Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
F S M
LORIDA  TATE  EDICAID 
 
 
F C U :
RAUD  ONTROL  NIT   
 
 
2015 O R  
  NSITE  EVIEW
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin 
Deputy Inspector General  
for Evaluation and Inspections 
 
June 2016 
OEI-07-15-00340   
   
EXECUTIVE SUMMARY:  FLORIDA STATE MEDICAID FRAUD CONTROL 
UNIT:  2015 ONSITE REVIEW 
OEI-07-15-00340 
 
WHY WE DID THIS STUDY  
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit 
(MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units 
performance in accordance with the requirements of the grant.  As part of this oversight, 
OIG conducts periodic reviews of all Units and prepares public reports based on these 
reviews.  These reviews assess the Units adherence to the 12 MFCU performance 
standards and compliance with applicable Federal statutes and regulations. 
 
HOW WE DID THIS STUDY 
We conducted an onsite review of the Florida Unit in September 2015.  We based our 
review on an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; (2) financial 
documentation for fiscal years (FYs) 2012 through 2014; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Units 
management; (6) a sample of files for cases that were open in FYs 2012 through 2014; 
and (7) observation of Unit operations.  
 
WHAT WE FOUND 
For FYs 2012 through 2014, the Florida Unit reported 193 convictions, 91 civil 
judgments and settlements, and combined criminal and civil recoveries of nearly 
$382 million.  The Unit also maintained proper fiscal control of its resources.  Unit 
management and OIG reported that colocation of staff promoted joint investigative work. 
However, we identified a few areas where the Unit should improve its operations.  
Specifically, 42 percent of the case files did not contain all periodic supervisory reviews 
of cases, as required by Unit policy.  The Unit did not report all convictions and adverse 
actions to Federal partners within required timeframes, and it investigated one sampled 
case that was not eligible for Federal funding.   
 
WHAT WE RECOMMEND  
We recommend that the Florida Unit:  (1) ensure that it conducts and documents 
supervisory reviews of Unit case files according to the Units policies and procedures; 
(2) implement processes to ensure it reports convictions and adverse actions to Federal 
partners within required timeframes; and (3) repay Federal matching funds spent on a 
case that was not eligible for Federal funding.  The Unit concurred with all three 
recommendations. 
   
   
TABLE OF CONTENTS 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................5 
From FY 2012 through FY 2014, the Unit reported 
193 convictions, 91 civil judgments and settlements, and 
combined criminal and civil recoveries of nearly $382 million .........5 
Forty-two percent of the case files did not contain documentation 
of all periodic supervisory reviews of cases, as required by Unit 
policy; however, almost all of the case files included 
documentation of supervisory approval to open and close cases .......6 
The Unit did not report all convictions and adverse actions to 
Federal partners within required timeframes .....................................7 
The Unit investigated one sampled case that was not eligible for 
Federal funding ..................................................................................8 
The Unit maintained proper fiscal control of its resources ................9 
Other observation:  Unit management and OIG reported that 
colocation of staff promoted joint investigative work ........................9 
Conclusion and Recommendations ............................................................ 11 
Unit Comments and Office of Inspector General Response ............12 
Appendixes ................................................................................................13 
A:  2012 Performance Standards ......................................................13 
B:  Unit Referrals by Referral Source for FYs 2012 Through 
2014 ..................................................................................................17 
C:  Investigations Opened and Closed by Provider Category 
for FYs 2012 Through 2014 .............................................................18 
D:  Detailed Methodology ................................................................20 
E:  Point Estimates and 95-Percent Confidence Intervals Based 
on Reviews of Case Files .................................................................24 
F:  Unit Comments ...........................................................................25 
Acknowledgments......................................................................................27
   
OBJECTIVE 
To conduct an onsite review of the Florida State Medicaid Fraud Control Unit 
(MFCU or Unit). 
BACKGROUND  
The mission of MFCUs is to investigate and prosecute Medicaid provider 
fraud and patient abuse or neglect under State law.1  The SSA requires 
each State to operate a MFCU, unless the Secretary of Health and Human 
Services (HHS) determines that operation of a Unit would not be 
cost-effective because minimal Medicaid fraud exists in a particular State 
and that the State has other adequate safeguards to protect Medicaid 
beneficiaries from abuse and neglect.2  Currently, 49 States and the 
District of Columbia (States) have MFCUs.3 
Each Unit must employ an interdisciplinary staff that consists of at least an 
investigator, an auditor, and an attorney.4  Unit staff review referrals of 
potential fraud and patient abuse or neglect to determine their potential for 
criminal prosecution and/or civil action.  In fiscal year (FY) 2015, the 
50 Units collectively reported 1,553 convictions, 795 civil settlements or 
judgments, and approximately $745 million in recoveries.5, 6 
Units must meet a number of requirements established by the SSA and 
Federal regulations.  For example, each Unit must: 
  be a single, identifiable entity of State government, distinct from 
the single State Medicaid agency;7   
  develop a formal agreement, such as a memorandum of 
understanding (MOU), which describes the Units relationship with 
the State Medicaid agency;8 and   
______________________________________________________ 
1 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 SSA  1903(q)(6); 42 CFR  1007.13. 
5 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2015.  
Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on February 17, 2016. 
6  All FY references in this report are based on the Federal FY (October 1 through     
September 30). 
7 SSA  1903(q)(2); 42 CFR  1007.5 and 1007.9(a). 
8 42 CFR  1007.9(d).  
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)  1 
   
