Department of Health and Human Services 
OFFICE OF 
 
  INSPECTOR GENERAL 
 
 
 
 
 
 
M  AINE STATE MEDICAID 
 
F C U :
  RAUD  ONTROL  NIT   
 
2015 O R  
  NSITE  EVIEW
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin 
Deputy Inspector General  
for Evaluation and Inspections 
 
September 2015 
OEI-07-15-00140   
   
EXECUTIVE SUMMARY:  MAINE STATE MEDICAID FRAUD CONTROL UNIT:  
2015 ONSITE REVIEW 
OEI-07-15-00140 
 
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 monitor Unit compliance with Federal grant requirements. 
 
HOW WE DID THIS STUDY 
We conducted an onsite review of the Maine Unit in April 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 files for 
cases that were open in FYs 2012 through 2014; and (7) an onsite observation of Unit 
operations.  We also determined whether the Unit had established policies and procedures 
as recommended in a previous OIG onsite review report. 
 
WHAT WE FOUND 
For FYs 2012 through 2014, the Maine Unit reported 19 criminal convictions, 28 civil 
judgments and settlements, and combined criminal and civil recoveries of $32 million.  
Our review of the Units performance identified opportunities for improvement.  
Specifically, we found that over two-thirds of the case files open longer than 90 days 
lacked documentation of periodic supervisory reviews.  We also found that a few cases 
had unexplained investigation delays of a year or more.  Additionally, we found that the 
Unit reported convictions to OIG for program exclusion timely, but could improve its 
reporting of adverse actions to the National Provider Data Bank (NPDB).  Further, the 
Unit did not conduct physical inventories of its property.  Finally, we noted that only a 
small portion of Unit fraud referralsless than 2 percentcame from the State Medicaid 
agencys Program Integrity Unit. 
 
WHAT WE RECOMMEND  
We recommend that the Maine Unit (1) implement policies and procedures to ensure that 
case files include documentation of supervisory approval for opening and closing cases 
and periodic supervisory review, (2) implement policies and procedures to document 
unexplained investigation delays, (3) implement processes to ensure that the Unit reports 
all adverse actions to the NPDB and within the required timeframe, and (4) establish 
policies and procedures for conducting physical inventories of its property.  The Unit 
concurred with all four recommendations. 
   
   
TABLE OF CONTENTS 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................5 
For FYs 2012 through 2014, the Maine Unit reported 19 criminal 
convictions, 28 civil judgments and settlements, and combined 
criminal and civil recoveries of $32 million ....................................5 
A Unit supervisor approved the opening and closing of almost 
all case files; however, over two-thirds of the case files open 
longer than 90 days lacked documentation of periodic 
supervisory reviews .........................................................................6 
A few cases had unexplained investigation delays of a year or 
more .................................................................................................6 
The Unit reported convictions to OIG for program exclusion 
timely, but could improve its reporting of adverse actions to the 
NPDB ...............................................................................................7 
The Unit did not conduct physical inventories of its property.........8 
Other observation:  only a small portion of Unit fraud 
referralsless than 2 percentcame from the State Medicaid 
agencys Program Integrity Unit. .....................................................8 
Conclusion and Recommendations ..............................................................9 
Unit Comments and Office of Inspector General Response .......... 11 
Appendixes ................................................................................................12 
A:  2012 Performance Standards ...................................................12 
B:  Maine State Medicaid Fraud Control Unit Referrals by 
Referral Source for FYs 2012 Through 2014 ................................16 
C:  Investigations Opened and Closed By Provider Category  
for FYs 2012 Through 2014 ..........................................................17 
D:  Detailed Methodology .............................................................19 
E:  Unit Comments.........................................................................22 
Acknowledgments......................................................................................24 
 
