Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
G S M
E ORGIA  TATE  EDICAID 
 
F C U : 
  RAUD  ONTROL  NIT   
 
2015 O R  
  NSITE  EVIEW 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin  
Deputy Inspector General  
for Evaluation and Inspections  
 
September 2015 
OEI-07-15-00090   
   
EXECUTIVE SUMMARY:  GEORGIA STATE MEDICAID FRAUD CONTROL UNIT: 
2015 ONSITE REVIEW 
OEI-07-15-00090 
 
WHY WE DID THIS STUDY 
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit (MFCU or 
Unit) grant awards, annually recertifies the Units, and oversees the Units performance in 
accordance with the requirements of the grant.  As part of this oversight, OIG conducts periodic 
reviews of all Units and prepares public reports based on these reviews  These reviews assess Unit 
performance in accordance with the 12 MFCU performance standards and its compliance with 
applicable Federal requirements. 
 
HOW WE DID THIS STUDY  
We conducted an onsite review of the Georgia Unit in March 2015.  We based our review on  
analysis of data from seven sources:  (1) a review of policies, procedures, and documentation 
related to the Units operations, staffing, and caseload for fiscal years (FYs) 2012 through 2014; 
(2) a review of financial documentation for FYs 2012 through 2014; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Units management; 
(6) an onsite review of a sample of files for cases that were open in FYs 2012 through 2014; and 
(7) an onsite observation of Unit operations. 
 
WHAT WE FOUND 
For FYs 2012 through 2014, the Georgia Unit reported 34 criminal convictions, 58 civil judgments 
and settlements, and combined criminal and civil recoveries of $179 million.  We identified areas 
where the Unit could improve its functioning.  Specifically, nearly a third of case files lacked 
documentation of supervisory approval to open cases and nearly half of the Units case files open 
longer than 90 days lacked documentation of periodic supervisory reviews.  Additionally, the Unit 
did not report all convictions and adverse actions to Federal partners within required timeframes.  
We also found that the Unit did not always exercise proper fiscal control of its resources.  
Specifically, the Unit did not comply with special terms added to its grant in one year; and did not 
have fiscal controls necessary to ensure accurate and timely fiscal reporting.   
 
WHAT WE RECOMMEND  
We recommend that the Georgia Unit: (1) implement processes to ensure that case files include 
documentation of supervisory approval for opening and closing cases and periodic supervisory 
review; (2) implement processes to ensure that convictions and adverse actions are reported to 
Federal partners within required timeframes; (3) work with OIG to repay the $47,550 offset that 
should have been made in FY 2012; and (4) implement additional controls to ensure that the Units 
expenditures are accounted for timely, accurately, and in compliance with the terms of the grant.  
The Unit concurred with all four recommendations. 
   
   
TABLE OF CONTENTS 
Objective ..................................................................................................... 1 

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

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

Findings....................................................................................................... 5 

For FYs 2012 through 2014, the Georgia Unit reported 

34 criminal convictions, 58 civil judgments and settlements,  

and combined criminal and civil recoveries of $179 million .......... 5 

Nearly a third of case files lacked documentation of supervisory 

approval to open cases; however, almost all case files included 

documentation of supervisory approval to close cases ................... 6 

Nearly half of the Units case files open longer than 90 days 
lacked documentation of periodic supervisory reviews .................. 6 

The Unit did not report all convictions and adverse actions to 

Federal partners within required timeframes .................................. 6 

In FY 2012, the Unit did not comply with special grant terms,  
resulting in a claim of $47,550 in unallowable Federal funds ........ 8 

During FYs 2012 through 2014, the Units fiscal controls did not 

ensure accurate and timely recording and reporting of 

expenditures .................................................................................... 8 

Conclusion and Recommendations ............................................................. 9 

Unit Comments and Office of Inspector General Response ......... 11 
 
Appendixes................................................................................................ 12 

A: 2012 Performance Standards ................................................... 12 

B: Georgia State Medicaid Fraud Control Unit Referrals by 

Referral Source for FYs 2012 Through 2014 ................................ 16 

C: Detailed Methodology ............................................................. 17 

D: Investigations Opened and Closed By Provider Category  

for FYs 2012 Through 2014 .......................................................... 21 

E: Point Estimates and 95-Percent Confidence Intervals Based 

on Reviews of Case Files .............................................................. 23 

F: Unit Comments ........................................................................ 24 

Acknowledgments ..................................................................................... 27 

 
   
OBJECTIVE 
To conduct an onsite review of the Georgia State Medicaid Fraud 
Control Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse 
and neglect under State law.1  Pursuant to Title XIX of the SSA, each 
State must maintain a certified Unit unless the Secretary of Health 
and Human Services determines that operation of a Unit would not 
be cost-effective because (1) minimal Medicaid fraud exists in that 
State and (2) that the State has other adequate safeguards to protect 
Medicaid beneficiaries from abuse and neglect.2  Currently, 49 States 
and the District of Columbia (States) have created such Units.3 In 
fiscal year (FY) 2014, combined Federal and State grant 
expenditures for the Units totaled $235 million.4, 5   That year, the 
50 Units employed 1,958 individuals.6    
To carry out its duties and responsibilities in an effective and 
efficient manner, each Unit must employ an interdisciplinary staff 
that consists of at least an investigator, an auditor, and an attorney.7   
Unit staff review complaints referred by the State Medicaid agency 
and other sources and determine their potential for criminal 
prosecution and/or civil action.  In FY 2014, the 50 Units 
collectively obtained 1,318 convictions and 874 civil settlements or 
______________________________________________________ 
1 Social Security Act (SSA)    1903(q).  Regulations at 42 CFR   1007.11(b)(1) 
 
add that the Units responsibilities may include  reviewing complaints of 
 
misappropriation of patients private funds in  residential health care facilities. 

2  SSA  1902(a)(61). 
   
3 North Dakota and the territories of  American Samoa, Guam, the Northern 

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

4 All FY references in this report are based on the Federal FY (October 1  through 
 
September 30). 
 
5  Office of  Inspector General (OIG),  MFCU  Statistical Data for Fiscal Year 2014. 

Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.pdf on February 25, 2015. 