   
  have either statewide authority to prosecute cases or formal 
procedures to refer suspected criminal violations to an agency with 
such authority.9   
MFCU Funding 
Each MFCU is funded jointly by its State and the Federal government.  
Federal funding for the MFCUs is provided as part of the Federal 
Medicaid appropriation, but it is administered by OIG.10  Each Unit 
receives Federal financial participation equivalent to 75 percent of its total 
expenditures, with State funds contributing the remaining 25 percent.11  In 
FY 2015, combined Federal and State expenditures for the Units totaled 
$251 million, $188 million of which represented Federal funds.12   
Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to administer the 
MFCU grant program.13  To receive Federal reimbursement, each Unit must 
submit an initial application to OIG for approval and be recertified each year 
thereafter.   
In annually recertifying the Units, OIG evaluates Unit compliance with 
Federal requirements and adherence to performance standards.  The Federal 
requirements for Units are contained in the SSA, regulations, and policy 
guidance.14  In addition, OIG has published 12 performance standards that it 
uses to assess whether a Unit is effectively performing its responsibilities.15  
The standards address topics such as staffing, maintaining adequate referrals, 
and cooperation with Federal authorities.  Appendix A contains the 
performance standards.   
OIG also performs periodic onsite reviews of the Units, such as this review 
of the Florida MFCU.  During these onsite reviews, OIG evaluates Units 
compliance with laws, regulations, and policies, as well as adherence to the 
12 performance standards.  OIG also makes observations about best 
______________________________________________________ 
9 SSA  1903(q)(1). 
10 SSA  1903(a)(6)(B). 
11 Ibid.  
12 OIG, MFCU Statistical Data for Fiscal Year 2015.  Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on February 17, 2016.   
13 The SSA authorizes the Secretary of HHS to award grants to the Units; the Secretary 
delegated this authority to the OIG. 
14 On occasion, OIG issues policy transmittals to provide guidance and instructions to 
MFCUs.   
15 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/files/Performance%20Standards.pdf on May 22, 2015.  On 
June 1, 2012, OIG published a revision of the performance standards at  
77 Fed. Reg. 32645.  Because our review covered FYs 2012 through 2014, we applied 
the standards published on June 1, 2012. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   2 
     
   
practices, provides recommendations to the Units, and monitors the 
implementation of the recommendations.  These evaluations differ from 
other OIG evaluations as they support OIGs direct administration of the 
MFCU grant program.  These evaluations are subject to the same internal 
quality controls as other OIG evaluations, including internal peer review. 
Additional oversight includes the collection and dissemination of data about 
MFCU operations and the provision of training and technical assistance. 
Florida Unit 
The Unit, a division of the Florida Office of the Attorney General, 
investigates and prosecutes cases of Medicaid fraud and patient abuse and 
neglect.  To investigate and prosecute such cases, the Unit employs staff in 
positions including law enforcement investigator, attorney, auditor, and 
fraud analyst.  The Unit also employs administrative and paralegal staff.   
At the time of our review, the Units 160 employees were located in eight 
offices.  For most operational purposes, the Unit is divided into three 
regions:  North, Central, and South.  The North region has offices in 
Jacksonville, Tallahassee, and Pensacola.  The Central region has offices 
in Orlando and Tampa.  The South region has offices in Miami, Ft. 
Lauderdale, and West Palm Beach.  The Units Complex Civil 
Enforcement Bureau, located in Tallahassee, handles the Units 
participation in qui tam cases, major forfeitures, and complex civil cases.  
The Florida Unit expended $16,910,095 in combined State and Federal 
funds in FY 2015.16   
Referrals.  The Unit receives referrals from a variety of sources, including 
but not limited to the State Medicaid agency, local law enforcement, Adult 
Protective Services, and private citizens.  The Units intake team receives 
referrals and may conduct preliminary work such as obtaining billing 
records.  Referrals are then sent to the field offices.  Appendix B depicts Unit 
referrals by referral source for FYs 2012 through 2014.  
Investigations and Prosecutions.  The law enforcement captain or designated 
lieutenant within the field office assigns the referral to an investigator, who 
assesses the merits of the referral to determine if the facts are sufficient to 
open a case.  Captains approve the opening of cases, and Chief Attorneys 
assign staff attorneys to opened cases.  Within 14 days of case assignment, 
the Lieutenant coordinates a meeting with the investigative team to develop 
an investigative plan.  Lieutenants conduct monthly case review meetings, 
attended by all investigative team members, to discuss current case status, 
______________________________________________________ 
16 OIG, MFCU Statistical Data for Fiscal Year 2015.  Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.pdf on February 17, 2016. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   3 
     