   
OBJECTIVE 
To conduct an onsite review of the Maine 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) 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.htm on May 5, 2015. 
6 Ibid. 
7 SSA  1903(q)(6); 42 CFR  1007.13. 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)  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 Maine and 43 other States, the 
Units are located within offices of State Attorney Generals that have 
this authority.  In the remaining six States, the Units are located in 
other State agencies; generally, such Units 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 May 5, 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 
May 5, 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.  
Maine MFCU 
Located in Augusta, the Maine Unit is an autonomous entity within the 
Maine Office of the Attorney General which investigates and 
prosecutes cases of Medicaid fraud and patient abuse.  To investigate 
and prosecute such cases, the Unit employs four detectives, two 
attorneys (which includes the Unit director), one auditor, and a legal 
secretary. 
Referrals.  The Unit receives referrals from a variety of sources, 
including the State Medicaid agency, the State survey and certification 
agency, the State Long-Term Care Ombudsman, and private citizens.  
Unit referrals by referral source for FYs 2012 through 2014 can be 
found in Appendix B. 
An incident report is created each time a referral is received.  The 
incident report includes such information as the date of the report; the 
name of the provider or facility at which the incident is alleged to have 
occurred; the type of referral (e.g., fraud, abuse); and a description of 
the allegations, including the alleged individuals involved and the 
name of the person making the referral.  The Unit director reviews the 
incident report to determine whether to open a case for investigation or 
refer the report to another appropriate entity (e.g., licensing board). 
Investigations and prosecutions.  Referrals that warrant opening as 
cases are investigated and prosecuted, as appropriate.  Once a case is 
opened, it is assigned to a detective and an attorney.  The detective 
works with the Units auditor to complete an investigation.  Upon 
completion of the investigation, the detective submits the case to the 
assigned attorney for review.  The attorney then makes a 
recommendation to the Unit director, who determines whether to 
prosecute the case.  After a case is successfully prosecuted, copies of 
______________________________________________________ 
17 SSA  1902(a)(61). 
18 77 Fed. Reg. 32645 (June 1, 2012). 
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all necessary court documents are collected and case information is 
reported to OIG for program exclusion and to the Health Services 
Resource Administration for reporting to the National Practitioner 
Data Bank (NPDB).19  See Appendix C for details on investigations 
opened and closed. 
Previous OIG Onsite Review 
In 2009, OIG published a report regarding its onsite review of the 
Maine Unit.  OIG found that the Unit was generally in compliance with 
all applicable Federal rules and regulations.  However, OIG identified 
that the Unit lacked formal MFCU-specific policies and procedures.  A 
draft policies and procedures manual was under development at the 
time of the 2009 review.  OIG recommended that the Unit complete the 
policies and procedures manual.  As part of this review, we determined 
that the Unit maintained a completed policies and procedures manual. 
METHODOLOGY 
We conducted an onsite review of the Maine Unit in April 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 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 files for cases that were open in FYs 2012 through 
2014; and (7) onsite observation of Unit operations.  Appendix D 
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. 
______________________________________________________ 
19 The NPDB is used 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 payment and adverse action history. 
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FINDINGS 
For FYs 2012 through 2014, the Maine Unit 
reported 19 criminal convictions, 28 civil 
judgments and settlements, and combined 
criminal and civil recoveries of $32 million 
For FYs 2012 through 2014, the Unit reported 19 criminal 
convictions and 28 civil judgments and settlements.  See Table 1 for 
yearly convictions and civil judgments and settlements.  Of the 
Units 19 convictions over the 3-year period, 11 involved provider 
fraud, 5 involved patient abuse and neglect, and 3 involved patient 
funds. 
Table 1:  Maine MFCU Criminal Convictions and Civil 
Judgments and Settlements, FYs 20122014* 
3-Year 
Outcomes  FY 2012  FY 2013  FY 2014  Total 
Criminal Convictions  2  8  9  19 
Civil Judgments and Settlements  10  6  12  28 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
For the same period, the Unit reported combined criminal and civil 
recoveries of $32 million.  See Table 2 for the Units yearly 
recoveries and expenditures.  Nearly all of the recoveries were 
obtained from global cases, which accounted for 99 percent of all 
recoveries during the 3-year review period.20 
Table 2:  Maine MFCU Recoveries and Expenditures, 
FYs 20122014* 
Type of Recovery  FY 2012  FY 2013  FY 2014  3-Year Total 
Global Civil  $17,810,162  $5,848,924  $8,156,435  $31,815,520 
Nonglobal Civil  $0  $219,533  $0  $219,533 
Criminal  $14,857  $109,607  $18,968  $143,432 
     Total           
$17,825,018  $6,178,064  $8,175,403  $32,178,485 
Recoveries 
     Total 
$674,779  $700,451  $728,262  $2,103,492 
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. 
   