6 Ibid. 

7  SSA  1903(q)(6); 42  CFR  1007.13.  

Georgia State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00090)   1 
   
   
judgments.8  That year, the Units reported recoveries of 
approximately $2 billion.9  
Units are required to have either statewide authority to prosecute 
cases or formal procedures to refer suspected criminal violations to 
an agency with such authority.10 In Georgia and 43 other States, the 
Units are located within offices of  State Attorneys General that have 
this authority.  In the remaining six States, the Units are located in 
other State agencies; generally, such Units must refer cases to other 
offices with prosecutorial authority.11  Additionally, each Unit must 
be a single, identifiable entity of State government, distinct from the 
single State Medicaid agency, and each Unit must develop a formal 
agreementi.e., a memorandum of understanding (MOU)that 
describes the Units relationship with that agency.12   
Oversight of the MFCU Program  
The Secretary of Health and Human Services delegated to OIG the 
authority both to annually certify the Units and to administer grant 
awards to reimburse States for a percentage of their costs of operating 
certified Units.13   All Units are currently funded by the Federal 
Government on a 75-percent matching basis, with the States 
contributing the remaining 25 percent.14   To receive Federal 
reimbursement, each Unit must submit an initial application to OIG.15   
OIG reviews the application and notifies the Unit if the application is 
approved and the Unit is certified. Approval and certification are for a 
1-year period; the Unit must be recertified each year thereafter.16 In 
addition to annual recertification, OIG performs periodic onsite 
reviews of the Units. 
______________________________________________________ 
8 OIG,  MFCU  Statistical Data  for Fiscal Year 2014. Accessed at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm on February 25, 2015. 

9 Ibid. 

10  SSA  1903(q)(1). 
 
11 OIG,  Medicaid Fraud Control Units.  Accessed at 

http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp on 
 
February 25, 2015. 

12  SSA  1903(q)(2); 42  CFR  1007.9(d). 
  
13 The portion of funds reimbursed to States by the Federal  Government for its
  
share of expenditures for the Federal Medicaid program, including the MFCUs, is 

called Federal Financial Participation.  

14  SSA  1903(a)(6)(B). 
  
15 42  CFR  1007.15(a). 
 
16 42 CFR   1007.15(b) and  (c). 

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Pursuant to Title XIX of the SSA, States must operate Units that 
effectively carry out their statutory functions and meet program 
requirements.17   To clarify the criteria that OIG applies in assessing 
whether a Unit is effectively carrying out these functions and meeting 
program requirements, OIG developed and issued 12 performance 
standards.18  Examples of the standards include maintaining an 
adequate caseload through referrals from several sources, maintaining 
a training plan for all professional disciplines, and establishing policy 
and procedure manuals.  See Appendix A for a description of each of 
the 12 performance standards.  
Georgia MFCU 
Located in Atlanta, the Unit is an autonomous entity within the 
Georgia Office of the Attorney General;19, 20 it investigates and 
prosecutes cases of Medicaid fraud and patient abuse and neglect.  
To investigate and prosecute such cases, the Unit employs 
investigators, attorneys, and auditors, as well as nurses and 
analysts.21  Cases are investigated using a team approach; teams are 
comprised of individuals from each of the above disciplines.  At the 
time of our review, the Unit had six investigative teams, including 
five criminal teams and one civil team. 
Referrals.  The Unit receives referrals from a variety of sources, 
including the State Medicaid agency, local law enforcement, 
and private citizens. Unit referrals by referral source for 
FYs 2012 through 2014 can be found in Appendix B. For each 
referral received, Unit management meets to evaluate the referral 
and determine what action needs to be taken (e.g., whether to open a 
case for preliminary investigation).  
Investigations and Prosecutions.   When a case is opened, it is assigned 
to one of the five criminal teams or to the civil team for investigation.  
Generally, each team is comprised of an attorney, two investigators, an 
auditor, a nurse, and an analyst; the attorney serves as the team leader.  
______________________________________________________ 
17  SSA  1902(a)(61). 
 
18  77  Fed.  Reg. 32645 (June 1, 2012). 

19 Prior to  our review period, the Unit operated through three State agencies:  the 

Georgia Attorney General's Office, the Georgia Department of Audits, and the 
 
Georgia Bureau of  Investigation.  On  July  1, 2011, the Unit was reorganized under 

the Attorney General's Office. 

20 The grantee for the Units operations is the Georgia Department of Law, which 
 
houses  the Georgia Office of the Attorney General and the Unit.  Hereinafter, we 

refer to the Department of Law as the Attorney General or the Office of the 

Attorney General. 

21 The Unit also employs administrative and information systems staff.  At the 

time of our onsite review, the Unit employed 48 staff members. 

Georgia State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00090)                                   3 
     
   
All team members are involved in planning the investigative strategy 
and in making decisions related to that strategy.  
The Unit investigates and prosecutes both criminal and civil cases.  For 
cases that involve criminal referrals, the Unit completes a preliminary 
investigation within 90 days to determine whether a full investigation 
is warranted.  If the Unit determines a full criminal investigation is not 
warranted, it decides whether to refer the case to the civil team, refer 
the case to another agency, or close the referral.   
Previous OIG Onsite Review  
In June 2008, OIG conducted an onsite review of the Georgia Unit and 
determined that the Unit did not maintain interim investigative  
memoranda, which note the progress of investigations.  Although the 
Unit did note case progress in the Units automated case tracking 
system, OIG stated that the inclusion of interim investigative 
memoranda in official case files was necessary to fully satisfy the 
performance standards.   
METHODOLOGY 
We conducted the onsite review in March 2015.  We based our review 
on an analysis of data from seven sources:  (1) a review of policies, 
procedures, and documentation related to the Units operations, 
staffing, and caseload for FYs 2012 through 2014; (2) a review of 
financial documentation for FYs 2012 through 2014; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; 
(5) structured interviews with the Units management; (6) an onsite 
review of a sample of files for cases that were open in 
FYs 2012 through 2014; and (7) an onsite observation of Unit 
operations. We also used these data sources to determine if any issues 
related to findings from the previous OIG onsite review persisted.  
Appendix C provides a detailed methodology.   
Standards 
These reviews are conducted in accordance with the Quality Standards 
for Inspection and Evaluation issued by the Council of the Inspectors 
General on Integrity and Efficiency. 
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FINDINGS 
For FYs 2012 through 2014, the Georgia Unit 
reported 34 criminal convictions, 58 civil 
judgments and settlements, and combined
criminal and civil recoveries of $179 million 
For FYs 2012 through 2014, the Unit reported 34 criminal 
convictions and 58 civil judgments and settlements.  See Table 1 for 
yearly convictions and civil judgments and settlements.  Of the 
Units 34 convictions over the 3-year period, 32 involved provider 
fraud and 2 involved patient abuse and neglect.  See Appendix D for 
details on investigations opened and closed by provider category. 
Table 1:  Georgia MFCU Criminal Convictions and Civil 
Judgments and Settlements, FYs 20122014  
3-Year 
Outcomes   FY 2012   FY 2013   FY 2014   Total  
Criminal Convictions  14  10  10  34 
Civil Judgments and Settlements   20  15  23  58 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
For the same period, the Unit reported combined criminal and civil 
recoveries of $179 million.  See Table 2 for the Georgia Units 
yearly recoveries and expenditures.  Most of the recoveries were 
obtained from global settlements, which accounted for 88 percent 
of all recoveries during the 3-year review period.22  
Table 2:  Georgia MFCU Recoveries and Expenditures, 
FYs 20122014*  
Type of Recovery   FY 2012   FY 2013   FY 2014   3-Year Total  
Global Civil  $92,780,423   $26,884,305   $38,359,021   $158,023,749 
Nonglobal Civil  $2,255,582   $736,220   $2,151,847   $5,143,650  
Criminal  $6,349,361   $1,789,638   $7,776,456   $15,915,455 
Total 
$101,385,366  $29,410,163  $48,287,325   $179,082,854 
Recoveries  
Total 
$3,818,352  $4,046,590   $4,523,319   $12,388,261  
Expenditures 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
  
