certain of these funds are, by law, set aside for OIG activities . . . with respect to 
Medicare and Medicaid.5  The HIPAA also requires the Attorney General and the 
Secretary of HHS to submit a joint annual report to Congress identifying expenditures 
and accomplishments under the law (Social Security Act,  1817(k)(5)).  These reports 
are available on the Web sites of both agencies at:  
  
o  http://oig.hhs.gov/reading/publications.html and  
o  http://www.usdoj.gov/dag/pubdoc.html.  
 
Since FY 1997, the HCFAC has been the primary source of funding for Medicare and 
Medicaid fraud investigations and prosecutions by both OIG and DOJ.   
 
  Medicaid Integrity Program.  The DRA established the MIP, through which OIG 
receives enhanced funding for fraud and abuse control activities with respect to the 
Medicaid program (section 6034(c) of the DRA).  This funding is to be provided 
annually from FY 2006 though FY 2010 in addition to OIGs HCFAC resources and is 
available until expended.  Specific DRA requirements that pertain to OIG are described 
in Appendix A. 
 
 
                                                 
2 U.S. Department of Health and Human Services Budget in Brief FY 2009, p. 1. 
3 Office of Inspector General Justification of Estimates for FY 2009, enacted amounts, p. 9. 
4 U.S. Department of Health and Human Services Budget in Brief FY 2009, p. 13. 
5 The Social Security Act,  1817(k)(3)(A).   
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Medicaid-Related Program Integrity Activities  2  Fiscal Year 2008     
Allocation of Statutory Funding Streams for 
Medicaid Integrity Oversight, FY 2005 FY 2008 
(Dollars in Millions) 
 
Statutorily Mandated  Estimated  
Funding Provided to  Estimated OIG  Percentage of OIG 
OIG for Health Care  Obligations for  Estimated Total  Health Care 
Oversight  Medicaid Oversight  OIG Obligations  Oversight 
Fiscal  HIPAA/  DRA/  for Medicaid  Obligations for 
Year  HCFAC  MIP  HCFAC  MIP7  Oversight   Medicaid Integrity6 
2005  160    36.8    36.8  23 % 
2006  160  25  44.8    44.8  28 % 
2007  165.9  25  24.6  24.8  49.4  26 % 
2008  169.7  25  32.5  28.3  60.8  31 % 
Note:  Numbers are approximate because of rounding. 
 
As illustrated in the preceding table, a sizeable portion of OIGs HCFAC funds has been used for 
Medicaid oversight in recent years.   
 
Because there is an overlap among the activities funded by the HCFAC, MIP, and other sources, 
OIG work activities relating to Medicaid may draw on funding from more than one source.  For 
investigations and subsequent prosecutions, it is particularly difficult (sometimes impossible) to 
accurately segregate enforcement activities by funding stream.  For example, even if OIG 
conducts a given investigation exclusively with MIP funds, the subsequent prosecution of that 
case could draw upon DOJs own HCFAC money, and the matter would be reportable pursuant 
to the requirements of both the HCFAC and MIP programs.  An overlap could also occur when 
an investigation involves fraud in both Medicaid and other Federal health care programs, such as 
Medicare, as is often the case.  For these reasons, this document does not artificially divide 
accomplishments between the funding sources; OIGs Medicaid successes are typically the result 
of the combined funding from available resources.   
 
In addition, OIGs audit, evaluation, and investigation work often requires more than 1 year to 
yield results.  As a consequence, many of the accomplishments summarized in this document 
reflect the results of OIG work performed over several years that culminated in FY 2008.   
 
 
OVERSIGHT DURING FISCAL YEAR 2008 
 
This section highlights OIGs Medicaid-related oversight and program integrity activities 
conducted during FY 2008, much of which has been described in OIGs Semiannual Reports to 
Congress.  Many of the Medicaid enforcement actions and collections cited in this document 
will also be included in the total figures set forth in OIGs annual State Medicaid Fraud Control 
                                                 
6 Figures given for FYs 2008 and 2009 are estimated percentages of the combined HIPAA/HCFAC and DRA/MIP 
funding streams. 
7 OIG began FY 2007 with $25 million of unspent MIP funds that were appropriated during FY 2006.  These funds 
are being used to fund OIGs continued Medicaid oversight from FY 2007 through FY 2010. 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  3  Fiscal Year 2008    Unit (MFCU) report and the joint OIG-DOJ annual HCFAC report.  When published, these 
reports will be made available on OIGs Web site at:   http://www.oig.hhs.gov/publications.asp.   
 
Medicaid-Related Audits and Evaluations  
 
As a result of audits and evaluations of the Medicaid program in FY 2008, OIG questioned 
$610.6 million in costs and identified $1.02 billion in funds that could be put to better use.  
Furthermore, management action on OIGs Medicaid-related recommendations resulted in audit 
disallowances of $662.1 million (Federal share). 
 
Appendix B of this document contains a list of OIGs audits and evaluations related to Medicaid 
that were completed in FY 2008.  Any publicly available reports published as a result of these 
reviews can be accessed through the Reports section of OIGs Web site at 
http://www.oig.hhs.gov/reports.asp.  Below are highlights of the findings from several of 
the Medicaid reviews listed in Appendix B.   
 
Generic Drug Price Increases.  Our review of the Medicaid drug rebate program found that, from  
1991 through 2004, the program could have received $966 million in additional rebates for the 
top 200 generic drugs ranked by Medicaid reimbursement if a rebate provision that applies to 
brand-name drugs had been extended to generic drugs.  For covered outpatient drugs to be 
eligible for Federal Medicaid funding, manufacturers must enter into rebate agreements with the 
Centers for Medicare & Medicaid Services (CMS) and pay quarterly rebates to the States.  
Manufacturers are required to pay an additional rebate when the average manufacturer price 
(AMP) for a brand-name drug increases by more than a specified inflation factor.  There is no 
similar inflation-based rebate provision for generic drugs.  The Presidents budget request for 
FY 2001 sought extension of the rebate provision to generic drugs, but the proposal has not been 
adopted.  In response to our recommendation to consider seeking legislative authority to extend 
the additional rebate provisions to generic drugs, CMS agreed to do so once it had sufficient time 
to assess the impact of recent changes to the Medicaid prescription drug program required by the 
DRA.  (A-06-07-00042) 
 
Unit of Measure Inconsistencies in the Medicaid Prescription Drug Program.  In our review 
of the impact of unit of measure inconsistencies on Medicaid rebate claims, we identified 
$11.8 million in inappropriately claimed Medicaid rebates during the first 6 months of 2006.  
The method for defining units determines the number of units in a package, or package size; 
the unit of measure and package size are used together to calculate the per unit reimbursement 
that Medicaid makes to retail pharmacies and per unit rebate amounts that prescription drug 
manufacturers pay to States.  We found specifically that most inconsistencies involved the unit 
type each; on average, States converted 45 percent of their utilization data for drugs with unit 
of measure inconsistencies; and States could not use package size data from CMS to efficiently 
detect or correct for unit of measure inconsistencies.  Inappropriately claimed Medicaid rebates 
can lead to incorrect rebate payments or disputes with manufacturers.  In addition, unit of 
measure inconsistencies have implications for future Medicaid reimbursement based on AMPs.  
We recommended that CMS provide more specific guidance to manufacturers regarding the 
unit type each and improve its guidance to States regarding detecting and converting unit of 
measure inconsistencies.  CMS disagreed, stating that unit of measure inconsistencies did not 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  4  Fiscal Year 2008    account for significant improper Medicaid rebate payments.  However, we believe that the 
effects of unit of measure inconsistencies may increase as AMP data are increasingly used for 
Medicaid reimbursement.  (OEI-05-07-00050) 
 
Medicaid Outpatient Prescription Drug Expenditures.  In our reviews of the Medicaid outpatient 
prescription drug expenditures in two States, we found that both States had claimed Federal 
Medicaid reimbursement for prescription drug expenditures that did not fully comply with 
Federal requirements.  Medicaid generally covers outpatient drugs if the drug manufacturers 
have rebate agreements with CMS and pay rebates to the States.  Under the Medicaid drug rebate 
program, CMS provides the States with a quarterly Medicaid drug tape, which lists all covered 
outpatient drugs, indicates a drugs termination date if applicable, and specifies whether the 
Food and Drug Administration has determined the drug to be less than effective.  CMS guidance 
instructs the States to use the tape to verify coverage of the drugs for which they claim 
reimbursement.  Our specific findings follow. 
 
 Illinois  For FYs 2004 and 2005, Illinois claimed $108,000 in unallowable 
expenditures for prescription drugs that were no longer eligible for reimbursement.  The 
State claimed an additional $3.5 million for drugs that were not listed on the quarterly 
drug tapes.  Because the State did not verify whether these drugs were eligible for the 
coverage, their costs may not be allowable.  We recommended that the State refund 
$108,000, work with CMS to resolve $3.5 million in payments for drugs that were not 
listed on the quarterly drug tapes, and strengthen its internal controls.  The State agreed 
with the first two recommendations but said that it would not change its internal controls 
because they were sufficient to comply with Federal requirements.  (A-05-07-00019) 
 
 Missouri  For FYs 2003 and 2004, Missouri claimed $2.9 million in unallowable 
expenditures for prescription drugs that were no longer eligible for reimbursement or 
were inadequately documented.  In addition, the State claimed $1.9 million for drugs that 
were not listed on the quarterly drug tapes and therefore may not be allowable.  We 
recommended that the State refund $2.9 million, work with CMS to resolve $1.9 million 
in payments for drugs that were not listed on the quarterly drug tapes, and strengthen its 
internal controls.  The State disagreed with all of our findings and said that its internal 
controls were adequate.  The State did not provide information that would cause us to 
revise our findings.  (A-07-06-04063) 
 
Hurricane Katrina Uncompensated Care Costs Claimed by Two Mississippi Medical Facilities.  
We issued reports on two Mississippi medical facilities claims, as of December 2006, for 
medically necessary uncompensated care furnished to Hurricane Katrina evacuees and other 
affected individuals without other coverage in eligible States.  In response to Hurricane Katrina, 
section 6201 of the DRA authorized Federal funding for such costs through Medicaid 
demonstration projects approved by CMS under the authority granted to the Secretary under 
section 1115 of the Social Security Act.  The findings of these reports follow. 
 
 Medical Center  We found that the State appropriately claimed most of the 
$17.9 million in uncompensated care reimbursement for services provided by a medical 
center.  However, 4 of the 200 claims that we sampled, totaling $22,400, were improper 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  5  Fiscal Year 2008    because the individuals who received the services had health care coverage under other 
programs. We recommended that the State refund to CMS the unallowable 
reimbursement and consider reviewing the medical centers claims that were not 
included in the sample to ensure that no other health care coverage was available and 
make refunds if appropriate. The State did not fully agree with the recommendations but 
said that it would make the proper adjustments in cooperation with CMS.  The State also 
provided detailed explanations for three of the seven claims we originally questioned.  
Based on this additional information, we allowed the three claims and amended our 
findings and recommendations accordingly.  (A-04-07-06004) 
 
 Hospital  We found that the State appropriately claimed $7.9 million in 
uncompensated care reimbursement for services provided by a hospital.  This report 
had no recommendations.  (A-04-07-06017) 
 
States Medicaid Claims for Hurricane Katrina Evacuees.  We issued five audit reports on the 
allowability of States claims for services provided to Hurricane Katrina evacuees from 
Alabama, Louisiana, and Mississippi.  To ensure the continuity of health care services for 
victims following Hurricane Katrina, States could apply to CMS for Medicaid demonstration 
projects authorized by section 1115 of the Social Security Act and, with an approved 
demonstration, be eligible under section 6201(a)(1)(A)(i) of the DRA to receive Federal payment 
of the non-Federal share of medical assistance costs for evacuees.  The results of our audits, 
which covered costs claimed as of March 31, 2007, follow. 
 
 Delaware  The State generally claimed reimbursement in accordance with its 
approved demonstration project.  However, we found no evidence that three applicants 
met displacement requirements.  As a result, the State claimed a net total of $9,300 (of a 
total of $173,000) in unallowable reimbursement.  We recommended that the State refund 
the $9,300 and revise its claims by our audit adjustment amounts.  In its comments on our 
draft report, the State generally disagreed with our findings and recommendations but did 
not provide information that caused us to revise our findings.  (A-03-07-00201) 
 
 District of Columbia  The District of Columbia improperly claimed reimbursement for 
services provided to 18 applicants after their eligibility periods had expired and to 
3 applicants who did not meet eligibility requirements.  As a result, the District claimed 
a net total of $44,900 (of a total of $246,000) in unallowable reimbursement.  We 
recommended that the District refund the $44,900 and revise its claims by our audit 
adjustment amounts.  The District generally agreed.  (A-03-07-00202) 
 
 Maryland  The State claimed a total of $1.3 million for medical assistance services 
provided to 929 evacuees; of this amount, $412,000 was not allowable.  Under section 
1115, CMS approved Marylands request for Medicaid demonstration authority to 
provide benefits to eligible hurricane evacuees for a maximum of 5 months, ending 
June 30, 2006, and limited eligibility to individuals from specified counties or parishes.  
The claims that we identified as unallowable were not supported by actual recorded 
expenditures, were for services provided to individuals whose eligibility had expired, or 
were for services provided to individuals who may not have met eligibility requirements.   
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  6  Fiscal Year 2008    We recommended that the State refund $412,000 and revise its waiver reports for 
Alabama, Louisiana, and Mississippi by our audit adjustment amounts.  The State agreed 
with our recommendation.  (A-03-07-00200) 
 
 Pennsylvania  The State claimed a total of $1.4 million for medical assistance services 
provided to 747 evacuees; of this amount, $552,000 was not allowable.  Under its 
approved section 1115 demonstration project, Pennsylvania was allowed to provide 
benefits to eligible evacuees for a maximum of 5 months.  Most of the claims that we 
identified as unallowable included costs for services provided to individuals after their 
eligibility periods had expired or costs that were not supported by actual recorded 
expenditures.  We recommended that the State refund $552,000 in unallowable 
reimbursement and revise its waiver reports for Alabama, Louisiana, and Mississippi by 
our audit adjustment amounts.  The State agreed with our recommendations.   
(A-03-07-00210) 
 
 Virginia  The State claimed nearly $523,000 for medical assistance services provided 
to 641 evacuees and associated administrative costs; we determined that of this amount,  
$73,000 was not allowable.  Under the terms of the approved section 1115 demonstration 
project and section 6201 of the DRA, the State could claim reimbursement for reasonable 
administrative costs related to providing services to evacuees.  The claims that we 
identified as unallowable were for administrative costs that did not pertain to the 
demonstration project, were for medical assistance costs that were erroneously reported, 
or were related to services provided to ineligible individuals.  We recommended that the 
State refund $73,000 in unallowable reimbursement and revise its waiver reports for 
Alabama, Louisiana, and Mississippi by our audit adjustment amounts.  The State agreed 
with our recommendation.  (A-03-07-00211) 
 
Medicaid Targeted Case Management Services Provided by Several States.  We issued five 
reports on States claims for Medicaid targeted case management (TCM) services.  Such services 
help specific Medicaid populations gain access to medical, social, educational, and other 
services.  CMS has specified that TCM services do not include direct medical, educational, or 
social services to which Medicaid eligibles have been referred.  All of the reports identified 
inappropriate claimed costs. 
 