   
case direction, and assigned tasks.  Upon approval of the Chief Attorney, the 
attorney prepares a referral letter to submit the case to the appropriate 
prosecuting authority.  Prosecutions may be handled by the local State 
Attorneys Office or the Office of Statewide Prosecution.  Alternatively, Unit 
attorneys may be cross-designated by the State Attorneys Office or U.S. 
Attorneys Office to prosecute the Units cases.  See Appendix C for details 
on investigations opened and closed by provider category. 
Previous Review 
A 2009 OIG onsite review of the Unit identified one concern related to 1 of 
the 12 performance standards.  OIG found that Unit investigators did not 
prepare interim investigative memorandums noting the progress of 
investigations as part of official case files.  OIG suggested that the Unit 
include interim investigative memorandums in official case files.  The Unit 
responded that it would research the use of investigative memorandums and 
hold management discussions on this topic, and likely implement an interim 
investigative memorandum policy in the future.  Our 2015 onsite review 
found no further evidence that the Unit did not document the progression of 
its investigations. 
METHODOLOGY 
We conducted the onsite review in September 2015.  We based our review 
on an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; 
(2) financial documentation for FYs 2012 through 2014; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
interviews with Unit management and selected staff; (6) a sample of files 
for cases that were open in FYs 2012 through 2014; and (7) observation of 
Unit operations.  Appendix D provides details of our 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. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   4 
     
   
FINDINGS 
Our review of the Florida Unit found that it was generally in compliance 
with applicable laws, regulations, and policy transmittals.  The Unit 
reported combined criminal and civil recoveries of $382 million, 
193 convictions, and 91 civil judgments and settlements for the review 
period.  However, the Unit should ensure that it adheres to the 
performance standards and other Federal requirements by including 
documentation of periodic supervisory reviews in its case files and 
reporting all convictions and adverse actions to the OIG and the National 
Practitioner Data Bank (NPDB) within required timeframes.   
For FYs 2012 through 2014, the Florida Unit reported 
193 criminal convictions, 91 civil judgments and 
settlements, and combined criminal and civil 
recoveries of nearly $382 million 
For FYs 2012 through 2014, the Unit reported 193 criminal convictions 
and 91 civil judgments and settlements.  See Table 1 for the Units yearly 
criminal convictions and civil judgments and settlements.  Of the Units 
193 convictions over the 3-year period, 134 involved provider fraud, 
47 involved patient abuse and neglect, and 12 involved misappropriation 
of patient funds.   
Table 1:  Florida MFCU Criminal Convictions and Civil Judgments 
and Settlements, FYs 20122014 
3-Year 
Outcomes  FY 2012  FY 2013  FY 2014  Total 
Criminal Convictions  66  66  61  193 
Civil Judgments and Settlements  17  39  35  91 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
For the same period, the Unit reported combined criminal and civil 
recoveries of nearly $382 million.  See Table 2 for the Units yearly 
recoveries and expenditures.  Slightly more than half of the recoveries 
were obtained from global cases, which accounted for 58 percent of all 
recoveries during the 3-year review period.17 
   
______________________________________________________ 
17 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. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   5 
     