* Due to rounding, dollar figures for each category of recoveries do not always sum to the total recoveries.   
______________________________________________________ 
22 Global cases are civil false claims actions involving the U.S. Department of 
Justice and a group of State MFCUs.  The National  Association of Medicaid Fraud 
Control Units facilitates the settlement of global cases. 
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Nearly a third of case files lacked documentation 
of supervisory approval to open cases; however, 
almost all case files included documentation of 
supervisory approval to close cases 
Twenty-nine percent of the case files lacked documentation of 
supervisory approval to open the cases; however, 93 percent of the 
Units closed cases included documentation of supervisory approval 
to close the case.  According to Performance Standard 5(b), Unit 
supervisors should approve the opening and closing of cases.  
Furthermore, the Units policy also requires that opening and closing 
documents be maintained in case files.  Supervisory approval to open 
cases indicates that Unit supervisors are monitoring the intake of  
cases, thereby facilitating progress in the investigation.  Supervisory 
approval of the closing of cases helps ensure the timely completion 
and resolution of cases.  Point estimates and confidence intervals can 
be found in Appendix E. 
Nearly half of the Units case files open longer 
than 90 days lacked documentation of periodic 
supervisory reviews  
Forty-four percent of cases open longer than 90 days lacked 
documentation of periodic supervisory review.  According 
to Performance Standard 7(a), supervisory reviews should be 
conducted periodically and noted in the case file.  Further, the Units 
policy requires that the Unit Director meet with each team for a 
case progress review on a quarterly basis (i.e., every 90 days).  
Following the case progress review, the Units policy states that the 
Director is required to sign and date a Quarterly Case Progress 
Report.23  Periodic supervisory reviews ensure timely completion of 
cases and may identify potential issues during the investigation. 
The Unit did not report all convictions and adverse 
actions to Federal partners within required 
timeframes 
The Unit did not report all convictions to OIG for the purpose of 
program exclusion or all adverse actions to the National Provider 
Data Bank (NPDB) within the required timeframes.  According  to  
Performance Standard 8(f), the Unit should transmit to OIG reports of 
all convictions for the purpose of exclusion from Federal health care 
programs within 30 days of sentencing.  Additionally, Federal  
______________________________________________________ 
23 Georgia Medicaid Fraud Control Unit, Unit Internal Operating Procedures, 
Quarterly Case Progress Reviews, Number 15, p. 1. 
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regulations require that Units report any adverse actions generated as 
a result of investigations or prosecutions of healthcare providers to 
the NPDB.24  
Nearly half of the Units convictions were not reported to 
OIG for program exclusion within the required timeframe 
Sixteen of the Units 34 convictions were not reported to OIG for 
program exclusion within 30 days of sentencing.  Of the cases that 
were not reported timely, 7 were reported over 100 days after 
sentencing, 6 were reported within 51 to 100 days of sentencing, and 
3  were reported within 31 to 50 days of sentencing.  If a Unit fails to 
ensure that convicted individuals are reported for exclusion, those 
individuals may be able to continue to submit claims to and receive 
payments from Medicaid and Federal healthcare programs. 
The Units management explained that individuals are not reported to 
OIG until the Unit has adequate conviction information.  Unit 
management reported that it must obtain copies of sentencing 
documents before referring the convicted individual to OIG.  The 
Units management reported that delays may occur in obtaining 
sentencing documents from the various courts in which individuals are  
sentenced. As a result, the Unit may not report convictions within 
30 days of sentencing. 
Just over half of the Units adverse actions were not 
reported to the National Practitioner Data Bank within the 
required timeframe 
Fourteen of the Units 25 adverse actions were not reported to the 
NPDB within 30 days of the action. Of the adverse actions that were 
not reported timely, 9 were reported over 90 days after the action; 
3 were reported within 61 to 90 days of the action; and 2 were 
______________________________________________________ 
24 SSA   1128E(g)(1) and  45 CFR   60.3.  In  addition to Federal regulations, the 
Performance Standards also require Units to report to NPDB.  Performance 
Standard  8(g) states that the Unit should  report qualifying cases to the Healthcare 
Integrity & Protection Databank [HIPDB],  the National Practitioner Data Bank, or  
successor data bases.  The NPDB is intended to restrict the ability of physicians, 
dentists, and  other health care practitioners to move from State to State without 
disclosure or  discovery of  previous medical malpractice and adverse actions.  We 
reviewed the reporting of adverse actions  under NPDB requirements because the 
HIPDB and the NPDB  were  merged during  our review  period (FYs 2012 through 
201478).  Fed. Reg. 20473 (April  5, 2013).   Examples of final adverse actions  
include, but are not limited to, convictions, civil judgments (but  not civil 
settlements), and program exclusions.  Final adverse actions must be reported to  
the NPDB within  30  days following the action.  See 45 CFR  60.5. 
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reported within 31 to 60 days of the action.  All of the Units adverse 
actions reported to the NPDB were convictions. 
Similar to reporting convictions to OIG for program exclusion, the 
Units management reported that they have the same difficulties 
obtaining required information for reporting adverse actions to the 
NPDB.  The Unit director reported that the sentencing documents 
contain specific information that is used to submit reports of adverse 
actions to the NPDB.  Such information includes the date that the 
sentence is imposed which is required by the NPDB.  As  a  result,  the 
Unit may not report adverse actions within 30 days of the action as 
required. 
In FY 2012, the Unit did not comply with special 
grant terms, resulting in a claim of $47,550 in
unallowable Federal funds  
The Unit did not comply with special grant terms, resulting in 
$47,550 in unallowable Federal funds in FY 2012.  According to 
Performance Standard 1, Units must conform to all applicable 
statutes, regulations, and policy directives, including the terms and 
conditions of the grant award.  When the Unit was reorganized under 
the Georgia Attorney Generals Office in 2011, the Units police cars 
were retained by the Georgia Bureau of Investigations. To account 
for this, OIG added a special term to the Units FY 2012 Notice of 
Award, stating that the Units Federal award was being offset and 
reduced by $47,550. However, the Unit did not reduce its claims by 
the required amount, resulting in it claiming $47,550 in unallowable 
Federal funds. 
During FYs 2012 through 2014, the Units fiscal 
controls did not ensure accurate and timely 
recording and reporting of expenditures  
During FYs 2012 through 2014, the Units accounting systems and 
procedures did not ensure accurate recording of expenditures or 
timely determination and reporting of allowable expenditures, as 
required by the terms of the grant.  According to Performance  
Standard 11, Units must exercise proper fiscal control over their 
resources. 
Subsequent to the period of review, the Unit self-identified several 
errors that occurred during the review period.  Some of the errors 
included: mistakenly claiming $141,578 in grant expenditures for 
invoices related to a one-time move of the Unit twice; not initially 
identifying and claiming allowable expenditures in 2013; and 
submitting inaccurate required reports for 2012, 2013, and 2014. 
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CONCLUSION AND RECOMMENDATIONS 
For FYs 2012 through 2014, the Georgia Unit reported 34 criminal 
convictions and 58 civil judgments and settlements, and combined 
criminal and civil recoveries of $179 million.   
We identified areas where the Unit could improve its functioning.  
Specifically, nearly a third of case files lacked documentation of 
supervisory approval to open cases and nearly half of the Units case 
files open longer than 90 days lacked documentation of periodic 
supervisory reviews. 
We also identified issues with the Units required reporting to 
Federal partners. Specifically, the Unit encountered challenges 
obtaining information needed for reporting convictions and adverse 
actions to Federal partners within 30 days as required. 
Finally, we found that the Unit did not always exercise proper fiscal 
control of its resources. Specifically, the Unit did not comply with 
special terms added to its grant in one year; and did not have fiscal 
controls necessary to ensure accurate and timely fiscal reporting. 
We recommend that the Georgia Unit: 
Implement processes to ensure that case files include 
documentation of supervisory approval for opening and 
closing cases and periodic supervisory review  
The Unit should implement processes to ensure that all case files 
include documented supervisory approval for opening and closing of 
cases. Such processes could include mechanisms to alert Unit staff 
when cases need approval for opening or closing and to ensure that 
documentation is maintained. 
The Unit should implement processes to ensure that periodic case 
reviews are documented consistent with the Units policy.  Such 
processes could include automated reminders to alert Unit staff when 
cases are due for periodic reviews and to ensure that documentation 
is maintained.   
Implement processes to ensure that convictions and 
adverse actions are reported to Federal partners within 
required timeframes 
The Unit should implement processes to ensure that convictions are 
reported to OIG within 30 days and that adverse actions are reported 
to NPDB within 30 days.  Such processes could include contacting 
the various courts to explain  the  necessity of receiving copies of 
sentencing documents so that the Unit can make required reports 
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within the required timeframes.  Additional processes could include 
automated reminders to alert Unit staff when to report convictions 
and adverse actions to Federal partners. 
Work with OIG to repay the $47,550 offset that should 
have been made in FY 2012 
The Unit should work with OIG to repay the $47,550 offset related 
to the police cars retained by the Georgia Bureau of Investigations 
after the Units reorganization under the Attorney Generals Office. 
Implement additional controls to ensure that the Units  
expenditures are accounted for timely, accurately, and in 
compliance with the terms of the grant    
The Unit should evaluate its grant reporting procedures and 
implement additional controls to prevent errors in required reporting 
and claims for grant funds.  Additional controls could include 
periodic reviews of Unit expenditures. 
   