 Georgia  For FYs 2003 and 2004, we estimated that the State claimed $4.7 million 
($2.8 million Federal share) in unallowable claims for TCM costs for individuals deemed 
at risk of incarceration.  Claims were unallowable because they were not supported as 
TCM in case records, were for TCM services provided to ineligible incarcerated 
juveniles, or had no supporting documentation.  We recommended that the State refund 
the estimated overpayment, examine later claims and refund any overpayment identified, 
and establish monitoring procedures to provide assurance that claims comply with 
Federal and State requirements.  The State said that it would refund the overpayment 
once a final determination had been made and that it would implement the other 
recommendations.  (A-04-06-00022) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  7  Fiscal Year 2008     Iowa   For FYs 2003 and 2004, we estimated that the State improperly claimed 
$2.5 million ($1.5 million Federal share) in unallowable TCM costs.  The State provides 
TCM services to Medicaid-eligible pregnant women; recipients with diagnoses of mental 
retardation, developmental disability, or chronic mental illness; eligibles under the Early 
and Periodic Screening, Diagnostic, and Treatment services program; and children from 
age 3 to 21 who meet the eligibility categories under Part B and Part C of the Individuals 
With Disabilities Education Act.  We questioned the costs because they lacked sufficient 
documentation or were for services that did not meet the definition of TCM services.  We 
also found that the State claimed direct medical services as TCM costs; because these 
costs may be allowable under other provisions of the Medicaid program, we set aside 
$303,000 ($196,000 Federal share) for CMS adjudication.  We recommended that the 
State refund $1.5 million to the Federal Government for unallowable TCM claims, work 
with CMS to determine the allowability of the $196,000 in direct medical services 
claimed as TCM services, and strengthen related internal controls.  The State partly 
agreed with the first two recommendations and fully agreed with the third.   
(A-07-06-03078) 
 
 Kansas  For State FYs 2001 through 2003, the State did not ensure that its 
$61.8 million ($37.2 million Federal share) in TCM claims for recipients of child welfare 
services was equal to or less than the limit specified in the States Medicaid plan.  
Because the State could not produce the rate and cost data necessary to apply the limit, 
we were unable to express an opinion on the reasonableness of the claim.  We 
recommended that the State work with CMS to determine the allowability of the 
$61.8 million claimed for the audit period, as well as claims for all subsequent periods, 
and strengthen internal controls to ensure that State plan requirements are followed in 
submitting future TCM claims.  The State generally agreed.  (A-07-06-03074) 
 
 Maine  For FYs 2002 and 2003, the State overstated by a total of $44.2 million 
($29.8 million Federal share) the cost of Medicaid TCM services provided to recipients 
of family services because the State did not have procedures for ensuring that Medicaid 
TCM costs were reasonable, allowable, and allocable and met Federal requirements.  We 
were unable to express an opinion on the remaining $12.4 million ($8.3 million Federal 
share) claimed for TCM-type activities that we were not able to separate from services 
provided by State family services programs.  We recommended that the State refund to 
the Federal Government $29.8 million in unallowable costs, work with CMS to determine 
the allowability of the $8.3 million for which we were unable to express an opinion, 
identify and refund any unallowable TCM costs reimbursed after the audit period, and 
establish procedures to ensure that claims for Medicaid TCM reimbursement include only 
allowable and adequately documented TCM costs.  The State disagreed with our findings 
and recommendations but did not provide information that would cause us to revise our 
findings.  (A-01-05-00004) 
 
 Minnesota  For FYs 2003 and 2004, we estimated that the State claimed $7.3 million 
($3.8 million Federal share) for various services for which the claims did not meet 
Federal and State documentation requirements.  We recommended that the State refund 
the $3.8 million overpayment and ensure that TCM services are properly documented.  
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  8  Fiscal Year 2008    The State did not address our recommendations but requested information about the 
claims that lacked documentation.  Based on a review of these claims, the State indicated 
that it may modify existing procedures or develop new ones to correct the problem.   
(A-05-05-00059) 
 
Tennessee Home- and Community-Based Mental Retardation Services.  Based on our review 
of Tennessees claims for home- and community-based services (HCBS) provided to Medicaid 
beneficiaries with mental retardation and developmental disabilities during State FY 2003, we 
estimated that the State claimed approximately $11 million ($7 million Federal share) for HCBS 
that were not supported by provider records. We recommended that the State refund the excess 
Federal reimbursement, establish certain HCBS controls and procedures, and review claims after 
the audit period and refund any overpayments.  The State did not address our recommended 
refund but agreed that additional oversight and controls were needed.  (A-04-03-03026) 
 
Medicaid School-Based Services in Utah.  We found that Utahs claims for Medicaid 
reimbursement of school-based services provided in FYs 2001 through 2005 generally did not 
comply with Federal requirements or the States Medicaid plan.  It was not possible to determine 
what portion of the $36.8 million Federal share claimed was allowable as final payments.  The 
State had not, as required by its plan, performed a cost settlement reconciling interim payments 
to actual costs to determine final payments.  The State concurred with our recommendations to 
work with CMS to determine what portion of the $36.8 million was allowable and to perform 
cost settlements to ensure that final payments for school-based services are based on actual costs.  
(A-07-06-04069) 
 
State Medicaid Agency Referrals to the Office of Inspector General Exclusions Program.  
We found that about two-thirds of providers with final actions imposed by State Medicaid 
agencies were not found in the OIG exclusions database.  Through the legal authorities 
contained in sections 1128 and 1156 of the Social Security Act, OIG established a program to 
exclude individuals and entities from participating in Medicaid, Medicare, and other Federal 
health care programs.  When State Medicaid agencies take final actions against providers, they 
are required to promptly report the providers to OIG to be considered for exclusion.  Our study 
matched data from the OIG exclusions database with information on providers with final actions 
taken by State Medicaid agencies.  We also surveyed State Medicaid agency officials.  OIG 
determined that match rates varied widely across States.  For 11 States, less than 25 percent of 
the final actions taken against providers were reflected in the OIG exclusions database.  For nine 
States, 75 percent were reflected in the OIG exclusions database.  Officials from State Medicaid 
agencies conveyed uncertainty about the types of information to send with referrals, the types of 
final actions to refer to OIG, and the outcomes of the referrals that they make.  They rated recent 
outreach from OIG as helpful and would welcome more information about exclusions processes.  
Although this report did not include specific recommendations, our results showed that 
opportunities exist for both OIG and State Medicaid agencies to increase the number of referrals 
of providers with final actions. OIG has efforts underway to improve its tracking of exclusions 
program referrals and outreach and communications to State agencies.  
(OEI-01-06-00301) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  9  Fiscal Year 2008    External Quality Review in Medicaid Managed Care.  We found that of the 37 States that 
had arranged for external quality reviews of Medicaid managed care organizations (MCO) in 
2005, most found the results of such reviews useful, but more than half reported concerns 
about the external review process.  The Social Security Act requires States to provide for 
external, independent reviews of their MCOs, which, as of 2006, enrolled 65 percent of the 
45.6 million Medicaid beneficiaries.  States contract with independent entities called external 
quality review organizations (EQRO) to conduct the reviews.  Our specific findings included the 
following:  33 States required their MCOs to make changes based on EQRO reports and 24 
States cited three primary concerns about external quality reviews, which related to staffing 
(turnover and training), EQRO report quality (timeliness and feasibility of recommendations), 
and redundancy with other monitoring efforts.  Some EQRO reports did not include all of the 
information required by the contracts.  We recommended that CMS work with States to ensure 
that EQROs provide complete information and provide States with additional technical 
assistance and written guidance.  In commenting on the draft report, CMS agreed with these 
recommendations and cited actions that it had taken in both areas.  (OEI-01-06-00510) 
 
New Jersey Medicaid Contingency Fee Contract Payments.  We found that New Jersey made 
improper claims of $16 million ($8 million Federal share) to the Medicaid program for 
contingency fees paid to two consultants.  The State had hired the consultants to generate 
increased Federal reimbursement by identifying and submitting to the Federal Government 
unclaimed State expenses.  According to the terms of the contracts, the consultants were paid 
fees contingent on additional Federal funds recovered.  Office of Management and Budget 
(OMB) Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments, 
prohibits Federal reimbursement for consultant services that are contingent on recovery of 
costs from the Federal Government.  We recommended that the State refund $8 million to the 
Federal Government.  The State disagreed with our interpretation of the OMB circular, but we 
maintained that OMB Circular A-87 prohibits Federal reimbursement for consultant services 
when the costs of those services are contingent on recovery of costs from the Federal 
Government.   (A-02-06-01006) 
 
Californias Medicaid Management Information System Expenditures.  In a review of costs 
claimed by California for operating its Medicaid Management Information System (MMIS) from 
July 1, 2003, to June 30, 2005, we found that most costs were allowable.  However, $2.3 million 
was improperly claimed, mostly because the costs were not equitably allocated to all benefiting 
programs, were not related to the Medicaid program, or were claimed twice.  The MMIS is a 
system of software and hardware used to process Medicaid claims and manage information about 
beneficiaries and services.  States may receive Federal reimbursement from CMS for the 
operation of an MMIS at an enhanced rate.  We recommended that the State refund the 
improperly claimed costs, strengthen its internal controls, and review the appropriateness of costs 
claimed after the audit period.  The State generally agreed with our recommendations.    
(A-09-06-00032) 
 
Medicaid Information Technology Audit Resolution Process.  In our review of CMSs resolution 
of 197 information technology (IT) recommendations that we made regarding the MMIS in 
16 reports between 2002 and 2005, we found that CMS:  resolved 17 recommendations within 
the required 6 months following report issuance; resolved 124 recommendations after the 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  10  Fiscal Year 2008    6 months had elapsed; and had not resolved 56 recommendations as of June 30, 2007.  CMS is 
responsible for resolving Federal and non-Federal audit report recommendations related to its 
activities, grantees, and contractors within 6 months after formal issuance of reports.  We 
recommended that CMS establish procedures to ensure that all IT audit recommendations are 
resolved within 6 months of receiving an audit report.  In commenting on our draft report, CMS 
concurred with our recommendation and described steps that it had taken to improve the audit 
resolution process.  (A-04-06-05039) 
 
Indiana Medicaid Disproportionate Share Hospital Eligibility.  In our review of Indianas 
compliance with Medicaid disproportionate share hospital (DSH) payment requirements, we 
found that from July 2000 through June 2003, the State paid $142.3 million ($88.2 million 
Federal share) to three State-owned psychiatric hospitals that were not eligible to receive 
DSH payments.  States are required to make additional Medicaid payments to hospitals that 
serve disproportionate numbers of low-income patients.  For psychiatric hospitals to qualify for 
such DSH payments, they are required to meet special Medicare conditions of participation 
related to staffing and medical records.  Although the State believed that the three hospitals met 
the special requirements by virtue of being accredited by the Joint Commission on Accreditation 
of Healthcare Organizations, we found that the hospitals had not complied with the more 
stringent requirements for psychiatric hospitals.  We recommended that the State refund 
$88.2 million and ensure that Medicaid DSH payments are made only to eligible hospitals.  The 
State disagreed with our finding and recommendations but did not provide additional information 
to demonstrate compliance with the special requirements for psychiatric hospitals.    
(A-05-06-00045) 
 
Texas Medicaid Upper Payment Limit for Hospitals.   In our review of Texass June 2005 upper 
payment limit (UPL) payments to State owned and operated hospitals for inpatient services, we 
were unable to determine whether the State had calculated UPL payments totaling $112.3 million 
in accordance with Federal regulations and the State plan because the State did not retain the 
required supporting documentation.  The Medicaid program provides payments to certain 
hospitals for inpatient services insofar as the aggregate payments do not exceed the UPL, which 
is a reasonable estimate of the amount that would be paid for Medicaid services under Medicare 
payment principles.  We recommended that the State work with CMS to recalculate the UPL, 
refund the Federal share of any overpayments identified, and implement procedures to retain 
supporting documentation for UPL payments.  In commenting on our draft report, the State said 
that it had recalculated the UPL and planned to provide the revised calculation and 
documentation to CMS.  The State also said that it had implemented the recommended 
procedures.  (A-06-07-00025) 
 
Substance Abuse Treatment Facilities.  In our reviews of two States claims for Federal 
Medicaid reimbursement for services provided in inpatient substance abuse treatment facilities, 
we found that both States had made improper claims.  Federal Medicaid funding generally does 
not cover substance abuse treatment when it is provided to residents of institutions for mental 
diseases (IMD) who are between the ages of 22 and 64.  The specific findings follow. 
 