   
Table 2:  Florida MFCU Recoveries and Expenditures,  
FYs 20122014* 
Type of Recovery  FY 2012  FY 2013  FY 2014  3-Year Total 
Global Civil  $147,077,424  $18,372,264  $54,177,449  $219,627,136 
Nonglobal Civil  $96,908,691  $13,470,829  $34,189,784  $144,569,305 
Criminal  $4,687,000  $9,035,625  $3,989,871  $17,712,496 
Total Recoveries**  $248,673,115  $40,878,718  $92,357,105  $381,908,938 
     Total Expenditures  $13,520,572  $14,179,446  $15,506,674  $43,206,691 
* Due to rounding, dollar figures for each category of recoveries do not always sum to the total recoveries. 
**Recovery amounts vary from year to year due to particular settlements.  For example, $85.6 million of the Units global 
civil recoveries in FY 2012 came from the settlements of three pharmaceutical cases. 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
Forty-two percent of the case files did not contain 
documentation of all periodic supervisory reviews of 
cases, as required by Unit policy; however, almost all 
of the case files included documentation of 
supervisory approval to open and close cases 
Forty-two percent of the Units case files lacked documentation of all 
periodic supervisory reviews, as required by Unit policy.18  This occurred 
even though the case management system generated automated reminders 
alerting supervisors to overdue reviews.   
Performance Standards 5(b) and 7(a) state that supervisors should 
periodically review the progress of cases, consistent with Unit policies and 
procedures, ensure that each stage of an investigation and prosecution is 
completed in an appropriate timeframe, and note in the case file that the 
reviews take place.  The Units policy for supervisory reviews of fraud 
and patient abuse and neglect cases states that lieutenants shall conduct 
monthly case review meetings.19, 20  The Units policy further states that 
lieutenants should electronically document action items discussed in the 
meetings in the case management system.  We note that the Units policy 
requires that supervisory reviews be held monthly, which is more 
frequently than the quarterly supervisory reviews other Units typically 
require. 
______________________________________________________ 
18 Appendix E contains the point estimates and 95-percent confidence intervals for all 
statistics in this report. 
19 Cases with a fugitive status require supervisory review every 6 months. 
20 The Units policy for supervisory reviews of complex civil cases, as written in the 
protocols for such cases, states that cases will be periodically reviewed every April and 
October (i.e., every 6 months). 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   6 
     
   
Although 42 percent of the case files did not contain documentation of all 
periodic supervisory reviews, we also found that, consistent with Unit 
policy, nearly all files contained documentation of supervisory approval to 
open and close cases.  Performance Standard 5(b) states that Unit 
supervisors should approve the opening and closing of cases.  Specifically, 
we found that 99 percent of the Units case files included documentation 
of supervisory approval to open the cases and all of the Units closed case 
files in our sample included documentation of supervisory approval to 
close the cases.21  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. 
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 or all adverse actions to the 
NPDB within the required timeframes.  Performance Standard 8(f) states 
that the Unit should transmit to OIG reports of all convictions for the 
purpose of exclusion from Federal health care programs, within 30 days of 
sentencing.  Additionally, Federal regulations require that Units report any 
adverse actions, generated as a result of prosecutions of healthcare 
providers, to the NPDB within 30 calendar days from the date the adverse 
action was taken.22, 23  The Units policies and procedures did not address 
the reporting of convictions to OIG or the reporting of adverse actions to 
the NPDB.  The Unit reported that staff error contributed to the failure to 
report convictions and adverse actions within the required timeframes.   
______________________________________________________ 
21 All closed case files in our sample included documentation of supervisory approval to 
close the cases.  However, we cannot be certainbecause of sampling errorthat all of 
the Units closed case files in the review period included this documentation.   As a 
statistical matter, we are 95-percent confident that at least 94.4 percent of the closed cases 
in the population had documentation of supervisory approval to close the case. 
22 SSA  1128E(g)(1); 45 CFR  60.3.  Examples of adverse actions include criminal 
convictions; civil judgments (but not civil settlements); exclusions; and other negative 
actions or findings. 
23 45 CFR  60.5.  In addition to Federal regulations, the Performance Standards also 
require the Unit 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). 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   7 
     
   
The Unit did not report half of its convictions to OIG in a timely 
manner and did not report 10 convictions 
The Unit obtained 193 convictions in the review period, half of which it 
did not report within the required timeframe and 10 that it did not report 
prior to the onsite review.24  Of the convictions reported to OIG, the Unit 
did not report half (92 of 183) within 30 days after sentencing.  Of the 
convictions that the Unit did not report on time, the Unit reported 
40 convictions within 31 to 60 days of sentencing, 17 convictions within 
61 to 90 days of sentencing, and 35 convictions more than 90 days after 
sentencing.  Late reporting of convictions to OIG could delay the initiation 
of the program exclusion process, resulting in improper payments to 
providers by Medicare or other Federal health care programs or possible 
harm to beneficiaries. 
The Unit did not report nearly two-thirds of its adverse actions 
to the NPDB in a timely manner 
The Unit reported all 192 adverse actions to the NPDB; however, it did 
not report 65 percent (124 of 192) within 30 days of the action.25  Of the 
adverse actions that the Unit did not report within the required timeframe, 
the Unit reported 57 within 31 to 60 days of the action, 36 within 
61 to 90 days of the action, and 31 more than 90 days after the adverse 
action.  The NPDB is designed 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. 
The Unit investigated one sampled case that was not 
eligible for Federal funding 
The Unit investigated one sampled case that was not eligible for Federal 
matching funds.  According to Federal statute and regulations, the scope 
of a Units grant authority includes the investigation of fraud allegations 
relating to Medicaid providers and patient abuse and neglect allegations in 
Medicaid-funded and board-and-care facilities.26  However, the scope of a 
Units grant authority does not extend to activities related to the 
investigation and prosecution of patient abuse and neglect allegations that 
do not occur in Medicaid-funded or board-and-care facilities.  A Unit may 
______________________________________________________ 
24 Following the onsite review, OIG received reports of all convictions by the end of 
January 2016. 
25 The number of adverse actions is 192 rather than 193 because 1 conviction was not a 
health-care related conviction. 
26 42 CFR  1007.11(a) and (b)(1); SSA  1903(q). 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   8 
     