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UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Georgia Unit concurred with all four of our recommendations.   
Regarding the first recommendation, the Unit stated that a form 
noting supervisory approval to open and close an investigation is 
now included in all case files. The Unit also stated that a form 
reflecting periodic supervisory reviews of the status of each case is 
now included in all case files and will be updated on a quarterly 
basis.  
Regarding the second recommendation, the Unit stated that because 
of the challenges it faces when obtaining required court documents, 
its ability to report convictions within required timeframes is often 
outside its control. Nevertheless, the Unit stated that it will continue 
to report convictions and adverse actions within the required 
timeframes so long as it is able to do so.   
Regarding the third recommendation, the Unit stated that it will 
repay the offset related to the police cars retained by the Georgia 
Bureau of Investigations. 
Regarding the fourth recommendation, the Unit stated that it has 
implemented controls to ensure accurate and timely completion of 
the required reporting and claims for grant funds. 
The full text of the Units comments is provided in Appendix F.  
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APPENDIX A 
2012 Performance Standards25   
1. A  UNIT CONFORMS WITH ALL APPLICABLE STATUTES, REGULATIONS, AND POLICY DIRECTIVES, 
INCLUDING:  
A. Section 1903(q) of the Social Security Act,  containing the basic requirements for operation of a MFCU;  
B. Regulations for operation of a MFCU contained in 42 CFR part 1007; 
C. Grant administration requirements at 45 CFR part 92 and Federal cost principles at 2 CFR part 225; 
D. OIG policy transmittals as maintained on the OIG Web site; and  
E. Terms and conditions of the notice of the grant award.  
2. A  UNIT MAINTAINS REASONABLE STAFF LEVELS AND OFFICE LOCATIONS IN RELATION TO THE 
STATES MEDICAID PROGRAM EXPENDITURES AND IN ACCORDANCE WITH STAFFING  
ALLOCATIONS APPROVED IN ITS BUDGET.   
A. The Unit employs the number of staff that is included in the Units budget estimate as approved by OIG.  
B. The Unit employs a total number of professional staff that is commensurate with the States total Medicaid 
program expenditures and that enables the Unit to effectively investigate and prosecute (or refer for 
prosecution) an appropriate volume of case referrals and workload for both Medicaid fraud and patient abuse 
and neglect. 
C. The Unit employs an appropriate mix and number of attorneys, auditors, investigators, and other 
professional staff that is both commensurate with the States total Medicaid program expenditures and that 
allows the Unit to effectively investigate and prosecute (or refer for prosecution) an appropriate volume of case 
referrals and workload for both Medicaid fraud and patient abuse and neglect. 
D. The Unit employs a number of support staff in relation to its overall size that allows the Unit to operate 
effectively.  
E. To the extent that a Unit maintains multiple office locations, such locations are distributed throughout the 
State, and are adequately staffed, commensurate with the volume of case referrals and workload for each 
location. 
3. A  UNIT ESTABLISHES WRITTEN POLICIES AND PROCEDURES FOR ITS OPERATIONS AND 
ENSURES THAT STAFF ARE FAMILIAR WITH, AND ADHERE TO, POLICIES AND PROCEDURES.   
A. The Unit has written guidelines or manuals that  contain current policies and procedures, consistent with 
these performance standards, for the investigation and (for  those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect.  
B. The Unit adheres to current policies and procedures in its operations. 
C. Procedures include a process for referring cases, when appropriate, to Federal and State agencies.  
Referrals to State agencies, including the State Medicaid agency, should identify  whether further investigation 
or other administrative action is warranted, such as the collection of overpayments or suspension of payments.  
D. Written guidelines and manuals are readily available to all Unit staff, either online or in hard copy.  
E. Policies and procedures address training standards for Unit employees.  
4. A  UNIT TAKES STEPS TO MAINTAIN  AN  ADEQUATE VOLUME AND QUALITY OF REFERRALS FROM  
THE STATE MEDICAID  AGENCY AND OTHER SOURCES.    
A. The Unit takes steps, such as the development of operational protocols, to ensure that the State Medicaid 
agency, managed care organizations, and other agencies refer to the Unit all suspected provider fraud cases.  
Consistent with 42 CFR 1007.9(g), the Unit provides timely  written notice to the State Medicaid agency when 
referred cases are accepted or declined for investigation. 
B. The Unit provides periodic feedback to the State Medicaid agency  and other referral sources on the 
adequacy of both the volume and quality  of its referrals. 
______________________________________________________ 
25 77 Fed. Reg. 32645, June  1, 2012. 
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C. The Unit provides timely information to the State Medicaid or other agency when the Medicaid or other 
agency requests information on the status of MFCU  investigations, including when the Medicaid agency 
requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii).  
D. For those States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and 
neglect cases, the Unit takes steps, such as the development of operational protocols, to ensure that pertinent 
agencies refer such cases to the Unit, consistent with patient confidentiality and consent.  Pertinent agencies 
vary by State but may include licensing and certification agencies, the State Long Term Care Ombudsman, and 
adult protective services offices.  
E. The Unit provides timely information, when requested, to those agencies identified in (D) above regarding 
the status of referrals. 
F. The Unit takes steps, through public outreach or other means, to encourage the public to refer cases to the 
Unit. 
5. A  UNIT TAKES STEPS TO MAINTAIN  A  CONTINUOUS CASE FLOW  AND TO  COMPLETE CASES IN AN  
APPROPRIATE TIMEFRAME BASED ON  THE COMPLEXITY OF THE CASES.  
A. Each stage of an investigation and prosecution is completed in an appropriate timeframe.  
B. Supervisors approve the opening and closing of all investigations and review the progress of cases and take 
action as necessary to ensure that each stage of an investigation and prosecution is completed in an 
appropriate timeframe.  
C. Delays to investigations and prosecutions are limited to situations imposed by resource constraints or other 
exigencies. 
6. A  UNITS CASE MIX, AS PRACTICABLE, COVERS ALL SIGNIFICANT PROVIDER TYPES AND 
INCLUDES A  BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.    
A. The Unit seeks to have a mix of cases from all significant provider types in the State. 
B. For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
D. As part of its case mix, the Unit maintains a balance of fraud and patient abuse and neglect cases for those 
States in which the Unit has original jurisdiction to  investigate or prosecute patient abuse and neglect cases.  
C. The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors. Special Unit initiatives may focus on specific provider types. 
E. As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7. A  UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER  AND DEVELOPS A  CASE  
MANAGEMENT SYSTEM THAT  ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.    
A. Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B. Case files include all relevant facts and information and justify the opening and closing of the cases. 
C. Significant documents, such as charging documents and settlement agreements, are included in the file.  
D. Interview summaries are written promptly, as defined by the Units policies and procedures.  
E. The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
F. The Unit has an information management system that allows for the monitoring and reporting of case 
information, including the following:  
1. The number of cases opened and closed and the reason that cases are closed. 
2. The length of time taken to determine whether to open a case referred by the State Medicaid agency  or other 
referring source.  
3. The number, age, and types of cases in the Units inventory/docket 
Georgia State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00090)                                   13 
     