 New Jersey  From January 2002 through December 2006, the State improperly 
claimed $1.7 million in Federal Medicaid reimbursement for substance abuse services 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  11  Fiscal Year 2008    provided to beneficiaries between the ages of 22 to 64 residing in facilities that were 
IMDs or to beneficiaries residing in nonparticipating institutional Medicaid facilities or 
nonaccredited psychiatric facilities.  This overpayment occurred because the State had 
not established controls to designate the claims in question as federally nonparticipating.  
The State informed us that following the period of our review, it had modified its controls 
to designate these facilities as federally nonparticipating.  We recommended that the 
State refund $1.7 million, ensure that its new controls are working properly, determine 
the amount of improper Federal Medicaid reimbursement claimed subsequent to our audit 
period, and refund the overpayments.  The State concurred with our findings and 
recommendations.  (A-02-07-01005) 
 
 New York  From April 2001 through March 2006, New York improperly claimed 
$21.5 million in Federal Medicaid reimbursement for services provided to beneficiaries 
between the ages of 22 and 64 who resided in IMDs.  The State had improperly 
designated certain detoxification claims as eligible for Federal Medicaid reimbursement; 
one provider had billed Medicaid for inpatient rehabilitation services using an outpatient 
category-of-service code; and the State had continued to claim Federal Medicaid 
reimbursement after another provider increased its number of beds and, as a result, met 
the Medicaid definition of an IMD.  After our audit period, the State refunded a portion 
of the overpayment.  We recommended that the State refund the $6.6 million balance of 
the overpayment, ensure that its controls to designate certain detoxification claims as 
federally nonparticipating are working properly, designate two providers as federally 
nonparticipating for beneficiaries under age 65, determine the amount of improper 
Federal Medicaid reimbursement claimed subsequent to our audit period, and refund 
the overpayments.  The State concurred with the recommendations.  (A-02-06-01021) 
 
Kansass Medicaid Claims for the Child Welfare Services and Family Preservation Programs.  
In our reviews of Kansass Medicaid claims for child welfare services during State FYs 2001 
through 2003, we found that the States documentation did not provide assurance that its 
$61 million ($36.9 million Federal share) claim for the Child Welfare Services program or its 
$3.4 million ($2 million Federal share) claim for the Family Preservation Program were, 
respectively, equal to or less than the limit specified in the States Medicaid plan.  Without 
auditable documentation, we were unable to express an opinion on the reasonableness of the 
States claims for these programs on its quarterly Medicaid reports to CMS.  CMS requested 
these reviews subsequent to its 2004 review of Kansass Child Welfare Services program, which 
found that the State had submitted claims for Federal reimbursement that did not reflect actual 
payments to providers.  CMS deferred reimbursement of expenditures that did not meet Federal 
and State requirements and requested these reviews.  For both programs, we recommended that 
the State work with CMS to determine the allowability of claims for the audit period and all 
subsequent periods and ensure that State plan requirements are followed in submitting future 
claims.  In response to both reports, the State concurred with our first recommendation but did 
not directly address our second recommendation.  (A-07-06-03079, A-07-06-03076) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility 
in Two States.  In our review of States payments in August 2003 on behalf of individuals who 
should not have been Medicaid eligible because of their eligibility in another State, we estimated 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  12  Fiscal Year 2008    that States paid approximately $2 million in that month on behalf of individuals who were 
already eligible in another State.  In each of these States, Medicaid eligibility depends in part on 
residency, and the general definition of residency provides that an individual can be a resident in 
only one State at a time.  Thus, when an individual establishes residency in one State, he or she 
should lose resident status (and Medicaid eligibility) in other States.  We recommended that 
CMS share the results of our review with all States to emphasize the need to identify beneficiary 
eligibility changes and encourage States to identify opportunities to use existing eligibility data 
to minimize concurrent Medicaid eligibility periods.  CMS concurred with the recommendations.  
(A-05-06-00057) 
 
Medicaid Buy-In Payments in North Carolina.  In our review of North Carolinas claims of 
Medicare Part B premiums that it paid on behalf of Medicaid beneficiaries for the quarters ended 
June 2004 through March 2007, we determined that the State had not met Federal requirements 
in claiming the Federal share of Medicare Part B premiums that it paid on behalf of some 
Medicaid beneficiaries.  Of the $722 million that the State claimed, approximately $24 million 
($16 million Federal share) was for beneficiaries in buy-in eligibility categories that were 
ineligible for the Federal share.  Under the buy-in program, States that have agreements with 
CMS may enroll individuals who are eligible for benefits under both Medicare and Medicaid 
(dual eligibles) in Medicare Part B and pay the monthly premium on behalf of these recipients.   
Participating States are eligible to receive the Federal Medicaid share of the Part B premiums for 
certain groups of dual eligibles.  We recommended that the State refund the $16 million, review 
claims submitted following our audit period, refund any unallowable Federal reimbursement, and 
develop adequate internal controls.  The State concurred with our finding and recommendations.   
(A-04-07-03011) 
 
Rhode Island Medicaid Transportation Claims.  In our review of Rhode Islands claimed 
nonemergency transportation costs for the period March 2004 through May 2005, we found that 
the State had not claimed the costs in accordance with Federal and State requirements.  States 
must ensure that Medicaid beneficiaries have transportation to and from medical providers and 
that the transportation is cost effective.  Rhode Island provided nonemergency transportation 
by distributing monthly bus passes.  We determined that the State could have saved at least 
$9.8 million ($4.9 million Federal share) by purchasing 10-ride bus passes instead of monthly 
passes.  We also found that the State had claimed $386,000 ($193,000 Federal share) in 
unallowable costs for beneficiaries of two non-Medicaid State programs.  We recommended that 
the State either refund $4.9 million or provide documentation to show that monthly bus passes 
were the most cost-effective means of providing nonemergency transportation, refund $193,000 
in unallowable costs, recalculate claims for bus passes reimbursed after our audit period and 
refund the excess reimbursement, and establish policies and procedures to comply with Federal 
requirements and the State plan.  The State agreed to refund the $193,000 related to our second 
recommendation but disagreed with the other recommendations.  After considering the States 
comments, we maintain that our findings and recommendations are valid.  (A-01-06-00007) 
 
Separate State Childrens Health Insurance Program Enrollees Eligibility for Medicaid in 2006.   
In this review, the third in a series of congressionally mandated reviews of State Childrens 
Health Insurance Program (SCHIP) enrollment, we found that 4 percent of the children enrolled 
in separate SCHIPs (16 sample cases and about 105,000 children projected nationwide) were 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  13  Fiscal Year 2008    eligible for their States Medicaid programs.  Federal regulations require States to screen SCHIP 
applicants for Medicaid eligibility in part to prevent inappropriate enrollment of Medicaid-
eligible children in SCHIP, whose expenditures have a higher Federal match than Medicaid 
expenditures.  Details of this review included the following: 
 
  The 4-percent enrollment error rate found in this review was somewhat higher than error 
rates found in our earlier reviews (i.e., 1.8 percent in 2000 and 1 percent in 2003). 
  The 16 cases were erroneously enrolled in SCHIP because of miscalculations of the 
families net incomes, clerical mistakes, and other unclassified errors. 
  An additional 4.5 percent of SCHIP enrollees (18 sample cases) lacked sufficient 
documentation to determine Medicaid eligibility, raising the possibility that the actual 
number of children enrolled in separate SCHIPs who were eligible for Medicaid in 2006 
could have been higher than our projection. 
 
We recommended that CMS take further action to ensure that children are appropriately enrolled 
in their States Medicaid programs.  In responding to our draft report, CMS indicated that it 
supported the spirit of the OIG recommendations and requested additional information on the 
cases that we had identified as enrollment errors.  (OEI-06-07-00310) 
 
Fee-for-Service Payments for Services Covered by Capitated Medicaid Managed Care.  
We reviewed the extent to which Medicaid programs in five States paid noninstitutional 
fee-for-service claims for services provided to beneficiaries enrolled in capitated Medicaid 
managed care plans during the first quarter of FY 2005.  We identified approximately $1.8 
million (State expenditures and Federal financial participation) in total Medicaid claims paid, or 
potentially paid, in error.  In capitated managed care arrangementsthrough which 65 percent of 
the Nations Medicaid beneficiaries received all or some of their health or mental health services 
in 2006State Medicaid programs pay managed care plans a fixed rate per Medicaid beneficiary 
in exchange for services included in the plan.  Except in limited circumstances specified by the 
State, Medicaid programs should not pay claims for services that are included in capitated 
Medicaid managed care plans on a fee-for-service basis.  Otherwise, Medicaid programs pay 
twice for the same service: once through the fee-for-service claim and once as a portion of the 
capitated payment.  Our specific findings included the following: 
 
  Four of the States reimbursed fee-for-service claims totaling nearly $864,000 
($462,000 Federal share) in error.  Manual overrides of Medicaid automated payment 
system edits and faulty system logic contributed to these errors. 
  Two States potentially paid an additional $974,000 in error, but Medicaid staff in these 
States were unable to confirm whether these fee-for-service claims were paid in error 
without conducting a detailed, resource-intensive claims-level review. 
 
We recommended that CMS work with States to prevent erroneous fee-for-service payments 
by issuing guidance to States addressing Medicaid payment systems vulnerabilities, identifying 
erroneous payments, and developing payment systems to prevent payment errors.  We also 
recommended that CMS take appropriate action to collect overpayments associated with 
Medicaid claims paid in error.  In responding to our draft report, CMS agreed with our 
recommendation and listed actions it planned to take to eliminate erroneous payments.  
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  14  Fiscal Year 2008    The agency also indicated that it would work with the four States to voluntarily collect the 
overpayments associated with erroneous fee-for-service payments.  (OEI-07-05-00320) 
 
Investigations and Legal Services 
 
In addition to conducting audits and evaluations of Medicaid, OIG investigates allegations of 
criminal and civil wrongdoing in Medicaid and, in conjunction with DOJ and others, conducts 
administrative enforcement and litigation and provides technical support to such efforts.  OIGs 
enforcement work and industry guidance are often designed to have broad impact on Federal 
health care programs.  In large part, OIGs industry outreach and enforcement efforts affect other 
health care programs as well as Medicaid.  The following table presents a summary of OIGs 
investigative, enforcement, and industry outreach activities during FY 2008 related to Medicaid.   
 
OIGs Medicaid-Related Investigations and Legal Services in FY 2008 
 
OIG Activity Area8  Number 
Enforcement    
  Medicaid Cases Worked  1,341 
  Joint Investigations Conducted With State 
879 
Medicaid Fraud Control Units  
  Total Medicaid Cases Opened  497 
  Criminal Convictions  149 
  Civil Actions9  88 
  Program Exclusions  Imposed  3,129 
  Program Exclusions  Appeal Proceedings  90 
  Civil Monetary Penalty Actions  47 
Emergency Medical Treatment and Labor Act 
32 
Actions (aka Patient Dumping) 
  Corporate Integrity Agreements  New  73 
  Corporate Integrity Agreements  Monitored  452 
Outreach   
  Advisory Opinions  26 
  
Criminal and Civil Enforcement 
 
One of the most common types of fraud perpetrated against Medicaid and other Federal health 
care programs involves filing false claims for reimbursement.  The filing of false claims may be 
pursued under Federal and State criminal statutes and, in appropriate cases, under the civil False 
Claims Act (FCA).   
 
The successful resolution of such civil FCA matters often involves the combined investigative 
efforts and resources of OIG, State MFCUs, and a variety of other law enforcement agencies.  
Many providers elect to settle their cases prior to litigation.  As part of their settlements, 
providers often agree to enter into integrity agreements with OIG to avoid exclusions and to be 
permitted to continue participating in Medicare, Medicaid, and other Federal health care 
programs.  Such agreements are monitored by OIG and require providers to enhance existing 
                                                 
8 Matters listed here are not necessarily Medicaid specific.  Many also involve fraud against other health care programs. 
9 The category Civil Actions does not include civil monetary penalty actions. 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  15  Fiscal Year 2008    compliance programs or establish new ones.  Providers that settle these cases generally do not 
admit that they were liable or that they committed the alleged conduct. 
 
In FY 2008, OIG opened 497 Medicaid-related cases for investigation of criminal or civil 
wrongdoing and participated in 149 successful criminal convictions and 135 civil actions.  In 
addition, the Governments enforcement efforts, including FCA cases, resulted in over $2 billion 
in investigative receivables related to Medicaid and other Federal health care programs.  Some 
successful enforcement actions are described below. 
  
Pharmaceutical Manufacturers and Distributors. 
 
 Illinois  CVS Caremark Corporation (CVS) agreed to pay $36.7 million and enter into 
a 5-year corporate integrity agreement (CIA) with OIG to resolve its FCA liability based 
on allegations that it fraudulently overcharged Medicaid programs in 23 States by 
improperly switching drugs it dispensed.  Specifically, the Government and relator 
alleged that CVS dispensed ranitidine (generic Zantac) capsules rather than tablets in 
order to increase its reimbursement from Medicaid.  As a result of dispensing and billing 
Medicaid for capsules, CVS was reimbursed, on average, four times what it would have 
been reimbursed had it dispensed tablets.  The CIA requires CVSs Board of Directors 
Audit Committee to oversee and evaluate CVSs compliance program and requires 
annual reviews by an independent review organization to determine whether similar 
conduct is occurring on an ongoing basis to avoid Federal upper limits (FUL) and 
maximum allowable costs (MAC).  No patient harm was alleged. 
 
 Massachusetts  The Bristol-Myers Squibb Company (BMS) and its wholly owned 
subsidiary, Apothecon, Inc., agreed to pay $499 million plus interest as part of the 
resolution of an FCA case associated with a variety of drug marketing and pricing 
practices.  The settlement and a 5-year CIA between BMS and OIG resolved, in whole 
or in part, allegations made in seven qui tam actions.  The investigation revealed that 
BMS and Apothecon devised and implemented fraudulent marketing and pricing schemes 
aimed at inducing providers to purchase and prescribe their drugs.  First, BMS and 
Apothecon allegedly reported fraudulent and inflated prices for a wide assortment of 
oncology and generic drug products with the knowledge that Federal health care 
programs established reimbursement rates based on those prices.  This type of pricing 
scheme benefits providers by creating a spread between the reimbursement rates for 
Federal health care providers and the actual prices for the drugs charged to BMS 
customers.  Second, BMS allegedly paid illegal remuneration to physicians and other 
health care professionals in the form of consulting fees and expenses associated with 
certain consulting programs.  Third, the Government alleged that Apothecon knowingly 
and willfully paid illegal remuneration to retail pharmacy and wholesaler customers to 
induce them to purchase its products.  Fourth, allegations were made that BMS used 
fraudulent marketing tactics to promote the sale of the drug Abilify, an antipsychotic 
drug, for pediatric uses and for treating dementia-related psychosisboth off-label uses.  
Finally, BMS allegedly violated the requirements of the Federal Medicaid drug rebate 
statute by failing to accurately report the best price at which it sold its antidepression 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  16  Fiscal Year 2008    drug Serzone.  The Government alleged that as a result, BMS underpaid rebates owed to 
the States under the Medicaid rebate program. 
 