   
not receive Federal matching funds for activities that fall outside the scope 
of its grant authority.27   
In one sampled case, the Unit investigated an allegation of abuse of a 
Medicaid recipient.  However, the incident did not occur in a Medicaid-
funded or board-and-care facility.  The case remained open for 5 months.   
We note that the Presidents FY 2017 Budget for HHS includes an OIG 
proposal to expand Units authority with regard to cases of patient abuse 
and neglect.28  As Medicaid has been increasingly relying on home and 
community-based services, the proposal would permit the investigation 
and prosecution of patient abuse and neglect arising when Medicaid 
services are provided in either of those settings.   
The proposal would give Units the same authority in the areas of patient 
abuse and neglect cases that they already have for fraud cases. 
The Unit maintained proper fiscal control of its 
resources  
The Unit maintained proper fiscal control of its resources during the 
review period.  Performance Standard 11 states that the Unit should 
exercise proper fiscal control over the Units resources.  The Units 
financial documentation indicated that the Units requests for 
reimbursement for FYs 2012 through 2014 represented allowable, 
allocable, and reasonable costs.  In addition, the Unit maintained adequate 
internal controls related to accounting, budgeting, personnel, procurement, 
property, and equipment.  
Other observation:  Unit management and OIG 
reported that colocation of staff promoted joint 
investigative work 
The Unit participates in the U.S. Department of Justices Medicare Strike 
Force in Miami.  Seven Unit staff (one lieutenant and six investigators) are 
colocated with OIG agents in OIG office space.    According to OIG staff, 
the arrangement has facilitated communication and promoted efficiency in 
the teams joint investigations.  Under this arrangement, OIG staff 
concentrate on investigating allegations of fraud in the Medicare program, 
while Unit staff concentrate on investigating the same allegations in the 
Medicaid program.  OIG reported that it spends no additional funds to 
______________________________________________________ 
27 42 CFR  1007.19(d). 
28 HHS, Fiscal Year 2017 Budget in Brief, Strengthening Health and Opportunity for all 
Americans, pp. 88-89.  Accessed at http://www.hhs.gov/sites/default/files/fy2017-budget-
in-brief.pdf on 
March 8, 2016. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   9 
     
   
maintain these workstations.  Unit management commented that the 
positive working relationship with OIG improved its rapport with other 
Federal partners such as the U.S. Attorneys Office and the Federal 
Bureau of Investigation. 
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   10 
     
   
CONCLUSION AND RECOMMENDATIONS 
Our review of the Florida Unit found that it was generally in compliance 
with applicable laws, regulations and policy transmittals.  For FYs 2012 
through 2014, the Florida Unit reported 193 criminal convictions and 
91 civil judgments and settlements, and combined criminal and civil 
recoveries of $382 million.  The Unit colocated some of its staff with OIG 
agents, thereby promoting joint investigative work.  Additionally, the Unit 
maintained proper fiscal control of its resources. 
We identified two areas where the Unit should improve its operations.  
Specifically, the Unit should ensure that all case files contain 
documentation of periodic supervisory reviews and report all convictions 
and adverse actions to Federal partners within required timeframes.  
Finally, we identified one case that the Unit investigated that was not 
eligible for Federal funding. 
We recommend that the Florida Unit: 
Ensure it conducts and documents supervisory reviews of 
Unit case files according to the Units policies and procedures 
The Unit should take steps to ensure that employees adhere to the Units 
written policy for conducting and documenting supervisory reviews of 
cases. 
Implement processes to ensure it reports convictions and 
adverse actions to Federal partners within required timeframes 
The Unit should implement processes to ensure it reports convictions to 
OIG within 30 days of sentencing and adverse actions to NPDB within 30 
days of the action.  The Unit may want to determine whether an automated 
reminder in its case management system might facilitate timely reporting. 
Repay Federal matching funds spent on the case that was not 
eligible for Federal funding 
The Unit should work with OIG to identify the staff hours and 
expenditures associated with the ineligible case and repay the Federal 
matching funds.   
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   11 
     