______________________________________________________ 
20 Global cases are civil false claims actions involving the U.S. Department of 
Justice and other State MFCUs.  The National Association of Medicaid Fraud 
Control Units facilitates the settlement of global cases. 
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A Unit supervisor approved the opening and 
closing of almost all case files; however, over 
two-thirds of the case files open longer than 
90 days lacked documentation of periodic 
supervisory reviews 
Eighty-eight percent of case files (92 of 105) included 
documentation of supervisory approval to open the case; case files 
for 98 percent of closed cases (83 of 85) included documentation of 
supervisory approval to close the case.  According to Performance 
Standard 5(b), Unit supervisors should approve the opening and 
closing of all cases.  Supervisory approval to open cases indicates 
that Unit supervisors are monitoring the intake of cases, thereby 
facilitating progress in the investigation.  Further, supervisory 
approval of the closing of cases helps ensure the timely completion 
and resolution of cases. 
The Units policy requires that supervisory reviews occur on a 
quarterly basis (i.e., every 90 days); however, 70 percent of case files 
open longer than 90 days (72 of 103) lacked documentation of 
periodic supervisory review.21  According to Performance Standard 
7(a), supervisory reviews should be conducted periodically, 
consistent with the Units policies and procedures, and noted in the 
case file.  Periodic supervisory reviews can help to ensure timely 
completion of cases and may identify potential issues during the 
investigation. 
Prior to December 2013, it was not the Units practice to note 
periodic supervisory reviews in the case file.  This practice may have 
contributed to the lack of documentation of periodic supervisory 
reviews in the case files.  Of the 72 case files lacking documentation 
of such reviews, all but 4 involved cases opened and investigated 
prior to December 2013.  The Unit director reported that since he 
became director, the Units practice has been to document periodic 
supervisory reviews in the case file. 
A few cases had unexplained investigation delays 
of a year or more 
Nine percent of the Units cases (5 of 53) exhibited unexplained 
investigation delays of a year or more.  According to Performance 
Standard 5, the Unit should take steps to maintain a continuous case 
flow and to complete cases in an appropriate timeframe based on the 
______________________________________________________ 
21 Two of the Units 105 cases had not been open longer than 90 days at the time 
of the onsite review. 
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complexity of the cases.  Additionally, Performance Standard 5(c) 
states that delays in investigation and prosecution should be limited 
to situations imposed by resource constraints or other exigencies.  
None of the five cases included documentation in the file to explain 
the delays; all five were criminal cases.  Of these five cases, one had 
an unexplained delay of at least 3 years, three had unexplained 
delays of at least 2 years, and 1 had an unexplained delay of at least 
a year.22  Further, documentation of periodic supervisory reviews 
was not present in the case files for any of these five cases.  All five 
files involved cases that had been opened and investigated during the 
tenure of previous Unit directors. 
The Unit reported convictions to OIG for program 
exclusion timely, but could improve its reporting 
of adverse actions to the NPDB 
The Unit reported its convictions to OIG for program exclusion 
timely, but did not report all adverse actions to the NPDB as 
required.  Of the 19 adverse actions that should have been reported 
to the NPDB, three were not reported.  These three actions were not 
reported to the NPDB because the actions involved cases with which 
the Unit was assisting OIG, and it was not the Units practice to 
report actions for cases with which it was assisting OIG.  Pursuant to 
Federal regulations, Units must report any adverse actions, generated 
as a result of investigations or prosecutions of healthcare providers, 
to the NPDB.23  Examples of adverse actions include criminal 
convictions; civil judgments (but not civil settlements); exclusions; 
and other negative actions or findings.24  Of the 16 adverse actions 
that were reported, 3 were not reported within 30 days of the action.  
Specifically, the Unit reported one adverse action 26 days late, one 
adverse action 12 days late, and one adverse action 6 days late.   
______________________________________________________ 
22 According to Performance Standard 7(b), case files should include all relevant 
facts and information. For the purposes of this report, we defined a delay as a 
period of at least a year with no documented activity in the case file. 
23 Units must report adverse actions to the NPDB within 30 calendar days from the 
date the final adverse action was taken.  45 CFR  60.5.  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.  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 2014).  78 Fed. Reg. 20473 
(April 5, 2013).   
24 SSA  1128E(g)(1); 45 CFR  60.3.  
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The Unit did not conduct physical inventories of 
its property 
For FYs 2012 through 2014, the Unit did not conduct physical 
inventories of its property.  Federal regulations require equipment to 
be managed in accordance with State laws and procedures.25  In 
Maine, the Department of Administrative & Financial Services 
requires that equipment and inventories be periodically counted.  
Further, Performance Standard 11(b) requires that the Unit maintain 
an equipment inventory that is updated regularly to reflect all of the 
property under the Units control.  Although the Unit did not conduct 
any physical inventories of its property, all sampled inventory items 
were located. 
Other observation:  only a small portion of Unit 
fraud referralsless than 2 percentcame from 
the State Medicaid agencys Program Integrity 
Unit 
Of the 532 fraud referrals received by the Unit during the 3-year 
review period, only 8 of those referrals came from the State 
Medicaid agencys Program Integrity (PI) Unit.  These referrals 
included three fraud referrals in FY 2012, five fraud referrals in 
FY 2013, and no referrals in FY 2014.  Typically, referrals from the 
PI Unit are an essential component of a Units ability to effectively 
investigate and prosecute Medicaid provider fraud.  The Unit 
director reported that he was concerned about the low number of 
referrals from the PI Unit.  Staff turnover within the PI Unit and the 
time taken to revise the State Medicaid agencys policies may have 
affected the PI Units ability to provide referrals. 
   