   
4. The number of referrals received by the Unit and the number of referrals by  the Unit to other agencies.  
5. The number of cases criminally prosecuted by the Unit or referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending prosecutions. 
6. The number of criminal convictions and the number of civil judgments. 
7. The dollar amount of overpayments identified. 
8. The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil judgments or prefiling settlements. 
8. A  UNIT COOPERATES WITH OIG AND OTHER FEDERAL AGENCIES IN THE INVESTIGATION AND 
PROSECUTION OF MEDICAID  AND OTHER HEALTH CARE FRAUD.    
A.  The Unit communicates on a regular basis with OIG and other Federal agencies investigating or 
prosecuting health care fraud in the State.  
B. The Unit cooperates and, as appropriate, coordinates with OIGs Office of Investigations and other Federal 
agencies on cases being pursued jointly, cases involving the same suspects or allegations, and cases that have 
been referred to the Unit by  OIG or another Federal agency.   
C. The Unit makes available, to the extent authorized by law and upon request by  Federal investigators and 
prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the 
Medicaid program. 
D. For cases that require the granting of extended jurisdiction to investigate Medicare or other Federal health 
care fraud, the Unit seeks permission from OIG or other relevant agencies under procedures as set by those 
agencies. 
E. For cases that have civil fraud potential, the Unit investigates and prosecutes such cases under State 
authority  or refers such cases to OIG or the U.S. Department of Justice.  
F. The Unit transmits to OIG, for  purposes of program exclusions under section 1128 of the Social Security Act, 
all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
G. The Unit reports qualifying cases to the Healthcare Integrity & Protection Databank, the National Practitioner 
Data Bank, or successor data bases. 
9. A  UNIT MAKES STATUTORY OR PROGRAMMATIC RECOMMENDATIONS, WHEN WARRANTED, TO  
THE STATE GOVERNMENT.    
A. The Unit, when warranted and appropriate, makes statutory  recommendations to the State legislature to 
improve the operation of the Unit, including amendments to the enforcement provisions of the State code. 
B. The Unit, when warranted and appropriate, makes other regulatory or administrative recommendations 
regarding program integrity issues to the State Medicaid agency  and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State legislature and the State Medicaid or other 
agencies in response to recommendations.  
10. A  UNIT PERIODICALLY REVIEWS ITS MEMORANDUM OF UNDERSTANDING (MOU) WITH THE 
STATE MEDICAID AGENCY TO  ENSURE THAT IT REFLECTS CURRENT PRACTICE, POLICY, AND  
LEGAL REQUIREMENTS.    
A. The MFCU documents that it has reviewed the MOU at least every 5 years, and has renegotiated the MOU  
as necessary, to ensure that it reflects current practice, policy, and legal requirements. 
B. The MOU meets current Federal legal requirements as contained in law or regulation, including 42 CFR  
455.21, Cooperation with State Medicaid fraud control units, and 42 CFR  455.23, Suspension of payments 
in cases of fraud. 
C. The MOU is consistent with current Federal and  State policy, including any policies issued by  OIG or the 
Centers for Medicare & Medicaid Services (CMS). 
D. Consistent with Performance Standard 4, the MOU establishes a process to ensure the receipt of an 
adequate volume and quality of referrals to the Unit from the State Medicaid agency.  
E. The MOU incorporates by  reference the CMS Performance Standard for Referrals of Suspected Fraud from  
a State Agency to a Medicaid Fraud Control Unit. 
   