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Florida Unit concurred with all three of our recommendations. 
Regarding the first recommendation, the Unit stated it is evaluating 
whether it should change its policy of requiring monthly case reviews to 
requiring quarterly case reviews.  The Unit stated that such a policy 
revision would still allow supervisors to review case progress and improve 
compliance with the Units policies and procedures. 
Regarding the second recommendation, the Unit stated it has revised its 
electronic case file system to capture reporting dates and permit staff to 
easily review convictions and verify reporting dates.  The Unit also stated 
it currently is reviewing system programming to enable the generation of 
electronic reminders of due dates for reporting convictions to OIG and 
adverse actions to NPDB.  Finally, the Unit stated it is reviewing its 
policies and procedures for potential revisions to address this 
recommendation.  Although the Unit stated that it will make every effort 
to meet the required reporting timeframes, it noted that the courts do not 
always make sentencing documents available within these timeframes. 
Regarding the third recommendation, the Unit has worked with OIG to 
identify Unit costs associated with the ineligible case and will repay grant 
funds. 
The Units comments are provided in Appendix F. 
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   12 
     
   
APPENDIX A 
2012 Performance Standards29  
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. 
______________________________________________________ 
29 77 Fed. Reg. 32645 (June 1, 2012). 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   13 
     
   
B.  The Unit provides periodic feedback to the State Medicaid agency and other referral sources on the 
adequacy of both the volume and quality of its referrals. 
C.  The Unit provides timely information to the State Medicaid or other agency when the Medicaid or other 
agency requests information on the status of MFCU investigations, including when the Medicaid agency 
requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii). 
D.  For those States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and 
neglect cases, the Unit takes steps, such as the development of operational protocols, to ensure that pertinent 
agencies refer such cases to the Unit, consistent with patient confidentiality and consent.  Pertinent agencies 
vary by State but may include licensing and certification agencies, the State Long Term Care Ombudsman, and 
adult protective services offices.  
E.  The Unit provides timely information, when requested, to those agencies identified in (D) above regarding 
the status of referrals. 
F.  The Unit takes steps, through public outreach or other means, to encourage the public to refer cases to the 
Unit. 
5. A UNIT TAKES STEPS TO MAINTAIN A CONTINUOUS CASE FLOW AND TO COMPLETE CASES IN AN 
APPROPRIATE TIMEFRAME BASED ON THE COMPLEXITY OF THE CASES. 
A.  Each stage of an investigation and prosecution is completed in an appropriate timeframe. 
B.  Supervisors approve the opening and closing of all investigations and review the progress of cases and take 
action as necessary to ensure that each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
C.  Delays to investigations and prosecutions are limited to situations imposed by resource constraints or other 
exigencies.   
6.  A UNITS CASE MIX, AS PRACTICABLE, COVERS ALL SIGNIFICANT PROVIDER TYPES AND 
INCLUDES A BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.   
A.  The Unit seeks to have a mix of cases from all significant provider types in the State. 
B.  For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
D.  As part of its case mix, the Unit maintains a balance of fraud and patient abuse and neglect cases for those 
States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and neglect cases. 
C.  The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors.  Special Unit initiatives may focus on specific provider types. 
E.  As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7.  A UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER AND DEVELOPS A CASE 
MANAGEMENT SYSTEM THAT ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.   
A.  Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B.  Case files include all relevant facts and information and justify the opening and closing of the cases. 
C.  Significant documents, such as charging documents and settlement agreements, are included in the file.  
D.  Interview summaries are written promptly, as defined by the Units policies and procedures. 
E.  The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
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. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   14 
     
   
2.  The length of time taken to determine whether to open a case referred by the State Medicaid agency or other 
referring source. 
3.  The number, age, and types of cases in the Units inventory/docket 
4.  The number of referrals received by the Unit and the number of referrals by the Unit to other agencies. 
5.  The number of cases criminally prosecuted by the Unit or referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending prosecutions. 
6.  The number of criminal convictions and the number of civil judgments. 
7.  The dollar amount of overpayments identified. 
8.  The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil judgments or prefiling settlements. 
8.  A UNIT COOPERATES WITH OIG AND OTHER FEDERAL AGENCIES IN THE INVESTIGATION AND 
PROSECUTION OF MEDICAID AND OTHER HEALTH CARE FRAUD.   
A.  The Unit communicates on a regular basis with OIG and other Federal agencies investigating or prosecuting 
health care fraud in the State. 
B.  The Unit cooperates and, as appropriate, coordinates with OIGs Office of Investigations and other Federal 
agencies on cases being pursued jointly, cases involving the same suspects or allegations, and cases that have 
been referred to the Unit by OIG or another Federal agency.  
C.  The Unit makes available, to the extent authorized by law and upon request by Federal investigators and 
prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the 
Medicaid program. 
D.  For cases that require the granting of extended jurisdiction to investigate Medicare or other Federal health 
care fraud, the Unit seeks permission from OIG or other relevant agencies under procedures as set by those 
agencies.  
E.  For cases that have civil fraud potential, the Unit investigates and prosecutes such cases under State 
authority or refers such cases to OIG or the U.S. Department of Justice. 
F.  The Unit transmits to OIG, for purposes of program exclusions under section 1128 of the Social Security Act, 
all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
G.  The Unit reports qualifying cases to the Healthcare Integrity & Protection Databank, the National Practitioner 
Data Bank, or successor data bases. 
9. A UNIT MAKES STATUTORY OR PROGRAMMATIC RECOMMENDATIONS, WHEN WARRANTED, TO 
THE STATE GOVERNMENT.   
A.  The Unit, when warranted and appropriate, makes statutory recommendations to the State legislature to 
improve the operation of the Unit, including amendments to the enforcement provisions of the State code. 
B.  The Unit, when warranted and appropriate, makes other regulatory or administrative recommendations 
regarding program integrity issues to the State Medicaid agency and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State legislature and the State Medicaid or other 
agencies in response to recommendations.  
10. A UNIT PERIODICALLY REVIEWS ITS MEMORANDUM OF UNDERSTANDING (MOU) WITH THE 
STATE MEDICAID AGENCY TO ENSURE THAT IT REFLECTS CURRENT PRACTICE, POLICY, AND 
LEGAL REQUIREMENTS.   
A.  The MFCU documents that it has reviewed the MOU at least every 5 years, and has renegotiated the MOU 
as necessary, to ensure that it reflects current practice, policy, and legal requirements. 
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. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   15 
     