______________________________________________________ 
25 45 CFR  92.32(b). 
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CONCLUSION AND RECOMMENDATIONS 
For FYs 2012 through 2014, the Maine Unit reported 19 criminal 
convictions, 28 civil judgments and settlements, and combined 
criminal and civil recoveries of $32 million. 
Our review of the Units performance identified opportunities for 
improvement.  Some of those opportunities for improvement relate 
to case file documentation and timely case progression.  Specifically, 
we found that over two-thirds of the case files open longer than 
90 days lacked documentation of periodic supervisory reviews.  
Further, a few cases had unexplained investigation delays of a year 
or more. 
Other opportunities for improvement relate to reporting to Federal 
partners and compliance with other Federal and State requirements.  
Specifically, we found that the Unit reported convictions to OIG for 
program exclusion timely, but could improve its reporting of adverse 
actions to the NPDB.  Additionally, the Unit did not conduct 
physical inventories of its property. 
We also noted that only a small portion of Unit fraud referralsless 
than 2 percentcame from the State Medicaid agencys Program 
Integrity Unit. 
We recommend that the Maine Unit: 
Implement policies and procedures to ensure that case 
files include documentation of supervisory approval for 
opening and closing cases and periodic supervisory 
review 
The Unit should implement policies and procedures to ensure that all 
case files include documented supervisory approval for opening and 
closing of cases.  The Unit should revise its policies and procedures 
manual to require such documentation in the case files.  The Unit 
could also implement procedures that include automated reminders 
or other mechanisms to alert Unit staff when cases need approval for 
opening or closing. 
The Unit should implement policies and procedures to ensure that 
cases are reviewed periodically, consistent with the Units policy.  
The Unit should revise its policies and procedures manual to require 
that periodic supervisory reviews be documented in case files, 
consistent with Performance Standard 7(a).  The Unit could also 
develop procedures that include automated reminders or other 
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mechanisms to alert Unit staff when cases are due for periodic 
reviews.   
Implement policies and procedures to document 
unexplained investigation delays 
The Unit should implement policies and procedures to ensure that 
explanations of delays are included in case files. 
Implement processes to ensure that the Unit reports all 
adverse actions to the NPDB and within the required 
timeframe 
The Unit should implement a tracking system or other means to 
ensure that it reports all adverse actions to the NPDB in accordance 
with Federal regulations. 
Establish policies and procedures for conducting 
physical inventories of its property 
The Unit should develop a policy for conducting physical inventories 
of its property and periodically review the inventory log to ensure all 
property is within its possession. 
 
   
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UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Maine Unit concurred with all four of our recommendations.   
Regarding the first recommendation, the Unit stated that it updated 
its policies and procedures manual to require documented 
supervisory approval for case opening and closing in each case file 
and will verify that such documentation is maintained in the case file 
prior to processing the case in the case management system.  The 
Unit also stated that it will require Unit personnel to complete, 
review, and sign a standardized Quarterly Case Review form once 
every 90 days. 
Regarding the second recommendation, the Unit stated that it has 
updated the standardized Quarterly Case Review form to include 
details about any delays. 
Regarding the third recommendation, the Unit stated that it updated 
its policies and procedures manual to require Unit personnel to 
schedule a reminder of NPDB reporting deadlines for all adverse 
actions. 
Regarding the fourth recommendation, the Unit stated that it updated 
its policies and procedures manual to require an annual physical 
inventory of the Units property. 
The full text of the Units comments is provided in Appendix E. 
   