 Michigan  Four institutional pharmacies owned by Omnicare, Inc., agreed to pay 
$3,498,570 and enter into an amendment to a preexisting CIA to settle allegations of 
improper Medicaid billing.  The TCPI Acquisition Corp.; Specialized Pharmacy Services, 
Inc.; Specialized Pharmacy Services North, Inc.; and excellRx, Inc. (collectively, 
Specialized) allegedly double-billed Medicaid for drugs provided to hospice patients. 
Specifically, in Michigan, Medicaid pays hospice providers a flat fee that includes all 
medications related to a hospice patients terminal diagnosis.  Therefore, the pharmacy is 
required to bill the hospice provider directly for all drugs related to the patients terminal 
diagnosis.  Drugs not related to the terminal diagnosis are not included in this flat fee, and 
the pharmacy must bill Medicaid directly for these other drugs.  The qui tam relator in the 
case alleged that Specialized knowingly billed Medicaid for all drugs that it dispensed to 
hospice patients, including those unrelated to the patients terminal diagnoses.  Therefore, 
Specialized allegedly caused Medicaid to pay twice for the same drugsone payment to 
the hospice provider and another payment to the pharmacy. 
  
 Pennsylvania and Louisiana  Merck and Company (Merck), Inc., agreed to pay 
$399 million plus interest to resolve its FCA liability in connection with certain 
discounting, pricing, and marketing practices associated with some of its drug products.  
The United States alleged that Merck failed to properly include the discounts in the best 
prices that are required to be reported to CMS under the Medicaid drug rebate program 
and, as a result, underpaid rebates owed to the States.  Specifically, the United States 
alleged that Merck had established certain tiered discount programs, in effect between 
1998 and March 2006, under which it offered hospitals deep discounts on Vioxx (no 
longer marketed), Zocor, and Mevacor.  Under these so-called nominal price programs, 
hospitals that met certain market share requirements could purchase the Merck products 
at discounts of up to 92 percent off the AMPs for the drugs.  The United States further 
contended that through this conduct, Merck overcharged covered entities that purchased 
Merck products under the 340B Drug Pricing Program, which limits the costs of certain 
outpatient prescription drugs to Federal entities and Federally Qualified Health Centers, 
such as community health centers and acquired immunodeficiency syndrome (AIDS) 
drug assistance programs that serve vulnerable populations.  Finally, the United States 
alleged that between January 1997 and December 2001, Merck sales representatives used 
approximately 15 different programs to induce physicians to use its drug products.  These 
programs consisted primarily of excess physician payments disguised as fees paid to 
them for training, consultation, or market research.  The Government alleged that 
these fees were, in fact, illegal kickbacks intended to induce the purchase of Merck drug 
products.  Merck agreed to pay $399 million to settle this matter at the same time that it 
settled a separate FCA lawsuit filed in the Eastern District of Louisiana for $250 million 
plus interest.  The Louisiana matter involved similar discounted pricing programs offered 
to hospitals for another Merck drug, Pepcid.  Merck allegedly offered incentives to 
hospitals to obtain the benefit of spillover business when patients continued to purchase 
Pepcid following their hospital stays.  Through both settlements, Merck agreed to pay a 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  17  Fiscal Year 2008    total of $649 million plus interest.  Merck further agreed to enter into a 5-year CIA with 
OIG that includes corrective measures to address its conduct in both cases. 
 
 Illinois  Walgreens Co. (Walgreens) agreed to pay the United States, 42 States, and 
Puerto Rico $35,214,026 to settle Medicaid prescription drug fraud claims.  The qui tam 
complaint alleged that Walgreens substituted different forms of generic prescription 
drugs for others (such as tablets for capsules) solely to increase its reimbursement rate 
rather than for any legitimate medical reason.  The drugs at issue were ranitidine (generic 
Zantac), fluoxetine (generic Prozac), and selegiline (generic Eldepryl).  The Government 
alleged that Walgreens systematic substitution of more expensive forms of these drugs 
for less expensive, prescribed forms was motivated by its intent to avoid CMSs FUL on 
prices for the drugs and States MACs for the drugs.  In addition, Walgreens entered into 
a 5-year CIA that requires an independent review organization to review its Medicaid 
reimbursement for generic drugs for which Government reimbursement is limited by 
FUL and MAC lists. 
 
Hospitals.  New York  Staten Island University Hospital (SIUH) agreed to pay $88,916,448 in 
a global settlement resolving allegations that it defrauded Medicare, Medicaid, and TRICARE 
(the militarys health insurance program).  The global settlement resolves two separate lawsuits 
filed in the U.S. District Court for the Eastern District of New York and two Government  
investigations.  As part of the global settlement, SIUH also entered into a 5-year CIA with OIG. 
In the first lawsuit, the Governments investigation led to allegations that SIUH fraudulently 
billed Medicaid and Medicare for inpatient alcohol and substance abuse detoxification treatment  
and that during the period July 1, 1994, through June 30, 2000, SIUH submitted claims for 
payment for treatment provided to patients in beds for which SIUH had received no certificate of 
operation from the New York State Office of Alcoholism and Substance Abuse Services 
(OASAS) and concealed the existence of those beds from OASAS.  SIUH has agreed to pay 
$11,824,056 to the United States and $14,883,883 to the State of New York.  The global 
settlement also addresses SIUHs billings to Medicare and Medicaid for treatment of psychiatric 
patients in unlicensed beds during the period July 2003 through September 2005.  The hospital 
has agreed to pay the United States $1,478,989 to settle this claim. 
  
Practitioners. 
 
 Texas  Dr. Raul Marquez, an orthopedic surgeon, agreed to pay $3,128,466 and enter 
into a CIA to resolve allegations of Medicare and Medicaid fraud brought against him 
and hospitals with which he was affiliated and in which he had an ownership interest.  
The Governments investigation, initiated with information presented in a qui tam suit, 
led to allegations that Marquez and the Orthopedic Surgery Center and Sports Medicine 
billed Medicare and Medicaid programs for services not rendered as represented.  Also, 
the Government alleged that Marquez and Cornerstone Regional Hospital obtained 
inflated payments from the Medicare program by billing postsurgical patients as though 
they had been discharged to home, when, in fact, they had been discharged to 
Cornerstone Rehabilitation Hospital for continuing treatment. 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  18  Fiscal Year 2008     Maryland  Podiatrist LaVergne Andre-Hayes agreed to pay the Government $534,884 
plus interest and entered into a 5-year integrity agreement with OIG to resolve allegations 
of false Medicare and Medicaid billing.  Dr. Andre-Hayes allegedly billed Medicare and 
Maryland Medicaid for separate evaluation and management services even though she 
performed no significant, separately identifiable evaluation and management service at 
the same time that she performed a procedure.  Dr. Andre-Hayes also allegedly submitted 
claims to Medicare and Maryland Medicaid for services not rendered and for noncovered 
services.  The Maryland State Board of Podiatric Medical Examiners had also previously 
investigated Dr. Andre-Hayes and on February 8, 2007, suspended her medical license in 
Maryland for 2 years (with 1 year stayed). 
 
 Illinois  Dr. Ajit Trikha, a psychiatrist, was sentenced to 30 months imprisonment 
and was ordered to pay restitution in the amount of $1,755,754 following his guilty plea 
to health care fraud.  TRX Health Systems PC (TRX), Dr. Trikhas business practice, was 
also ordered to pay a $400 special assessment for mail fraud.  Dr. Trikha and TRX billed 
Medicare and Medicaid for individual psychotherapy, group psychotherapy, and 
pharmacologic management services that he did not render.  In some cases, Dr. Trikha 
was traveling outside the United States on the claimed dates of service. 
 
Clinics.  Mississippi  Frank Wiley and Michael Yant owned and operated Canton Rehabilitation 
Services, Inc., which billed Medicare and Medicaid for fraudulently rendered physical therapy 
services.  The scheme involved the submission of claims purporting that the physical therapy 
services were rendered by a physician or a licensed physical therapist under the direct 
supervision of a physician, as required by Medicare.  The services were in fact rendered by 
unlicensed, untrained, and unsupervised individuals.  Wiley and Yant also owned and operated 
Mississippi Central Rehabilitation, Inc., which was operated in the same manner.  Wiley and 
Yant were sentenced to 37 and 48 months in prison, respectively, and ordered to pay restitution 
in the amount of $4,568,560. 
 
Transportation Providers.  District of Columbia  Leonard Young, owner of nonemergency 
transportation company Young Star Tours (YST), was sentenced to 1 year and 1 day in prison 
and 6 months home detention and ordered to pay $173,491 and forfeit $37,950 previously 
seized from his bank accounts.  YST billed DC Medicaid for 6,660 transportation services that 
he never provided. 
 
Individuals.  Ohio  Joe Winston Langley, who pleaded guilty to aggravated identity theft, was 
sentenced to 2 years imprisonment and ordered to pay $155,485 in restitution, of which 
$93,915 is owed to the Medicaid program.  Langley stole the identity of a Texas resident 
approximately 20 years ago and, beginning in 1998, falsely represented his identity to the State 
of Ohio to receive Medicaid and public assistance benefits.  When the identity theft victim 
became eligible for Medicare in 2004, Langley began using the stolen identity to incur charges 
that were paid by the Medicare program. 
 
Joint Investigations With State Medicaid Fraud Control Units.  In FY 2008, OIG participated 
in 879 joint investigations with MFCUs and opened 497 investigations into potential fraud 
involving the Medicaid program.  MFCUs are key partners in the fight against fraud, waste, 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  19  Fiscal Year 2008    and abuse in State Medicaid programs.  State MFCUs operate in 49 States and the District of 
Columbia pursuant to the Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977 with 
the objective of strengthening the Governments capability to detect, prosecute, and punish fraud 
against Medicaid programs.  MFCUs investigate and prosecute, or refer for prosecution, 
providers alleged to have defrauded the Medicaid program or to have abused or neglected 
beneficiaries in Medicaid-sponsored facilities.  OIG partners with MFCUs in conducting joint 
investigations and outreach work.  Examples of joint investigations include the following: 
 
 Georgia  Chiropractors Rafael Razuri and Eric Baty were sentenced to 5 years  
imprisonment and 42 months imprisonment, respectively, and ordered to pay 
$1.8 million in restitution because of their convictions for conspiracy to commit health 
care fraud. While owners and operators of Southside Medical & Rehabilitation Center, 
Razuri and Baty conspired to bill over $5 million in fraudulent physical therapy claims to 
Medicare and Georgia Medicaid.  The investigation involved OIG, the Federal Bureau of 
Investigation (FBI), and the Georgia MFCU.  
 
 Texas  Psychologist Joe Lerma was sentenced to 4 years in Federal prison and ordered 
to pay $530,000 in restitution for fraudulently billing Medicare and Medicaid.  A jury 
found Lerma guilty of billing Medicare and Medicaid for psychological interviews and 
testing as if he performed the services when, in fact, the services were performed by 
unlicensed technicians and associates.  The investigation involved OIG and the Texas 
MFCU. 
 
 Wisconsin  Nicole Stewart was sentenced to 5 years imprisonment and ordered to 
pay $320,603 in restitution for defrauding the Wisconsin Medicaid program.  Stewart 
owned and operated Compassionate Mothers, a company she founded to provide prenatal 
and child care coordination services.  An investigation revealed that she billed the 
Medicaid program for services never rendered and for services not covered.  In addition, 
Stewart attempted to cover up the fraudulent billings by paying employees to fabricate 
records to support the claims submitted.  Four codefendants had been previously 
sentenced for their roles in fabricating documents.  The investigation involved OIG and 
the Wisconsin MFCU. 
 
 Indiana  Varnador K. Sutton, the sole owner and operator of Regenerations, Inc. 
(Regenerations), purportedly a mental health counseling agency employing high- and 
mid-level psychologists and counselors, was sentenced to 120 months imprisonment and 
ordered to pay $3,288,347 in restitution for health care fraud.  An investigation revealed 
that Sutton and Regenerations billed for 84,000 psychotherapy services that were never 
rendered and used 2,500 separate Medicaid recipients identities and benefits to defraud 
the Medicaid program.  The investigation involved OIG, the FBI, and the Indiana MFCU. 
   
 Indiana  Jennifer Williams was sentenced to 30 months imprisonment and ordered 
to pay $79,000 in restitution following her guilty plea to charges of health care fraud 
and being a felon in possession of a firearm.  Williams, the owner of A New Way 
Transportation, knowingly submitted approximately 5,000 claims to Medicaid as 
nonambulatory transports when, in fact, the majority of the beneficiaries transported 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  20  Fiscal Year 2008    were ambulatory.  During the investigation, large amounts of marijuana and prescription 
narcotics were found.  Additionally, a semiautomatic handgun was recovered.  This 
investigation involved OIG; the Bureau of Alcohol, Tobacco, Firearms and Explosives; 
and the Indiana MFCU. 
 
 Illinois  Heartland Dental Care, Inc., a provider of management services to dental 
practitioners located throughout the United States, and Richard E. Workman 
(collectively, Heartland) agreed to pay the United States and the State of Illinois a total 
of $1.65 million to resolve allegations that Heartland violated the Federal FCA and the 
Illinois FCA.  Specifically, Heartland allegedly allowed dentists to call in prescriptions 
for Medicaid beneficiaries under other dentists Drug Enforcement Administration 
registration numbers, in violation of the Controlled Substances Act; billed Medicaid for 
nonsurgical tooth extractions as surgical tooth extractions; and billed Medicaid for crown 
buildups, which are noncovered services, as four-surface restorations or amalgams, which 
are covered services.  In addition, Heartland entered into a 5-year CIA with OIG.  The 
investigation involved OIG and the Illinois MFCU. 
 