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11. A  UNIT EXERCISES PROPER FISCAL CONTROL OVER UNIT RESOURCES.    
A. The Unit promptly submits to OIG its preliminary budget estimates, proposed budget, and Federal financial 
expenditure reports.   
B. The Unit maintains an equipment inventory that is updated regularly to reflect all property under the Units 
control. 
C. The Unit maintains an effective time and attendance system and personnel activity  records.  
D. The Unit applies generally accepted accounting  principles in its control of Unit funding. 
E. The Unit employs a financial system in compliance with the standards for financial management systems 
contained in 45 CFR 92.20.  
12. A  UNIT CONDUCTS TRAINING THAT  AIDS IN THE MISSION OF THE UNIT.    
A. The Unit maintains a training plan for each professional discipline that includes an annual minimum number 
of training hours and that is at least as stringent as required for professional certification.  
B. The Unit ensures that professional staff comply with their training plans and maintain records of their staffs 
compliance.  
C. Professional certifications are maintained for all staff, including those that fulfill continuing education 
requirements.  
D. The Unit participates in MFCU-related training, including training offered by  OIG and other MFCUs, as such 
training is available and as funding permits. 
E. The Unit participates in cross-training with the fraud detection staff of the State Medicaid agency.  As part of 
such training, Unit staff provide training on the elements of successful fraud referrals and receive training on the 
role and responsibilities of the State Medicaid agency.   
 
   
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APPENDIX B 
Georgia State Medicaid Fraud Control Unit Referrals by  
Referral Source for FYs 2012 Through 2014 
  FY 2012   FY 2013   FY 2014  
Abuse &   Patient  Abuse &   Patient  Abuse &   Patient 
Referral Source   Fraud   Fraud   Fraud  
Neglect   Funds   Neglect   Funds   Neglect   Funds  
Medicaid agency   
PI/SURS26   22  2  0  37  0  2  13  7  10 
Medicaid agency  
6  18  14  3  4  17  5  1  7 
other  
Managed care 
0  0  0  0  0  0  0  0  0 
organizations 
State survey and  
0  0  0  1  0  0  0  0  0 
certification agency 
Other State 
0  0  0  7  0  0  5  0  0 
agencies 
Licensing board  0  0  0  0  0  0  0  0  0 
Law  enforcement   9  0  0  1  2  1  2  0  0 
Office of Inspector 
5  1  0  7  0  0  4  0  0 
General 
Prosecutors  2  0  0  0  0  0  0  0  0 
Providers  6  0  0  2  0  0  3  0  1 
Provider 
1  0  0  1  0  0  3  0  0 
associations 
Private health 
0  0  0  0  0  0  0  0  0 
insurer 
Long-term-care 
0  0  0  0  0  0  1  0  1 
ombudsman  
Adult protective 
0  0  0  0  0  0  0  0  0 
services  
Private citizens  130  8  2  136  2  0  157  2  1 
MFCU hotline   0  1  1  0  0  0  0  0  0 
Self-generated   0  0  0  0  0  0  0  0  0 
Other   13  1  0  6  0  0  4  0  0 
   Total   194  31  17  201  8  20  197  10  20 
   Annual Total   242  229  227 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
   