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APPENDIX A 
2012 Performance Standards26  
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. 
______________________________________________________ 
26 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 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   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. 
11. A UNIT EXERCISES PROPER FISCAL CONTROL OVER UNIT RESOURCES.   
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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.  
 
 
 
 
 
 
   
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   15 
     
   
APPENDIX B 
Maine 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/SURS27  3  0  0  5  0  0  0  0  0 
Medicaid agency  
2  0  0  1  0  0  0  0  0 
other 
State survey and 
63  1,072  161  97  674  138  82  703  203 
certification agency 
Other State 
3  3  0  6  2  0  16  6  2 
agencies 
Licensing board  0  0  0  2  1  0  0  0  0 
Law enforcement  7  1  0  5  1  0  5  0  3 
Office of Inspector 
7  0  0  3  0  1  1  0  0 
General 
Prosecutors  3  0  0  12  0  0  5  0  2 
Providers  27  3  3  38  1  5  24  0  0 
Provider 
2  2  0  1  0  0  0  0  0 
associations 
Private health 
0  0  0  0  0  0  0  0  0 
insurer 
Long-term-care 
1  22  1  0  28  1  1  12  1 
ombudsman 
Adult protective 
3  1  0  0  0  0  0  0  0 
services 
Private citizens  18  3  0  7  1  0  11  3  0 
MFCU hotline  12  7  1  19  2  0  16  3  0 
Self-generated  0  0  0  0  0  0  0  0  0 
Other  10  10  1  4  2  1  10  9  1 
   Total  161  1,124  167  200  712  146  171  736  212 
   Annual Total  1,452  1,058  1,119 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
   
______________________________________________________ 
27 The abbreviation PI stands for program integrity; the abbreviation SURS 
stands for Surveillance and Utilization Review Subsystem. 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   16 
     
   
APPENDIX C 
Investigations Opened and Closed By Provider Category 
for FYs 2012 Through 2014 
Table C-1:  Fraud Investigations  
Provider Category  FY 2012  FY 2013  FY 2014 
Facilities  Opened  Closed  Opened  Closed  Opened  Closed 
     Hospitals  1  0  0  1  0  0 
     Nursing facilities  0  1  0  0  0  0 
     Other long-term-care  
0  1  2  1  0  1 
     facilities 
     Substance abuse treatment            
2  0  0  1  0  0 
     centers  
     Other   2  1  3  1  4  1 
   Subtotal  5  3  5  4  4  2 
Practitioners  Opened  Closed  Opened  Closed  Opened  Closed 
     Doctors of medicine or  
0  1  0  2  1  0 
     osteopathy 
     Dentists  2  2  1  3  1  0 
     Podiatrists  0  0  0  1  0  0 
     Optometrists/opticians  0  0  0  0  0  0 
     Counselors/psychologists  0  1  2  1  4  1 
     Chiropractors  0  0  0  0  0  0 
     Other   0  0  0  1  0  0 
   Subtotal  2  4  3  8  6  1 
Medical Support  Opened  Closed  Opened  Closed  Opened  Closed 
     Pharmacies  1  2  0  1  2  1 
     Pharmaceutical  
0  0  0  0  0  0 
     manufacturers 
     Suppliers of durable medical 
0  0  0  1  0  0 
     equipment and/or supplies 
     Laboratories  0  0  0  0  0  0 
     Transportation services  2  0  1  1  0  0 
     Home health care agencies  1  1  0  2  2  2 
     Home health care aides  1  3  1  1  2  2 
     Nurses, physician assistants,  
     nurse practitioners, certified   2  3  5  3  0  5 
     nurse aides 
     Radiologists  0  0  0  0  0  0 
     Medical supportother   0  0  1  2  1  1 
   Subtotal  7  9  8  11  7  11 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   17 
     
   
 
Table C-1 (Continued):  Fraud Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
Program Related  Opened  Closed  Opened  Closed  Opened  Closed 
     Managed care   0  0  0  0  0  0 
     Medicaid program  
0  0  2  0  0  2 
     administration 
     Billing company  0  0  0  0  0  0 
     Other  0  0  0  0  2  1 
   Subtotal  0  0  2  0  2  3 
   Total Provider Categories  14  16  18  23  19  17 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
 
Table C-2:  Patient Abuse and Neglect Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nursing facilities  0  0  0  1  1  0 
     Other long-term-care facilities  0  0  2  1  0  2 
Nurses, physicians 
assistants, nurse    
4  4  4  3  3  2 
practitioners, certified nurse           
aides 
     Home health aides  0  0  0  0  0  0 
     Other  0  0  0  0  2  1 
   Total  4  4  6  5  6  5 
Source: OIG analysis of Unit-submitted documentation, 2015. 
 