 Oregon  Susan Ilene Pearson was sentenced to 39 months imprisonment and ordered 
to pay $108,225 in restitution and fines after being convicted of making false claims and 
theft.  A 3-day jury trial revealed that Pearson, an in-home caregiver paid with Medicaid 
funds, and her codefendant, Carolyn Elliott, a Medicaid recipient, engaged in a 7-year 
fraud scheme whereby Elliot would pretend to be disabled and Pearson would claim to be 
providing caregiver services to Elliott.  Each month for 7 years, Elliott and Pearson 
would bill the State Medicaid program for phantom services Pearson claimed to provide 
and then split the Medicaid payments.  Elliott died 1 month before trial; charges against 
her were dismissed.  The investigation involved OIG, the Social Security Administration, 
and the Oregon MFCU. 
 
Oversight of Federal Grants to Medicaid Fraud Control Units 
  
In addition to conducting audits, evaluations, and investigations and providing legal services, 
OIG is responsible for administering the Medicaid fraud control grant program and providing 
oversight and guidance to State MFCUs.  In FY 2008, OIG oversaw the distribution and 
administration of $185 million to MFCUs in 49 States and the District of Columbia.  The Social 
Security Act,  1902(a)(61), as amended by the Omnibus Budget Reconciliation Act of 1993, 
 13625, required MFCUs to operate in accordance with applicable standards.  The standards 
were developed in consultation with the MFCU community and made effective on September 26, 
1994 (59 Fed. Reg. 49080).  They are used to assess the effectiveness and efficiency of MFCUs 
and enable OIG to determine whether the MFCUs are carrying out their duties and 
responsibilities in an effective manner and in accordance with applicable laws.   
 
During FY 2008, we conducted onsite reviews of 11 selected MFCUs to determine their 
compliance with the following: 
 
  42 CFR pt. 1007, entitled State Medicaid Fraud Control Units, containing 
regulations for MFCUs;  
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  21  Fiscal Year 2008      45 CFR pt. 92, entitled Uniform Administrative Requirements for Grants and 
Cooperative Agreements to State and Local Governments, establishing uniform 
administrative rules for Federal grants; and  
  the 12 MFCU performance standards developed by OIG in consultation with the 
National Association of Medicaid Fraud Control Units.   
 
As part of the onsite review process, we made recommendations and suggestions to improve the 
operation of the MFCUs reviewed.   
 
Administrative Sanctions 
 
OIG has the authority to impose administrative sanctions for instances of fraud or abuse or 
other activities that pose a risk to Federal health care programs and their beneficiaries.  These 
sanctions include the exclusion of individuals and entities from Federal health care programs and 
the imposition of CMPs for submitting false or fraudulent claims to a Federal health care 
program or violating the anti-kickback statute, physician self-referral statute, or the patient 
dumping provision of the Social Security Act. 
 
Program Exclusions 
 
Through the legal authorities contained in sections 1128 and 1156 of the Social Security Act, 
OIG established a program to exclude individuals and entities from participation in Medicaid, 
Medicare, and other Federal health care programs.  OIG maintains a list of all currently excluded 
parties called the List of Excluded Individuals/Entities, available on OIGs Web site at 
http://www.oig.hhs.gov/fraud/exclusions/exclusions_list.asp.   The bases for exclusion include 
convictions for program-related fraud, patient abuse, State licensing board actions, default on 
Health Education Assistance Loans, and violation of existing CIAs.  Many of these are acts 
committed against the Medicaid program or its beneficiaries. 
 
During FY 2008, OIG excluded 3,129 individuals and entities from participating in Medicaid, 
Medicare, and other health care programs.  Most of the exclusions resulted from convictions for 
crimes relating to Medicare or Medicaid.  The following are examples of Medicaid-related 
program exclusions in FY 2008. 
 
 New York  Neil E. Norwood, a pharmacist, was excluded for a minimum of 25 years 
based on his conviction for his scheme to defraud Medicaid and a private insurer. As part 
of the scheme, Norwood provided patients with less medication than prescribed but billed 
Medicaid and the private insurer as if the full prescription had been dispensed. Norwood 
was sentenced to 2 to 6 years imprisonment and ordered to pay $3 million. 
 
 Virginia  Kenneth D. Beverly, the owner of a rehabilitation facility, was excluded 
for a minimum of 25 years based on his scheme to bill Medicaid for psychosocial 
rehabilitation services for Medicaid beneficiaries who were not eligible to receive such 
services.  In addition, Beverly was convicted of various other charges, including charges 
related to income tax evasion.  Beverly was ordered to pay $2,604,500 in restitution and 
was sentenced to 151 months imprisonment. 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  22  Fiscal Year 2008     
 Ohio  Wilma Kpohanu, a home health agency owner, was excluded for a minimum of 
30 years as a result of her conviction for health care fraud and health care false 
statements.  Through her agency, Kpohanu submitted claims to Medicaid for skilled 
nursing and home health aide services that were not rendered or performed from 
September 1999 to March 2006.  Kpohanu was ordered to pay restitution of 
approximately $2,712,148 and was sentenced to 97 months of incarceration. 
 
 Kansas  Johnnie Franklin-El and Peggy Franklin-El, counseling center 
owners/operators, were each excluded for a minimum of 25 years based on their 
convictions on multiple counts of health care fraud.  From June 2003 to January 2006, 
they submitted, or caused to be submitted, false claims to Medicaid for community-based 
drug and alcohol abuse services that were not provided.  Both subjects were sentenced to 
92 months imprisonment and ordered to pay approximately $1,243,244 in joint and 
several restitution.  They were also convicted of obstruction of justice. 
 
Civil Monetary Penalties  
 
The Civil Monetary Penalties Law (CMPL) authorizes OIG to impose administrative penalties 
and assessments against a person who, among other things, submits or causes to be submitted, 
claims to a Federal health care program, including Medicaid, that the person knows or should 
know are false or fraudulent.  The following are examples of CMP actions that were resolved 
during FY 2008 and which involved the improper billing of Medicaid services. 
 
 New York  The State Office of the Medicaid Inspector General entered into a CMPL 
Settlement Agreement with St. Barnabas Hospital (SBH).  The settlement resolved the 
liability of SBH and Cardiology Physicians, P.C. arising from the hiring of several 
excluded persons.  Under the terms of the settlement, SBH agreed to pay the 
United States $132,000.  In addition, SBH was required to certify that it had policies and 
procedures in place to prevent the future hiring of excluded persons. 
 
 Michigan  OIG entered into a CMPL settlement with Courtyard Manor of Farmington 
Hills, Inc. (Courtyard Manor).  The settlement resolves Courtyard Manors liability 
arising from its receipt of Federal health care program funds while the entity was 
excluded.  Under the terms of the settlement, Courtyard Manor agreed to pay the United 
States $1,700,000 and to be excluded from all Federal health care programs, including 
Medicaid, for 2 years in addition to the 10-year period of exclusion effective August 20, 
2002.  The State of Michigan will receive $742,954 of the settlement amount. 
 
 Massachusetts  Caritas Christi, the parent entity of a health care system comprising 
hospitals, physicians groups, laboratories, and home care agencies in southern New 
England, agreed to pay $250,060 to resolve its liability under the CMPL.  In May 2007, 
Caritas Christi disclosed to OIG that it employed or contracted with five individuals who 
were excluded from participating in Federal health care programs (including Medicaid). 
Caritas Christi discovered this problem during an annual review of the Federal sanctions 
lists in late 2006.  After disclosing this matter, Caritas Christi cooperated with OIG in 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  23  Fiscal Year 2008    determining the damages related to the employment of four of these individuals and a 
one-time contract with the fifth person.  In addition, as part of the settlement agreement, 
Caritas Christi provided a certification of its policy and procedures to prevent hiring or 
contracting with ineligible providers.  
 
Of the CMPs imposed in FY 2008, some were pursued under the Emergency Medical Treatment 
and Labor Act of 1986 (EMTALA), codified at 42 U.S.C.  1395dd, with regulations at 42 CFR 
 489.24.  EMTALA, or the patient dumping law, is designed to ensure patient access to 
appropriate emergency medical services.  The requirements of EMTALA apply to all Medicare-
participating hospitals, irrespective of the presenting individuals coverage or ability to pay.  
As such, OIGs imposition of CMPs for EMTALA violations help ensure that Medicaid patients, 
among others, obtain needed emergency care.     
 
Outreach and External Activities 
 
As part of OIGs ongoing efforts to promote the highest level of ethical and lawful conduct by 
the health care industry, we have continued to issue advisory opinions and other guidance to 
educate industry and other stakeholders on how to avoid waste, fraud, and abuse. 
 
Advisory Opinions to Outside Parties 
 
Pursuant to section 205 of the HIPAA, OIG, in consultation with DOJ, issues advisory opinions 
to outside parties regarding the interpretation and applicability of certain statutes relating to 
Federal health care programs.  This authority allows OIG to provide case-specific formal 
guidance regarding the application of the anti-kickback statute, safe harbor provisions,10 and 
other OIG health care fraud and abuse authorities.  The following are examples of advisory 
opinions issued in FY 2008 that relate to the Medicaid environment: 
 
 Advisory Opinion 07-18  OIG considered an existing and a proposed arrangement 
whereby a nonprofit, tax-exempt charitable organization would subsidize cost-sharing 
and premium obligations associated with outpatient drug treatment owed by financially 
needy Medicare and Medicaid patients with certain chronic diseases.  The organization 
was funded mostly by manufacturers of drugs used to treat the covered diseases, and all 
donations were in either cash or cash equivalents.  OIG determined that although the 
arrangements could implicate the anti-kickback statute, OIG would not impose sanctions.  
In addition, OIG determined that the arrangements would not constitute grounds for the 
imposition of CMPs under section 1128A(a)(5) of the Social Security Act, which 
prohibits inducements to beneficiaries.  OIG made these determinations following an 
analysis of two remunerative aspects of the arrangements:  the donor contributions to the 
organization and the organizations grants to beneficiaries.  With respect to the former, 
OIG determined that it appeared unlikely that the donor contributions would influence 
any beneficiarys selection of a provider, practitioner, supplier, or product or the selection 
of any particular insurance plan and that there appeared to be a minimal risk that the 
                                                 
10 The safe harbor regulations specify various payment and business practices that, although potentially capable of 
inducing referrals of business reimbursable under the Federal health care programs, would not be treated as criminal 
offenses under the anti-kickback statute.   
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  24  Fiscal Year 2008    donor contributions would improperly influence referrals by the organization.  With 
respect to the latter, OIG determined that the organizations subsidy for certain eligible, 
financially needy Medicare and Medicaid beneficiaries would not be likely to improperly 
influence any beneficiarys selection of a particular provider, practitioner, supplier, or 
product.  OIG reached these conclusions based on a combination of many factors more 
fully described in the opinion. 
 
 Advisory Opinion 08-04  OIG considered a proposed arrangement whereby a 
manufacturer of health care products and pharmaceuticals would provide one 
complimentary trial supply of a hemophilia medication to hemophilia A patients, 
including Medicare and Medicaid beneficiaries.  An eligible patient would receive the 
medication free of charge after a participating physician prescribed it, and the patient 
submitted enrollment and authorization forms to an administrator of the proposed 
arrangement.  No third-party payors, including Federal health care programs, would be 
billed for the medication dispensed under the proposed arrangement.  OIG determined 
that although the proposed arrangement could implicate the anti-kickback statute, OIG 
would not impose sanctions for a combination of reasons.  First, with respect to whether 
the proposed arrangement would entail an offer of remuneration from the manufacturer to 
the participating physicians, OIG concluded that there would be no direct or indirect 
monetary or economic remuneration to the physicians, and OIG did not discern any other 
benefit to the physicians of the type that would be subject to sanctions.  Second, with 
respect to whether patients would be receiving remuneration in the form of the free one-
time trial supply of the medication as an inducement to self-refer to the medication in the 
future, OIG concluded that the risk would be low based on a number of considerations, 
for example, that the proposed arrangement entailed no cost to Federal health care 
programs; the risk of steering associated with starting patients on a particular course of 
treatment was reduced in the proposed arrangement, the proposed arrangement would not 
likely result in overutilization of the medication, and the proposed arrangement included 
a number of additional safeguards that limit the risk of fraud. 
 
Provider Self-Disclosure Protocol 
 
Since 1998, OIG has made available comprehensive guidelines describing the process for 
providers to voluntarily submit self-disclosures of fraud, waste, or abuse.  The guidelines, 
entitled Provider Self-Disclosure Protocol, enable providers to minimize the potential costs 
and disruptions that a full-scale OIG audit or investigation may entail if fraud is uncovered.  The 
self-disclosure also enables the provider to negotiate a fair monetary settlement and potentially 
avoid being excluded from doing business with Federal health care programs.  After making an 
initial disclosure, the provider or supplier undertakes a thorough internal investigation of the 
nature and cause of the matters uncovered and makes a reliable assessment of their economic 
impact, e.g., estimated losses to Federal health care programs.  OIG evaluates the reported results 
of each internal investigation to determine the appropriate course of action.  On April 15, 2008, 
OIG published an Open Letter to Health Care Providers describing refinements to the Self-
Disclosure Protocol, such as actions to streamline OIGs internal procedures.   
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  25  Fiscal Year 2008    During FY 2008, self-disclosure cases resulted in $56.4 million in HHS receivables.  Many 
disclosure situations involve Medicaid as well as Medicare.  For example, Inglis House, a 
specialty nursing care facility for adults with physical disabilities, agreed to pay $5,547,940 to 
resolve its liability under the CMPL and Pennsylvania State law.  Inglis used OIGs Provider 
Self-Disclosure Protocol to report that it submitted eight types of false claims to Medicare and 
Medicaid.  Violations included overly frequent comprehensive resident assessments, which 
improperly inflated Ingliss Medicaid case mix index; billing Medicaid for services covered by 
Medicare Part A; billing Medicare part B and Medicaid for services that should have been 
included in the Medicare Part A payment; and wrongfully billing Medicare and Medicaid for 
Certified Registered Nurse Practitioner services.  In addition to entering into the monetary 
settlement, Inglis entered into a 5-year CIA with OIG.   
 