   
E.  The MOU incorporates by reference the CMS Performance Standard for Referrals of Suspected Fraud from 
a State Agency to a Medicaid Fraud Control Unit. 
11. A UNIT EXERCISES PROPER FISCAL CONTROL OVER UNIT RESOURCES.   
A.  The Unit promptly submits to OIG its preliminary budget estimates, proposed budget, and Federal financial 
expenditure reports.   
B.  The Unit maintains an equipment inventory that is updated regularly to reflect all property under the Units 
control. 
C.  The Unit maintains an effective time and attendance system and personnel activity records. 
D.  The Unit applies generally accepted accounting principles in its control of Unit funding. 
E.  The Unit employs a financial system in compliance with the standards for financial management systems 
contained in 45 CFR 92.20. 
12. A UNIT CONDUCTS TRAINING THAT AIDS IN THE MISSION OF THE UNIT.   
A.  The Unit maintains a training plan for each professional discipline that includes an annual minimum number 
of training hours and that is at least as stringent as required for professional certification.  
B.  The Unit ensures that professional staff comply with their training plans and maintain records of their staffs 
compliance. 
C.  Professional certifications are maintained for all staff, including those that fulfill continuing education 
requirements. 
D.  The Unit participates in MFCU-related training, including training offered by OIG and other MFCUs, as such 
training is available and as funding permits. 
E.  The Unit participates in cross-training with the fraud detection staff of the State Medicaid agency.  As part of 
such training, Unit staff provide training on the elements of successful fraud referrals and receive training on the 
role and responsibilities of the State Medicaid agency.  
 
 
 
 
 
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   16 
     
   
APPENDIX B 
Table B-1:  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 
State Medicaid 
agency  PIU30  33  0  0  25  1  2  25  0  0 
Medicaid agency  
18  19  2  12  37  1  6  7  3 
other 
Managed care 
5  0  0  2  0  0  7  0  0 
organizations 
State survey and 
0  0  0  1  0  0  0  0  0 
certification agency 
Other State 
20  3  2  14  3  1  16  1  0 
agencies 
Licensing board  0  0  0  0  0  0  0  0  0 
Law enforcement  7  1  1  8  5  3  13  1  0 
Office of Inspector 
19  9  0  10  11  0  23  9  1 
General 
Prosecutors  1  0  0  0  0  0  0  0  0 
Providers  26  3  3  44  0  3  31  1  2 
Provider 
0  0  0  1  0  0  0  0  0 
associations 
Private health 
1  0  0  1  0  1  2  0  0 
insurer 
Long-term-care 
0  2  1  0  0  1  0  1  1 
ombudsman 
Adult protective 
5  446  28  4  453  35  5  777  77 
services 
Private citizens  444  45  22  580  68  26  498  30  17 
MFCU hotline  0  0  0  0  0  0  0  0  0 
Other  129  20  3  155  20  2  173  9  0 
   Total  708  548  62  857  598  75  799  836  101 
   Annual Total  1,318  1,530  1,736 
Source:  OIG analysis of Unit-submitted documentation, FYs 20122014, 2015. 
   