______________________________________________________ 
26 The abbreviation PI stands  for program integrity; the abbreviation  SURS 
stands for Surveillance and  Utilization Review Subsystem.  
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APPENDIX C 
Detailed Methodology 
Data collected from the seven sources below was used to describe 
the caseload and assess the performance of the Georgia MFCU. 
Data Collection 
Review of Unit Documentation. Prior to the onsite visit, we analyzed 
information regarding the Units investigation of Medicaid cases, 
including information about the number of referrals the Unit 
received, the number of investigations the Unit opened and closed, 
the outcomes of those investigations, and the Units case mix.  We  
also collected and analyzed information about the number of cases 
that the Unit referred for prosecution and the outcomes of those 
prosecutions. 
We gathered this information from several sources, including the 
Units quarterly statistical reports, its annual reports, its 
recertification questionnaire, its policy and procedures manuals, and 
its MOU with the State Medicaid agency.  Additionally, we 
confirmed with the Unit director that the information we had was 
current as of January 2015, and as necessary, we requested any 
additional data or clarification.  
Review of Unit Financial Documentation. To evaluate internal 
control of fiscal resources, we reviewed policies and procedures 
related to the Units budgeting, accounting systems, cash 
management, procurement, property, and staffing.  We reviewed 
records in the Payment Management System (PMS) 27 and revenue 
accounts to determine the accuracy of the Federal Financial Reports 
(FFRs) for FYs 2012 through 2014. We also obtained the Units 
claimed grant expenditures from its FFRs and the supporting 
schedules. From the supporting schedules, we requested and 
reviewed supporting documentation for the selected items.  We noted 
any instances of noncompliance with applicable regulations.   
We selected three purposive samples of (1) transactions, (2) items 
from the Units inventory, and (3) documentation related to 
employees time and effort.  Specifically, using our professional 
judgment and experience, we selected a purposive sample of 
______________________________________________________ 
27 The PMS is a grant payment system operated and maintained  by the Department  
of Health and Human Services, Program Support Center, Division  of Payment  
Management.  The PMS provides disbursement, grant  monitoring,  reporting, and 
case management services to  awarding agencies and grant recipients, such  as 
MFCUs. 
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100 items from 3,554 non-payroll transactions and manual 
accounting adjustments.  We selected routine and nonroutine 
transactions representing a variety of budget categories and payment 
amounts.   
We also selected and verified a purposive sample of 30 items from  
the current inventory list of 263 items.  To ensure a variety in our 
inventory sample, we included items that were portable, high value, 
or unusual in nature (e.g., a pole camera).   
Finally, to assess time and effort, we selected a purposive sample of 
30 of 67 Unit employees that were paid during the review period.  
We selected employees representing a variety of job descriptions, 
salaries, and durations of employment.  For each selected employee, 
we selected one pay period for review.  We then requested and 
reviewed documentation (e.g., time  card records) to support the time 
and effort of that employee in the selected pay period. 
Interviews with Key Stakeholders. In February 2015, we interviewed 
key stakeholders, including officials in the United States Attorneys  
Offices, the State Attorney Generals Office, and other State agencies 
that interacted with the Unit (i.e., the Medicaid Program Integrity Unit, 
the Office of the State Long-Term Care Ombudsman, and the 
Healthcare Facility Regulation Division).  We also interviewed 
supervisors from OIGs Region IV offices who work regularly with the 
Unit. We focused these interviews on the Units relationship and 
interaction with OIG and other Federal and State authorities, and we 
identified opportunities for improvement.  We used the information 
collected from these interviews to develop subsequent interview 
questions for Unit management. 
Survey of Unit Staff.  In February 2015, we conducted an online 
survey of all 41 nonmanagerial Unit staff within each professional 
discipline (i.e.,  investigators, auditors, attorneys, analysts, and nurse 
investigators) as well as support staff.  The response rate was 
100 percent. Our questions focused on operations of the Unit, 
opportunities for improvement, and practices that contributed to the 
effectiveness and efficiency of Unit operations and/or performance.  
The survey also sought information about the Units compliance with 
applicable laws and regulations. 
Onsite Interviews with Unit Management.   We conducted structured 
interviews with the Units management during the onsite review in 
March 2015.  We interviewed the Unit director, chief analyst, chief 
auditor, chief investigator, chief nurse investigator, and chief 
prosecutor. We asked these individuals to provide information 
Georgia State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00090)                                   18 
     
   
related to (1) the Units operations, (2) Unit practices that 
contributed to the effectiveness and efficiency of Unit operations 
and/or performance, (3) opportunities for the Unit to improve its 
operations and/or performance, and (4) clarification regarding 
information obtained from other data sources. 
Onsite Review of Case Files and Other Documentation. We  
requested that the Unit provide us with a list of cases that were open 
at any point during FYs 2012 through 2014. This list of 743 cases 
included, but was not limited to, the current status of the case; 
whether the case was criminal, civil, or global; and the date on which 
the case was opened. From this list of cases, we excluded 259 cases 
that were categorized as global, 45 cases categorized as 
assistance rendered, and 7 cases that had been closed prior to the 
period of our review and thus should not have been included in the 
list.28  The remaining number of case files was 432.  We limited this 
population of 432 case files to cases that were open greater than 
90 days, which resulted in 236 remaining case files.29   
From the remaining 236 cases, we selected a simple random sample 
of 100 cases for review.  This sample included 71 cases that were 
closed at some point during our review.  Two of the sampled cases 
were not reviewed.  One was an open case that the Unit was assisting 
Federal prosecutors with; the Unit was prohibited from releasing any 
information about the case to parties not involved with prosecuting 
it. The second was not actually a case file, but rather an open 
records request; it should  not have been eligible for selection in the 
sample.  Exclusion of these two sampled cases brought the total 
sampled cases we reviewed to 98. 
Through our case file review, we determined that not all sampled 
cases required periodic supervisory review, despite limiting the 
population to cases that were open greater than 90 days.  For 
16 sampled cases, the Units investigative work ceased prior to the 
case being open 90 days, but the case was not officially closed until 
after 90 days. For example, the case may have been referred to 
another agency prior to 90 days, but the closing memo was not 
signed until after 90 days. For four more sampled cases, either the 
______________________________________________________ 
28 Ten of the 45 cases categorized as assistance rendered were also closed  prior 
to the period  of our review.  
29  We limited the population  of cases from which we selected the sample to those 
open greater than 90 days to ensure that every sampled case would be required to  
have at least one periodic review.  We calculated the number of days each case in 
the population data was open based on the case opened and case closed  dates 
provided to us  by the Unit. 
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opened date or closed date the Unit provided was revised through 
our case review.  Based on the revised opened or closed dates, these 
four cases were not open greater than 90 days.  The one remaining 
sampled case was a referral that was never opened for full 
investigation. Only 77 sampled cases required periodic supervisory 
review.  
Using the results of our review of the sampled case files, we made 
population estimates for various characteristics.  All estimates and 
95-percent confidence intervals for projections can be found in 
Appendix E. 
From the initial sample of 100 case files, we selected a simple 
random sample of 50 files for a more indepth review of selected 
issues, such as the timeliness of investigations and case 
development.  An OIG investigator conducted this indepth review.  
We did not make any population estimates based on the sample of 
50 case files.  
Onsite Review of Unit Operations. During our March 2015 onsite 
visit, we reviewed the Units workspace and operations.  
Specifically, we visited the Unit headquarters in the State capital. 
While onsite, we observed the Units offices and meeting spaces, 
security of data and case files, location of select equipment, and the 
general functioning of the Unit. 
Data Analysis  
We analyzed data to identify any opportunities for improvement and 
any instances in which the Unit did not fully meet the performance 
standards or was not operating in accordance with laws, regulations, 
or policy transmittals.30  
   