Medicaid Integrity Program Conferences 
 
In FY 2008, OIG hosted the remaining 7 of 13 Medicaid Integrity Program (MIP) training 
conferences involved in a national Medicaid fraud and abuse outreach effort initiated in 2007.  
The seven conferences provided 900 attendees training in Medicaid oversight and enforcement 
activities and set in motion working relationships and future collaboration among OIG, Federal 
and State investigators, auditors, attorneys, and analysts from 24 States.   
 
 
Medicaid Integrity Program Conferences 
  
  Region  Location  Dates  Attendance 
FY 2007  New York  Cape May, NJ  March 57, 2007  90 
Boston  Boston, MA  May 910, 2007  90 
Dallas  Dallas, TX  June 57, 2007  100 
Chicago  Indianapolis, IN  July 1011, 2007  120 
Atlanta  Atlanta, GA  August 2122, 2007  110 
Dallas  Baton Rouge, LA  September 1113, 2007  140 
FY 2008  Philadelphia  State College, PA  October 1618, 2007  125 
Atlanta  Orlando, FL  November 57, 2007  130 
Los Angeles   
Monterey, CA  November 2729, 2007  225 
San Francisco 
San Francisco  Spokane, WA  April 810, 2008  135 
Kansas City  Des Moines, IA  May 7 8, 2008  120 
Kansas City  Denver, CO  June 1112, 2008  100 
Los Angeles  Phoenix, AZ  July 1516, 2008  95 
 
Organizing and holding the MIP conferences has enabled OIG to involve each of the following 
agencies in a strategic planning process to collaboratively address Medicaid fraud and abuse:  
CMS, the CMS Medicaid Integrity Group (CMS/MIG); District Attorneys Offices; the FBI; 
independent/nonprofit health insurance associations (e.g., the National Insurance Crime Bureau); 
MFCUs; CMS Program Safeguard Contractors; State agencies (e.g., State Health and Human 
Services Departments, Divisions of Medical Assistance and Human Services, Offices of the State 
Comptroller); State Attorney General Offices; State Medicaid Inspector General Offices; and 
United States Attorneys Offices. 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  26  Fiscal Year 2008    Holding multiple conferences across the country enabled OIG to address program integrity issues 
and vulnerabilities that differ substantially across State lines and within various regions.  Each 
agenda was tailored to address specific needs unique to the States within the hosting OIG region.  
Breakout sessions helped further achieve these goals by focusing on specific areas with the 
highest risk for fraud. 
 
Collaboration With Medicaid Integrity Group 
 
OIG collaborates with CMS/MIG to coordinate and maximize our respective activities to protect 
the integrity of Medicaid.  OIG has provided feedback and technical assistance to CMS/MIG on 
a number of products, including the statement of work, task orders, and audit protocols for its 
Medicaid integrity contractors and letters to State Medicaid Directors.  OIG has also offered 
input into the curriculum for CMS/MIGs training programs for its newly hired staff and for 
State Medicaid program integrity staff.  In addition, OIG and CMS/MIG jointly developed 
procedures for CMS/MIGs Medicaid integrity contractors to refer cases of potential fraud to 
OIG.  Finally, in followup to OIGs report on suspected fraud referrals from State Medicaid 
programs to MFCUs, OIG provided technical assistance to CMS/MIG on the development of 
suspected fraud referral performance standards for State Medicaid agencies.  On September 30, 
2008, CMS/MIG implemented its Performance Standard for Referrals of Suspected Fraud From 
a Single State Agency to a Medicaid Fraud Control Unit.  
 
Government-Industry Roundtable 
 
On December 6, 2007, OIG and the Health Care Compliance Association (HCCA) cosponsored 
a Government-industry roundtable, Driving for Quality in Long-Term Care:  A Board of 
Directors Dashboard.  The roundtable discussions enabled representatives from the long-term 
care industry to share experiences and inform OIG and HCCA of issues related to boards of 
directors oversight of quality of care.  On January 31, 2008, OIG and HCCA published a report 
summarizing the roundtable discussions.  The report is available on the OIG Web site at: 
http://www.oig.hhs.gov/fraud/docs/complianceguidance/Roundtable013007.pdf. 
 
Collaboration With Department of Justice on Litigation 
 
DOJ and OIG launched a program in which OIG attorneys serve as Special Assistant United 
States Attorneys (SAUSA).  Some are detailed full-time to DOJs Criminal Division, Fraud 
Section, for 6-month assignments; others prosecute matters on a case-by-case basis.  Both 
arrangements offer excellent litigation training for OIG attorneys and enhance collaboration 
between the departments in fighting fraud.  Under this program, OIG attorneys have successfully 
litigated important criminal cases relating to durable medical equipment as well as other 
Medicare and Medicaid fraud.  Given the SAUSA programs success, OIG and DOJ plan to 
expand the it to augment prosecutorial resources in districts across the country. 
 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  27  Fiscal Year 2008    OVERSIGHT IN FISCAL YEAR 2009 AND BEYOND 
 
At the beginning of each FY, OIG publishes its Work Plan to highlight the areas in which it 
expects to conduct oversight and program integrity activities during the coming year.  In addition 
to being a planning document, the Work Plan serves as a means for focusing public attention on 
the areas deemed important and identified as particularly vulnerable to fraud, waste, and abuse.   
 
Throughout each FY, OIG work undertaken may change for a number of reasons.  Some 
activities announced in the Work Plan may shift from higher to lower priority or may be 
postponed until future years as a result of the changing focus of Congress, the Secretary, or OIG; 
because of an intervening emergency; or in response to trends identified in related work.  As 
such, OIGs work planning is an evolving process that enables OIG to remain adaptable to the 
changing priorities of its stakeholders.  
 
Appendix C of this document identifies the Medicaid work in progress and new work that OIG 
anticipates undertaking during FY 2009.  Although most Work Plan items will be initiated in 
FY 2009, many will not be completed within the FY.  Some of these reviews increase the scope 
and depth of prior OIG work by conducting follow-up activities and others expand into new and 
emerging areas of interest.  OIG will also continue its investigative and enforcement activities, as 
well as its outreach and guidance to the health care industry.  Detailed summaries of OIGs 
anticipated work activities for FY 2009 can be found in the OIG Work Plan, which is located in 
the Publications section of the OIG Web site at http://www.oig.hhs.gov/publications.asp. 
 
In addition, we are planning other activities to enhance Medicaid enforcement and fraud 
prevention.  For example, we expect to continue working with CMS, State MFCUs, and the 
National Association for Medicaid Program Integrity to improve coordination and collaboration 
on joint investigations, projects, and issues.  OIG will continue to closely analyze the Medicaid 
program for vulnerabilities and to develop new methods and initiatives to identify and combat 
evolving fraud, waste, and abuse activities. 
 
 
CONCLUSION 
 
The varied and far-reaching activities described in this document and its appendixes help 
position OIG and its partners to effectively monitor the integrity of funds appropriated to HHS to 
operate and oversee Medicaid and related programs.   
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  28  Fiscal Year 2008    APPENDIX A:   
DEFICIT REDUCTION ACT REQUIREMENTS  
 
Sections 6001, 6031, and 6034 of the Deficit Reduction Act of 2005 (DRA) include provisions 
that require the Department of Health and Human Services (HHS), Office of Inspector General 
(OIG), to conduct specified activities, as well as to report annually on overall Medicaid 
activities.  These sections are summarized below. 
 
Section 6001:  Federal Upper Payment Limit for Multiple Source Drugs and Other Drug 
Payment Provisions  
  
Effective January 1, 2007, section 6001 required the Centers for Medicare & Medicaid Services 
(CMS) to change its Federal upper limit (FUL) calculations (i.e., the method of setting limits on 
what the Federal Government would reimburse Medicaid State agencies for prescription drug 
payments) to base the limits on average manufacturer price (AMP) and to provide AMP data to 
States on a monthly basis beginning July 1, 2006.  This section also required OIG to, by no later 
than June 1, 2006, (1) review the requirements for, and manner in which, AMPs are determined 
under section 1927 of the Social Security Act and (2) submit to the Secretary of HHS and 
Congress recommendations for changes in such requirements or manner as the Inspector General 
determines to be appropriate. 
   
On May 30, 2006, OIG issued a report entitled Determining Average Manufacturer Prices for 
Prescription Drugs Under the Deficit Reduction Act of 2005 (A-06-06-00063), which fulfilled 
this statutory requirement.  In this report, OIG found that existing requirements for determining 
aspects of AMP were unclear and that manufacturers methods of calculating AMPs were 
inconsistent.  OIG recommended that the Secretary direct CMS to clarify requirements in regard 
to the definition of retail class of trade and the treatment of pharmacy benefit manager rebates 
and Medicaid sales and to consider addressing issues raised by industry groups.  OIG also 
recommended that the Secretary direct CMS to issue guidance that specifically addresses the 
implementation of the AMP-related reimbursement provisions of the DRA and to encourage 
States to analyze the relationship between AMP and pharmacy acquisition cost before using 
AMP for their reimbursement methodology.   
 
In July, 2007, CMS issued a final regulation at 72 Fed. Reg. 39142, which implemented the 
requirements of the DRA by establishing a new method of calculating FULs, based on AMPs 
and aimed at reining in inflated drug product payments.  The rule was to take effect on January 1, 
2008.  However, in December 2007, a Federal district court issued a preliminary injunction 
prohibiting CMS from implementing the new FULs.  Additionally, in July 2008, Congress 
enacted the Medicare Improvements for Patients and Providers Act of 2008 delaying the 
implementation of the new FULs and prohibiting public disclosure of AMPs until October 2009.  
While this prohibition is in effect, CMS continues to calculate FUL amounts based on the 
previous formula (i.e., 150 percent of the lowest published price).   
 
During FY 2007, OIG continued to address topics related to the FUL for multiple source drugs 
and other drug payment provisions by issuing an evaluation report in June 2007 entitled  
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  29  Fiscal Year 2008    Deficit Reduction Act of 2005:  Impact on the Medicaid Federal Upper Limit Program  
(OEI-03-06-00400).  
   
Section 6031:  Encouraging the Enactment of State False Claims Acts   
 
Effective January 1, 2007, this section provides a financial incentive for States to enact false 
claims acts (FCA) that establish liability to the States for the submission of false or fraudulent 
claims to the States Medicaid programs.  If a States FCA is determined to meet certain 
enumerated requirements, the Federal share of Medicaid recoveries under the State FCA will be 
reduced by 10 percent, increasing the States share by 10 percent. 
 
Specifically, for a State to be eligible for the 10-percent increase in its share of false claims 
recoveries, the State law relating to false and fraudulent claims must be determined by OIG, in 
consultation with the Attorney General, to meet the following criteria:  it establishes liability to 
the State for false or fraudulent claims described in the FCA with respect to Medicaid 
expenditures; it contains provisions that are at least as effective in rewarding and facilitating 
qui tam actions as those in the FCA; it contains a requirement for filing an action under seal for 
60 days with review by the State Attorney General; and it contains a civil penalty that is not less 
than the amount authorized by the FCA.  
 
On August 21, 2006, OIG published in the Federal Register (71 Fed. Reg. 48552) its guidelines 
for evaluating State FCAs under the requirements of section 6031 of the DRA.  This notice was 
developed in consultation with the Department of Justices (DOJ) Civil Division.  In the notice, 
OIG invited the States to request review of their FCAs.     
 
During FY 2008, OIG provided written responses to 10 States and approved 4 of the State 
lawsthose passed by California, Georgia, Indiana, and Rhode Islandfor the DRA incentive.   
OIG made these determinations in consultation with DOJs Civil Division.  The response letters 
are published on OIGs Web site at http://www.oig.hhs.gov.   
 
Section 6034:  Medicaid Integrity Program   
 
This section establishes the Medicaid Integrity Program and requires the Secretary to enter into 
contracts to enhance the capacity of CMS to conduct oversight of Medicaid expenditures.  The 
programs activities include:  review of the actions of individuals or entities furnishing items or 
services for which a Medicaid payment may be made; audit of claims for payment for items or 
services furnished or for administrative services rendered; and education of service providers, 
managed care entities, beneficiaries, and other individuals with respect to payment integrity and 
quality of care.  The section further establishes that from fiscal year (FY) 2006 through FY 2010, 
$25 million shall be appropriated to OIG for the Medicaid activities of OIG in addition to any 
other amounts appropriated or made available for Medicaid oversight.  Such funds shall remain 
available until expended.  This section of the DRA also requires OIG to identify to Congress the 
use and effectiveness of OIGs use of such funds no later than 180 days after the end of each FY.  
This document responds to that requirement for FY 2008.  
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  30  Fiscal Year 2008    APPENDIX B:   
AUDIT AND EVALUATION REVIEWS COMPLETED IN FISCAL YEAR 2008 
 
This appendix contains report titles and reference numbers for the Office of Inspector Generals 
(OIG) Medicaid-related audits and evaluations that were completed during fiscal year 2008.  Any 
publicly available reports published as a result of these reviews are available on OIGs Web site 
at http://www.oig.hhs.gov. 
 