Table C-3:  Patient Funds Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nondirect care  0  0  0  0  0  0 
Nurses, physicians 
assistants, nurse    
1  0  0  1  0  0 
practitioners, certified nurse           
aides 
     Home health aides  0  0  0  0  0  0 
     Other  0  0  0  0  1  1 
   Total  1  0  0  1  1  1 
Source: OIG analysis of Unit-submitted documentation, 2015. 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   18 
     
   
APPENDIX D 
Detailed Methodology 
Data collected from the seven sources below was used to describe 
the caseload and assess the performance of the Maine MFCU. 
Data Collection  
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information regarding the Units investigation of Medicaid cases, 
including information about the number of referrals the Unit 
received, the number of investigations the Unit opened and closed, 
the outcomes of those investigations, and the Units case mix.  We 
also collected and analyzed information about the number of cases 
that the Unit referred for prosecution and the outcomes of those 
prosecutions.   
We gathered this information from several sources, including the 
Units quarterly statistical reports, annual reports, recertification 
questionnaire, policy and procedures manuals, and MOU with the 
State Medicaid agency.  Additionally, we confirmed with the Unit 
director that the information we had was current as of March 2015. 
Review of Unit Financial Documentation.  We reviewed the Units 
control over its fiscal resources to identify any internal control issues 
or other issues involving use of resources.  We also reviewed the 
Units financial policies and procedures; its response to an internal 
control questionnaire; and documents (such as financial status 
reports) related to MFCU grants.  During the onsite review, we 
reviewed a sample of the Units purchase and travel transactions.  In 
addition, we reviewed vehicle records, the supply inventory, and a 
sample of time and effort records. 
Interviews with Key Stakeholders.  In March 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 (e.g., the Medicaid Program Integrity 
Unit, the Office of the State Long-Term Care Ombudsman).  We also 
interviewed supervisors from OIGs Region I 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 March 2015, we conducted an online survey 
of all six nonmanagerial Unit staff within each professional 
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discipline (e.g., investigators, auditors, attorneys) 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 in April 2015.  We 
interviewed the Unit director and the Senior Detective.  We asked 
these individuals to provide information 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.  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 111 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.  We selected all 
111 cases for review.  From the population of 111 cases, we 
purposively assigned 56 for a more indepth review of selected issues, 
such as the timeliness of investigations and case development.28  
This indepth review was conducted by an OIG investigator. 
During our onsite review, we determined that 6 of the 111 cases were 
not eligible for review.  Specifically, we identified that five of the 
cases were categorized as global cases.  One additional case was 
closed prior to the period of review and should not have been 
included in the case list.  We excluded these six ineligible cases from 
our review, resulting in a total of 105 cases reviewed.  Of these 
105 cases, 103 were open longer than 90 days and 85 were closed as 
of the start of the onsite review. 
Onsite Review of Unit Operations.  During our April 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, 
______________________________________________________ 
28 During our onsite visit, we identified that 3 of the 56 cases were categorized as 
global cases.  As a result, these cases were dropped from our review and the 
remaining number of cases reviewed for selected issues was 53. 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   20 
     
   
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.29 
   
______________________________________________________ 
29 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   21 
     
   
APPENDIX E 
Unit Comments 
 
 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   22 
     
   
   
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   23 
     
   
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.  Office of Investigations staff also 
participated in the review.  Central office staff who provided support 
include Jordan R. Clementi, Kevin Farber, Lonnie Kim, and 
Jacquelyn Towns. 
Maine State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00140)                                   24 
     
Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying 
out their respective responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud, waste, or abuse and promoting 
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 
of fraud and misconduct related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI utilizes its resources 
by actively coordinating with the Department of Justice and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to criminal 
convictions, administrative sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
OIG, rendering advice and opinions on HHS programs and operations and providing all 
legal support for OIGs internal operations.  OCIG represents OIG in all civil and 
administrative fraud and abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program guidance, publishes fraud alerts, and provides other 
guidance to the health care industry concerning the anti-kickback statute and other OIG 
enforcement authorities.