______________________________________________________ 
30 All relevant  regulations, statutes, and  policy transmittals are available online at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu.  
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APPENDIX D 
Investigations Opened and Closed By Provider Category  
for FYs 2012 Through 2014 
Table D-1: Fraud Investigations  
Provider Category   FY 2012   FY 2013   FY 2014  
Facilities   Opened  Closed   Opened  Closed   Opened   Closed 
 Hospitals  29  12  28  26  26  20 
     Nursing facilities  4  3  3  5  1  2 
     Other long-term-care  
1  0  0  0  6  2 
     facilities  
     Substance abuse treatment       
1  1  1  0  3  3 
centers 
     Other   10  8  7  12  8  6 
   Subtotal   45  24  39  43  44  33 
Practitioners   Opened   Closed  Opened   Closed  Opened   Closed 
     Doctors of medicine or  
23  12  18  25  11  15 
     osteopathy  
Dentists  3  6  5  5  10  7 
Podiatrists  0  1  0  0  0  2 
     Optometrists/opticians  0  0  0  0  2  0 
     Counselors/psychologists  12  10  10  16  9  7 
     Chiropractors  0  1  1  0  0  0 
     Other   5  4  21  9  11  10 
   Subtotal   43  34  55  55  43  41 
Medical Support  Opened  Closed   Opened  Closed   Opened   Closed 
 Pharmacies  13  4  11  19  19  8 
Pharmaceutical 
28  21  33  125  19  13 
     manufacturers  
Suppliers of durable medical 
8  7  9  7  13  4 
     equipment and/or supplies 
     Laboratories  4  1  9  12  7  2 
     Transportation services  3  2  2  3  4  3 
     Home health care agencies  13  3  9  14  13  14 
     Home health care aides  0  0  0  0  1  1 
     Nurses, physician assistants, 
     nurse practitioners, certified   1  1  0  1  0  0 
nurse aides  
Radiologists  0  0  0  1  1  2 
     Medical supportother   16  17  19  22  21  6 
   Subtotal   86  56  92  204  98  53 
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Table D-1 (Continued):  Fraud Investigations  
Program Related   Opened   Closed  Opened   Closed  Opened   Closed 
     Managed care    2  1  2  6  1  0 
     Medicaid program  
2  0  1  3  0  0 
administration 
     Billing company   1  0  1  1  0  1 
     Other   15  3  9  18  11  11 
   Subtotal   20  4  13  28  12  12 
   Total Provider Categories   194  118  199  330  197  139 
Source:  OIG analysis of Unit-submitted documentation, 2015.  
 
Table D-2: Patient Abuse and Neglect Investigations  
Provider Category   FY 2012   FY 2013   FY 2014  
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nursing facilities  14  17  1  4  3  3 
     Other long-term-care facilities   1  0  1  2  1  2 
Nurses, physicians 
assistants, nurse     
6  6  3  3  1  1 
practitioners, certified nurse      
aides 
     Home health aides  2  2  1  1  1  2 
     Other   8  7  2  4  5  5 
   Total   31  32  8  14  11  13 
Source: OIG analysis of Unit-submitted documentation,  2015. 
 
Table D-3: Patient Funds Investigations  
Provider Category   FY 2012   FY 2013   FY 2014  
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nondirect care   1  1  2  2  1  1 
Nurses, physicians 
assistants, nurse     
2  2  3  3  1  1 
practitioners, certified nurse      
aides 
     Home health aides  0  0  0  0  0  0 
     Other   7  7  15  13  17  16 
Total   10  10  20  18  19  18 
Source: OIG analysis of Unit-submitted documentation,  2015  
   
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APPENDIX E 
Point Estimates and 95-Percent Confidence Intervals 
Based on Reviews of Case Files 
95-Percent Confidence 
Sample  Point  Interval  
Estimate  
Size*  Estimate  
Lower  Upper  
Percentage of case files that lacked 
documentation of supervisory approval for  98*  28.6%  22.2%  35.9%  
opening  
Percentage of closed case files that included 
documentation of supervisory approval for  71  93.0%  86.7%  96.4%  
closing  
Percentage of case files that were open longer 
than 90 days that lacked documentation of  77  44.2%  35.8%  52.8%  
periodic supervisory  review  
*Two sampled case files were ineligible to be in the  sample.  One  case  file was an open grand jury case for which  
the Unit could not release information to us; the other one  was an open records request rather than an actual  case.   
Source:  OIG analysis of  Georgia MFCU case files, 2015. 
 
 
   
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APPENDIX F 
Unit Comments 
   
Georgia State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00090)                                   24 
     
   
   
Georgia State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00090)                                   25 
     
   
 
   
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ACKNOWLEDGEMENTS 
This report was prepared under the direction of Brian T.  Whitley, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office.   
Rae Hutchison served as the project leader for this study.  Other 
Office of Evaluation and Inspections staff who conducted the study 
include Michael P. Barrett and Michala Walker.  Office of 
Investigations staff also participated in the review.  Central office 
staff who provided support include Susan Burbach, Kevin Farber, 
Lonnie Kim, and Jacquelyn Towns.  Office of Audit Services staff 
who contributed to this study include Beverly Farley and 
Samantha Forey.  
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Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.