Medicaid Audits and Evaluations  
Completed in Fiscal Year 2008 
 
Reviews 
Health Care Sectors 
Completed 
Medicaid Hospitals  6 
Medicaid Home, Community, and Nursing Home Care  9 
Medicaid Prescription Drugs  48 
Other Medicaid Services  13 
Medicaid Administration  33 
Medicaid Information Systems and Data Security  10 
Medicaid and State Childrens Health Insurance Program  2 
Total  121 
 
 
Medicaid Hospitals 
 
Review of Medicaid Services Provided on the Day of Admission to an Inpatient Hospital or 
During an Inpatient Hospital Stay in New York State (A-02-04-01006) 
 
Review of Disproportionate Share Hospital Payments Made by Pennsylvania to Temple 
University Hospital for State Fiscal Year 2005-2006 (A-03-07-00207) 
 
Review of Disproportionate Share Hospital Payments Made by Penn State Milton S. Hershey 
Medical Center for State Fiscal Year 2005-2006 (A-03-07-00208) 
 
Review of Disproportionate Share Hospital Payments Made by Pennsylvania to University of 
Pittsburgh Medical CenterPresbyterian/Shadyside for State Fiscal Year 2005-06  
(A-03-07-00209) 
 
Review of Indiana Medicaid Disproportionate Share Hospital Eligibility for July 1, 2000, 
Through June 30, 2003 (A-05-06-00045) 
 
Review of Missouris Determination of Medicaid Disproportionate Share Hospital Eligibility for 
State-Owned Institutions for Mental Diseases (A-07-06-03086) 
 
Medicaid Home, Community, and Nursing Home Care 
 
Review of Medicaid Targeted Case Management Services Provided by the Maine Bureau of 
Child and Family Services During Federal Fiscal Years 2002 and 2003 (A-01-05-00004) 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  31  Fiscal Year 2008     
Review of Personal Care Services Claimed by The Center for Living and Working, Inc.  
(A-01-06-00011) 
 
Review of Selected Alabama Medicaid Rehabilitation Services Costs for State Fiscal Year 2002 
(A-04-04-04005)  
 
Review of Medicaid Targeted Case Management Services Rendered by the Georgia Department 
of Juvenile Justice During Federal Fiscal Years 2003 and 2004 (A-04-06-00022) 
 
Review of Minnesota Medicaid Reimbursement for Targeted Case Management Services for 
Fiscal Years 2003 and 2004 (A-05-05-00059) 
 
Review of Kansass Medicaid Payments for Targeted Case Management for the Period July 1, 
2000, Through June 30, 2003 (A-07-06-03074) 
 
Iowa Medicaid Payments for Targeted Case Management for Fiscal Years 2003 Through 2004 
(A-07-06-03078) 
 
Duplicate Medicaid and Medicare Home Health Payments:  Medical Supplies and Therapeutic 
Services (OEI-07-06-00640) 
 
Payments Made in Error for Personal Care Services During Institutional Stays  
(OEI-07-06-00620) 
 
Medicaid Prescription Drugs 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Connecticut (A-01-08-00002) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Vermont (A-01-08-00004) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in New York (A-02-07-01055) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in New Jersey (A-02-07-01056) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in the District of Columbia  
(A-03-07-00216) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Delaware (A-03-07-00217) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Virginia (A-03-07-00218) 
 
Review of Medicaid Outpatient Drug Expenditures in West Virginia for the Period October 1, 
2003, Through September 30, 2005 (A-03-07-00220) 
 
Follow-Up Audit of Medicaid Drug Rebate Program in Pennsylvania (A-03-08-00201) 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  32  Fiscal Year 2008     
Follow-Up Review of the Medicaid Drug Rebate Program in Florida (A-04-07-07022) 
 
Follow-Up Review of the Medicaid Drug Rebate Program in Alabama (A-04-07-07024) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Tennessee (A-04-07-07026) 
 
Follow-Up Review of Medicaid Drug Rebate Program in North Carolina (A-04-07-07028) 
 
Review of Medicaid Outpatient Drug Expenditures in Illinois for the Period October 1, 2003, 
Through September 30, 2005 (A-05-07-00019) 
 
Review of the Medicaid Drug Rebate Program in Minnesota (A-05-08-00010) 
 
Review of Medicaid Drug Rebate Program in Illinois (A-05-08-00011) 
 
Follow-Up Review of the Medicaid Drug Rebate Program in Wisconsin (A-05-08-00012) 
 
Follow-Up Review of the Medicaid Drug Rebate Program in Michigan (A-05-08-00014) 
 
Follow-Up Review of the Medicaid Drug Rebate Program in Kentucky (A-05-08-00015) 
 
Review of Minnesotas Drug Rebate Accounts Receivable Balance Report on the Form CMS-64 
(A-05-08-00058) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Arkansas (A-06-07-00015) 
 
Review of Average Manufacturer Price Calculations  Manufacturer A (A-06-07-00041) 
 
Review of Average Manufacturer Price Calculations  Manufacturer B (A-06-07-00040)   
 
Review of Average Manufacturer Price Calculations  Manufacturer C (A-06-07-00039)   
 
Review of Generic Drug Price Increases (A-06-07-00042) 
 
Follow-Up Audit of the Drug Rebate Program in Louisiana (A-06-07-00067) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Oklahoma (A-06-07-00069) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in New Mexico (A-06-07-00071) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Texas (A-06-08-00028) 
 
Review of Medicaid Outpatient Drug Expenditures in Missouri for the Period October 1, 2002, 
Through September 30, 2004 (A-07-06-04063) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  33  Fiscal Year 2008    Follow-Up Audit of Medicaid Drug Rebate Program in Iowa (A-07-07-03094) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Missouri (A-07-07-03096) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Nebraska (A-07-07-03097) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Utah (A-07-07-03098) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Montana (A-07-07-03101) 
 
Review of Medicaid Outpatient Drug Expenditures in Montana for the Period October 1, 2001, 
Through September 30, 2004 (A-07-07-04103) 
 
Review of Medicaid Outpatient Drug Expenditures in Colorado for the Period October 1, 2002, 
Through September 30, 2004 (A-07-07-04113) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Kansas (A-07-08-03102) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in North Dakota (A-07-08-03105) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Wyoming (A-07-08-03106) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Colorado (A-07-08-03108) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in South Dakota (A-07-08-03110) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Oregon (A-09-07-00052) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Washington State (A-09-07-00062) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Idaho (A-09-07-00064) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in Hawaii (A-09-07-00081) 
 
Follow-Up Audit of the Medicaid Drug Rebate Program in California (A-09-07-00084) 
 
Unit of Measure Inconsistencies in the Medicaid Prescription Drug Program 
(OEI-05-07-00050) 
 
Other Medicaid Services 
 
Review of New Jerseys Medicaid School-Based Rates (A-02-04-01017) 
 
Review of New Jersey Family Planning Claims for the Period July 1, 1997, Through March 31, 
2002 (A-02-05-01016) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  34  Fiscal Year 2008    Review of Outpatient Medicaid Claims Billed as Family Planning by New Jersey  
(A-02-06-01010) 
 
Review of Inpatient Hospital Claims Billed as Family Planning Under New Jersey Medicaid 
Program (A-02-06-01020) 
 
Review of Medicaid Claims Made by Freestanding Residential Treatment Facilities in New York 
State (A-02-06-01021) 
 
Review of Federal Medicaid Claims for Beneficiaries in the Family Planning Benefit Program in 
New York State (A-02-07-01001) 
 
Review of Federal Medicaid Claims Made by Inpatient Substance Abuse Treatment Facilities in 
New Jersey (A-02-07-01005) 
 
Review of Non-Emergency Transportation Services Provided by Epps Transportation Services, 
Inc. from January 1, 2004, Through December 31, 2006 (A-03-07-00204) 
 
Review of Wisconsins Non-Emergency Medical Transportation Costs for Services Provided by 
American United Taxicab, Inc. for January 1 Through December 31, 2005 (A-05-08-00040) 
 
Review of Kansass Medicaid Payments for the Family Preservation Program for the Period 
July 1, 2000, Through June 30, 2003 (A-07-06-03076) 
 
Review of Kansass Medicaid Payments for the Child Welfare Services Program for the Period 
July 1, 2000, Through June 30, 2003 (A-07-06-03079) 
 
Medicaid School-Based Services in Utah  Review of Payment Rates (A-07-06-04069) 
 
External Quality Reviews in Medicaid Managed Care (OEI-01-06-00510) 
 
Medicaid Administration 
 
Review of Rhode Islands Medicaid Nonemergency Transportation Costs for March 1, 2004, 
Through May 31, 2005 (A-01-06-00007) 
 
Review of Medicaid Credit Balance at Boston Medical Center for the Period Ending March 31, 
2007 (A-01-07-00008) 
 
Review of Medicaid Overpayments at First Atlantic Nursing Facilities in Maine for Calendar 
Years 2004 Through 2006 (A-01-07-00009) 
 
Review of Medicaid Overpayments at North Country Associates, Inc. in Maine for Calendar 
Years 2004 Through 2006 (A-01-07-00012) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  35  Fiscal Year 2008    Review of New Jersey Medicaid Contingency Fee Contract Payments for the Period April 1, 
1996, Through June 30, 2001 (A-02-06-01006) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in New 
Jersey and New York for July 1, 2005, Through June 30, 2006 (A-02-07-01029) 
 
Medicaid Payments Services Provided to Beneficiaries With Concurrent Eligibility in New York 
and New Jersey for July 1, 2005, Through June 30, 2006 (A-02-07-01030) 
 
Medical Assistance Provided by Maryland to Hurricane Katrina Evacuees (A-03-07-00200) 
 
Medical Assistance Provided by Delaware to Hurricane Katrina Evacuees (A-03-07-00201) 
 
Medical Assistance Provided by the District of Columbia to Hurricane Katrina Evacuees  
(A-03-07-00202) 
 
Medical Assistance Provided by Pennsylvania to Hurricane Katrina Evacuees  (A-03-07-00210) 
 
Medical Assistance Provided by Virginia to Hurricane Katrina Evacuees (A-03-07-00211) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in the 
District of Columbia and Maryland for July 1, 2005, Through June 30, 2006 (A-03-07-00214) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in 
Maryland and the District of Columbia for July 1, 2005, Through June 30, 2006  
(A-03-07-00215) 
 
South Carolina Medicaid Durable Medical Equipment Provider Enrollment Practices From 
March 21, 1995, Through June 30, 2005 (A-04-05-04010) 
 
Audit of North Carolinas Buy-In of Medicare Part B Premiums for Medicaid Beneficiaries 
From April 2004 Through March 2007 (A-04-07-03011) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in 
Georgia and Florida for July 1, 2005, Through June 30, 2006 (A-04-07-03033) 
 
Review of Hurricane Katrina Uncompensated Care Costs Claimed by Mississippi for the 
University of Mississippi Medical Center (A-04-07-06004) 
 
Review of Hurricane Katrina Uncompensated Care Costs Claimed by Mississippi for Forrest 
General Hospital (A-04-07-06017) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in Florida 
and Georgia for July 1, 2005, Through June 30, 2006 (A-04-08-03034) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  36  Fiscal Year 2008    Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in Two 
States During August 2003 (A-05-06-00057) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in Illinois 
and Indiana for July 1, 2005, Through June 30, 2006 (A-05-06-00069) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in Indiana 
and Illinois for July 1, 2005, Through June 30, 2006 (A-05-06-00070) 
 
Review of Section 1915(c) Mental Retardation or Related Condition Waiver Services at 
Dungarvin, Minnesota, From July 1, 2004, Through June 30, 2005  (A-05-07-00023) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in 
Arizona and California for July 1, 2005, Through June 30, 2006 (A-05-07-00057) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in 
California and Arizona for July 1, 2005, Through June 30, 2006  (A-05-07-00058) 
 
Review of Social Security Act Section 1915(c) Waiver Payments for Home and Community-
Based Services at Chicago ARC, July 1, 2004, Through June 30, 2005 (A-05-07-00080) 
 
Review of Social Security Act Section 1915(c) Waiver Payments for Home and Community-
Based Services at Seguin Services, Inc., July 1, 2004, Through June 30, 2005 (A-05-08-00018) 
 
Upper Payment Limit Payments to Texas State Hospitals for Inpatient Services (A-06-07-00025) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in 
Missouri and Kansas for July 1, 2005, Through June 30, 2006  Missouri Department of Social 
Services  (A-07-07-04078) 
 
Medicaid Payments for Services Provided to Beneficiaries With Concurrent Eligibility in Kansas 
and Missouri for July 1, 2005, Through June 30, 2006  Kansas State Agency  (A-07-07-04079) 
 
Review of Californias Medicaid Management Information System Expenditures for the Period 
July 1, 2003, Through June 30, 2005 (A-09-06-00032) 
 
State Medicaid Agency Referrals to the Office of Inspector General Exclusions Program  
(OEI-01-06-00301) 
 
Medicaid Information Systems and Data Security 
 
Review of Centers for Medicare & Medicaid Services Medicaid Information Technology Audit 
Resolution Process (A-04-06-05039) 
  
Medicaid Information Technology Controls at the State of Indiana  Follow-Up  
(A-05-07-00071)  
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  37  Fiscal Year 2008     
Review of Information System Controls Over New Mexicos Medicaid Claims Processing  
(A-06-06-00084) 
  
Review of Information System General Controls Over New Mexicos Eligibility System for 
Entitlement Programs (A-06-07-00076) 
 
Audit of General Controls for Montana Medicaid Claims Processing (A-07-07-00255)  
 
Audit of General Controls for Medicaid Eligibility Determination at the Montana Department of 
Public Health and Human Services (A-07-07-00256)  
 
Review of Technical Support Component of South Dakota Bureau of Information and 
Telecommunications (A-07-08-00261) 
 
Review of Information System General Controls Over Arizonas Medicaid Claims Processing 
(A-09-07-00022)  
 
Review of Data Security Controls Over Medicaid Claims Processing at Arizonas Department of 
Administration Data Center (A-09-07-00057)  
 
Fee-for-Service Payments for Services Covered by Capitated Medicaid Managed Care  
(OEI-05-07-00320) 
 
Medicaid and State Childrens Health Insurance Program 
 
Review of State Childrens Health Insurance Program Payments in Puerto Rico (A-02-04-01019) 
 
Separate State Childrens Health Insurance Program Enrollees Eligibility for Medicaid in 2006 
(OEI-06-07-00310)
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  38  Fiscal Year 2008    APPENDIX C:   
WORK IN PROGRESS AND NEW STARTS 
 
This appendix lists Medicaid-related audit and evaluation work included in the Office of 
Inspector Generals (OIG) fiscal year (FY) 2009 Work Plan designated as work in progress (as 
of October 1, 2008) or as new starts to begin during FY 2009 or FY 2010.  The work will be 
conducted by OIGs Office of Audit Services (OAS) and Office of Evaluation and Inspections 
(OEI).  Summaries of the objectives and context of each project are provided in the Work Plan, 
which is available in the Publications section of the OIG Web site at:  
http://www.oig.hhs.gov/publications.asp. 
 
Medicaid Hospitals  
 
Hospital Outlier Payments 
(OAS; W-00-08-31069; various reviews; expected issue date:  FY 2009; work in progress)  
 
States Disproportionate Share Hospital Payments for Care for Individuals in Institutions for 
Mental Diseases 
(OAS; W-00-08-31300; various reviews; expected issue date:  FY 2009; work in progress)  
 
Provider Eligibility for Medicaid Reimbursement   
(OAS; W-00-07-31301; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Disproportionate Share Hospital Payment Distribution   
(OAS; W-00-08-31302; various reviews; expected issue date:  FY 2009; work in progress)  
 
Supplemental Payments to Private Hospitals   
(OAS; W-00-09-31126; various reviews; expected issue date:  FY 2010; new start)  
 
Potentially Excessive Medicaid Payments for Inpatient and Outpatient Services   
(OAS; W-00-09-31127; various reviews; expected issue date:  FY 2009; new start)  
 
Medicaid Home, Community, and Nursing Home Care  
 
Community Residence Rehabilitation Services   
(OAS; W-00-08-31087; various reviews; expected issue date:  FY 2009; work in progress)  
 
Targeted Case Management 
(OAS; W-00-05-31082; W-00-06-31082; W-00-08-31082; various reviews; expected issue date:  
FY 2009; work in progress)  
 
Medicaid Payments to Continuing Day Treatment Providers  
(OAS; W-00-09-31128; various reviews; expected issue date:  FY 2010; new start)  
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  39  Fiscal Year 2008    Medicaid Payments to Nursing Homes While Dual-Eligible Beneficiaries Received Covered 
Medicare Part A Services  
(OAS; W-00-09-31129; various reviews; expected issue date:  FY 2009; new start)  
 
Transparency Within Nursing Facility Ownership  
(OAS; W-00-09-31130; various reviews; expected issue date:  FY 2010; new start)  
 
Medicaid Home Health Agency Claims  
(OAS; W-00-08-31304; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Payments for Personal Care Services  
(OAS; W-00-07-31035; W-00-08-31035; various reviews; expected issue date:  FY 2009; work 
in progress)  
 
Medicaid Payments for Medicare-Covered Home Health Services  
(OAS; W-00-08-31305; various reviews; expected issue date:  FY 2009; work in progress)  
 
Compliance With States Requirements for Medicaid-Funded Personal Care Service Attendants  
(OEI-07-08-00430; expected issue date:  FY 2009; work in progress)  
 
State and Federal Oversight of Home- and Community-Based Services Provided in Assisted 
Living Facilities  
(OEI; 09-08-00360; expected issue date:  FY 2009; work in progress)  
 
State and Federal Oversight of Home- and Community-Based Services  
(OEI; 02-08-00170; expected issue date:  FY 2009; work in progress)  
 
Medicaid Adult Day Health Service Payments for Ineligible and Absent Beneficiaries  
(OEI; 09-07-00500; expected issue date:  FY 2009; work in progress)  
 
Community Transition Services Provided to Medicaid Home- and Community-Based Services 
Waiver Beneficiaries  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start)  
 
Plans of Care:  Addressing Minimum Data Set and Resident Assessment Protocols Through 
Provided Services  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start)  
 
States Use of Civil Monetary Penalty Funds  
(OAS; W-00-08-31303; various reviews; expected issue date:  FY 2010; work in progress; OEI; 
00-00-00000; expected issue date:  FY 2010; new start)  
 
Payments for Bed Holds  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start)  
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  40  Fiscal Year 2008    Medicaid Prescription Drugs  
 
Timely Submission of Average Manufacturer Price Data  
(OEI; 00-00-00000; expected issue date:  FY 2009; new start)  
 
Manufacturer Submissions of Outlier Average Manufacturer Prices  
(OEI; 03-07-00740; expected issue date:  FY 2009; work in progress)  
 
Calculation of Average Manufacturer Prices  
(OAS; W-00-09-31202; various reviews; expected issue date:  FY 2010; new start)  
 
States Medicaid Drug Claims  
(OAS; W-00-07-31203, W-00-08-31203; various reviews; expected issue date:  FY 2009; 
work in progress) 
 
Medicaid Payments for Drugs Not Approved for Use by Children  
(OAS; W-00-09-31131; various reviews; expected issue date:  FY 2009; new start)  
 
Family Planning Access and Care and Treatment Adjustments  
(OAS; W-00-09-31132; various reviews; expected issue date:  FY 2010; new start)  
 
Alien Emergency Drug Claims  
(OAS; W-00-09-31133; various reviews; expected issue date:  FY 2010; new start)  
 
Medicaid Third-Party Liability for Prescription Drug Payments  
(OAS; W-00-09-31134; various reviews; expected issue date:  FY 2009; new start) 
  
Compound Drugs  
(OAS; W-00-08-31317; A-09-08-00034; expected issue date:  FY 2009; work in progress)  
 
Medicaid Reimbursement for Unapproved Drugs  
(OEI; 03-08-00500; expected issue date:  FY 2009; work in progress)  
 
Zero Dollar Unit Rebate Amounts  
(OAS; W-00-08-31106; various reviews; expected issue date:  FY 2009; work in progress)  
 
States Accountability Over Medicaid Drug Rebate Programs  
(OAS; W-00-07-31205; W-00-08-31205; various reviews; expected issue date:  FY 2009; 
work in progress)  
 
Additional Rebates of Brand-Name Drugs  
(OAS; W-00-09-31306; various reviews; expected issue date:  FY 2009; new start)  
 
Assessing the Accuracy of Drug Type Classification in the Medicaid Drug Rebate Initiative File  
(OEI; 03-08-00300; expected issue date:  FY 2009; work in progress)  
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  41  Fiscal Year 2008    Comparison of Medicaid Federal Upper Limit Amounts to Wholesale, Retail, and Medicare 
Pricing  
(OEI; 03-08-00490; expected issue date:  FY 2009; work in progress)  
 
Other Medicaid Services  
 
Medicaid Dental Services  
(OAS; W-00-09-31135; various reviews; expected issue date:  FY 2009; new start)  
 
Family Planning Services  
(OAS; W-00-06-31078; W-00-07-31078; W-00-08-31078; various reviews; expected issue date:  
FY 2009; work in progress)  
 
Medicaid Payments for Transportation Services  
(OAS; W-00-07-31121; W-00-08-31121; various reviews; expected issue date:  FY 2009; work 
in progress)  
 
State Policies To Safeguard Medicaid Nonemergency Transportation Services  
(OEI; 06-07-00320; expected issue date:  FY 2009; work in progress) 
 
Medical Equipment  
(OAS; W-00-08-31307; various reviews; expected issue date:  FY 2009; work in progress)  
 
Early and Periodic Screening, Diagnostic, and Treatment Services  
(OEI; 05-08-00520; expected issue date:  FY 2009; work in progress)  
 
Providers Billing More Time Than Is Feasible in a Day  
(OAS; W-00-09-31137; various reviews; expected issue date:  FY 2009; new start)  
 
Rehabilitative Services  
(OAS; W-00-08-31028; various reviews; expected issue date:  FY 2009; work in progress)  
 
Enhanced Reimbursement to States for Indian Health Service Claims  
(OAS; W-00-09-31138; various reviews; expected issue date:  FY 2009; new start) 
 
Reimbursement Rates for Services Provided by Indian Health Service Facilities  
(OAS; W-00-07-31221; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medical Services for Undocumented Aliens  
(OAS; W-00-07-31108; W-00-08-31108; various reviews, expected issue date:  FY 2009; work 
in progress)  
 
Medicaid Payments for Laboratory Services for Dual-Eligible Beneficiaries  
(OEI; 04-07-00340; expected issue date:  FY 2009; work in progress)  
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  42  Fiscal Year 2008    Medicaid Administration  
 
Contingency Fee Payment Arrangements  
(OAS; W-00-06-31045; W-00-07-31045; W-00-08-31045; various reviews; expected issue date:  
FY 2009; work in progress) 
  
Medicaid Payments for Services Provided Under Section 1115 Demonstration Projects  
(OAS; W-00-08-31208; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Waiver Safety Net Care Pools  
(OAS; W-00-09-31308; various reviews; expected issue date:  FY 2009; new start)  
 
Medicaid Payments for Services Provided Under Section 1915(b) Managed Care/Freedom of 
Choice Waivers  
(OAS; W-00-08-31125; W-00-08-31316; various reviews; expected issue date:  FY 2009; work 
in progress)  
 
Sections 1915(b) and (c) Concurrent Waivers  
(OAS; W-00-08-31309; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Payments for Services Provided Under Section 1915(c) Home- and Community-Based 
Service Waivers  
(OAS; W-00-07-39045; W-00-07-31124; W-00-08-31124; various reviews; expected issue date:  
FY 2009; work in progress)  
 
Enrollment of Excluded Medicaid Providers  
(OEI; 09-08-00330; expected issue date:  FY 2009; work in progress)  
 
Medicaid Transformation Grants  
(OAS; W-00-09-31139; various reviews; expected issue date:  FY 2010; new start)  
 
Medicaid Provider Tax Issues  
(OAS; W-00-08-31094; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Eligibility in Multiple States  
(OAS; W-00-08-31114; various reviews; expected issue date:  FY 2009; work in progress)  
 
Duplicate Medicaid Payments to Providers on Behalf of Hurricane Evacuees  
(OAS; W-00-08-31117; various reviews; expected issue date:  FY 2009; work in progress)  
 
State Agencies Redeterminations of Medicaid Eligibility  
(OAS; W-00-09-31140; various reviews; expected issue date:  FY 2010; new start)  
 
Use of Public Assistance Reporting To Reduce Improper Medicaid Payments by Multiple States  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start)  
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  43  Fiscal Year 2008    Medicaid Administrative Costs  
(OAS; W-00-07-39044; W-00-06-31123; W-00-08-31123; various reviews; expected issue date:  
FY 2009; work in progress)  
 
Medicare/Medicaid Credit Balances  
(OAS; W-00-08-31311; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Management Information System Costs  
(OAS; W-00-08-31312; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Statistical Information System Data Reporting  
(OEI; 04-07-00240; expected issue date:  FY 2009; work in progress)  
 
Medicaid Managed Care Encounter Data:  Reporting and Utilization  
(OEI; 07-06-00540; expected issue date:  FY 2009; work in progress)  
 
State Buy-In of Medicare Coverage  
(OAS; W-00-08-31220; various reviews; expected issue date:  FY 2009; work in progress)  
 
Medicaid Services to Incarcerated Juveniles  
(OAS; W-00-07-31222; various reviews; expected issue date:  FY 2009; work in progress)  
 
Early Implementation of the Medicaid Transfer of Asset Rules  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start) 
 
Medicaids All-Inclusive Rate for Reimbursement to the Indian Health Service  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start)  
 
States Subsidies of Employer-Sponsored Insurance Premium Assistance Programs  
(OEI; 00-00-00000; expected issue date:  FY 2010; new start)  
 
Medicare and Medicaid Information Systems and Data Security  
 
Medicare and Medicaid:  Security of Portable Devices Containing Personal Health Information 
at Contractors and Hospitals  
(OAS; W-00-09-41047; various reviews; expected issue date:  FY 2009; new start)  
 
Medicare and Medicaid Health Information Data Security and Privacy  
(OAS; W-00-08-41021; W-09-00-41050; various reviews; expected issue date:  FY 2009; work 
in progress and new start; OEI; 00-00-00000; various reviews; expected issue date:  FY 2009; 
new start)  
 
Medicaid Management Information SystemsBusiness Associate Agreements  
(OAS; W-00-09-41045; various reviews; expected issue date:  FY 2009; new start) 
 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  44  Fiscal Year 2008    Medicaid:  Security Controls Over State Web-Based Applications  
(OAS; W-00-09-41046; various reviews; expected issue date:  FY 2009; new start)  
 
Medicaid:  Security Controls at the Mainframe Data Center That Processes States Claims Data  
(OAS; W-00-07-40019; expected issue date:  FY 2009; work in progress)  
 
Medicaid and State Childrens Health Insurance Program  
 
Medicaid and State Childrens Health Insurance Program Citizenship Requirements  
(OAS; W-00-09-31224; various reviews; expected issue date:  FY 2010; new start)  
 
Dually Enrolled Beneficiaries in a State  
(OAS; W-00-08-31314; A-04-08-03036; expected issue date:  FY 2009; work in progress)  
 
Medicaid and State Childrens Health Insurance Program Payment Error Rate Measurement  
(OAS; W-00-09-31141; various reviews; expected issue date:  FY 2009; new start)  
 
Medicaid and State Childrens Health Insurance Program Payment Error Rate for One States 
Managed Care Program  
(OAS; W-00-09-40037; expected issue date:  FY 2009; new start) 
______________________________________________________________________________ 
Medicaid-Related Program Integrity Activities  45  Fiscal Year 2008    APPENDIX D:  ACRONYMS AND ABBREVIATIONS 
 
The following is a list of selected acronyms and abbreviations used in this publication. 
 
AMP    average manufacturer price          
CIA    corporate integrity agreement  
CMP    civil monetary penalty 
CMPL   Civil Monetary Penalties Law       
CMS    Centers for Medicare & Medicaid Services 
CMS/MIG  CMS, Medicaid Integrity Group        
DOJ    Department of Justice          
DRA    Deficit Reduction Act of 2005        
DSH    disproportionate share hospital          
EMTALA  Emergency Medical Treatment and Labor Act 
EQRO   external quality review organization   
FCA    False Claims Act 
FUL    Federal upper limit                  
FY    fiscal year 
HCBS   home- and community-based services              
HCCA   Health Care Compliance Association 
HCFAC   Health Care Fraud and Abuse Control Program 
HHS     Department of Health and Human Services    
HIPAA  Health Insurance Portability and Accountability Act 
IMD    institution for mental diseases 
IT     information technology 
MAC    maximum allowable cost 
MCO    managed care organization       
MFCU   Medicaid Fraud Control Unit 
MIP    Medicaid Integrity Program    
MMIS   Medicaid Management Information System       
OAS    Office of Audit Services          
OEI    Office of Evaluation and Inspections       
OIG    Office of Inspector General 
OMB    Office of Management and Budget          
SAUSA  Special Assistant United States Attorney 
SCHIP   State Childrens Health Insurance Program 
TCM    targeted case management 
UPL    upper payment limit   
 
 
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Medicaid-Related Program Integrity Activities  46  Fiscal Year 2008