______________________________________________________ 
30 The abbreviation PIU stands for Program Integrity Unit. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   17 
     
   
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  5  3  14  5  8  6 
     Nursing facilities  4  4  1  4  6  1 
     Other long-term-care  
9  10  7  12  4  10 
     facilities 
     Substance abuse treatment            
0  0  0  0  0  0 
     centers  
     Other   5  3  3  5  3  0 
   Subtotal  23  20  25  26  21  17 
Practitioners  Opened  Closed  Opened  Closed  Opened  Closed 
     Doctors of medicine or  
38  30  18  43  32  38 
     osteopathy 
     Dentists  8  7  4  7  10  10 
     Podiatrists  0  2  0  2  0  1 
     Optometrists/opticians  0  0  1  0  1  0 
     Counselors/psychologists  6  2  1  2  3  5 
     Chiropractors  0  0  0  1  0  0 
     Other   0  0  0  0  0  0 
   Subtotal  52  41  24  55  46  54 
Medical Support  Opened  Closed  Opened  Closed  Opened  Closed 
     Pharmacies  22  10  22  19  22  19 
     Pharmaceutical  
41  28  39  60  26  55 
     manufacturers 
     Suppliers of durable medical 
15  5  22  18  25  3 
     equipment and/or supplies 
     Laboratories  3  4  11  4  11  2 
     Transportation services  1  1  2  3  5  3 
     Home health care agencies  36  50  15  43  16  30 
     Home health care aides  6  3  0  5  2  4 
     Nurses, physician assistants,  
     nurse practitioners, certified   5  2  1  6  5  2 
     nurse aides 
     Radiologists  2  1  0  1  0  2 
     Medical supportother   15  20  25  34  54  36 
   Subtotal  146  124  137  193  166  156 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   18 
     
   
 
Table C-1 (Continued):  Fraud Investigations 
Program Related  Opened  Closed  Opened  Closed  Opened  Closed 
     Managed care organizations  4  1  4  7  3  3 
     Medicaid program  
0  1  0  0  0  0 
     administration 
     Billing company  2  0  0  0  0  1 
     Other  0  0  2  0  0  0 
   Subtotal  6  2  6  7  3  4 
   Total Provider Categories  227  187  192  281  236  231 
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  15  14  6  7  8  9 
     Other long-term-care facilities  16  27  15  19  10  15 
Nurses, physician assistants, 
nurse practitioners, certified  13  7  12  8  16  14 
nurse aides 
     Home health aides  0  0  0  0  0  0 
     Other  10  7  12  3  20  18 
   Total  54  55  45  37  54  56 
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  9  9  8  8  6  3 
Nurses, physician assistants, 
nurse practitioners, certified  0  0  1  0  3  1 
nurse aides 
     Home health aides  0  0  0  0  0  0 
     Other  2  6  4  3  3  3 
   Total  11  15  13  11  12  7 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   19 
     
   
APPENDIX D 
Detailed Methodology 
We used data collected from the seven sources below to describe the 
caseload and assess the performance of the Florida Unit.   
Data Collection  
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information from several sources 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 status reports; annual reports; recertification questionnaire; 
policy and procedures manuals; and MOU with the State Medicaid 
agency.  We requested any additional data or clarification from the Unit as 
necessary. 
Review of Unit Financial Documentation.  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)31 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 reviewed three purposive samples to assess the Units internal control 
of fiscal resources.  The three samples included the following: 
1.  To assess the Units expenditures, we selected a purposive sample 
of 1,258 accounting records from 41,803 accounting records.  The 
accounting records were selected from 4 of 38 Unit-supplied files.  
We selected routine and nonroutine accounting records 
representing a variety of budget categories and payment amounts.   
______________________________________________________ 
31 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. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   20 
     
   
2.  To assess inventory, we selected and verified a purposive sample of 
32 items from the current inventory of 209 items listed as located 
in the Units Tallahassee offices.  To ensure a variety in our 
inventory sample, we included items that were portable, high 
value, or unusual in nature (e.g., vehicles, communication 
equipment).   
3.  To assess employee time and effort, we selected a purposive 
sample of 30 of 159 Unit employee names that were paid.  We then 
requested and reviewed documentation (e.g., time card records) to 
support the time and effort of the employees. 
Interviews with Key Stakeholders.  In August and September 2015, we 
interviewed key stakeholders, including officials in the U.S. Attorneys 
Office (Criminal and Civil Divisions), the State Attorney Generals Office, 
and State agencies that interacted with the Unit (i.e., Adult Protective 
Services, Agency for Health Care Administration, Agency for Persons with 
Disabilities, Department of Health, Long-Term Care Ombudsman, Office of 
Statewide Prosecution, and Office of the State Attorney).  We also 
interviewed a supervisor from OIGs Region M Office of Investigations who 
works regularly with the Unit.  We focused these interviews on the Units 
relationship and interaction with OIG and other Federal and State authorities 
and opportunities for improvement.  We used the information collected from 
these interviews to develop subsequent interview questions for Unit 
management. 
Survey of Unit Staff.  In August 2015, we conducted an online survey of 
Unit staff.32  We requested responses from 131 staff members and received 
completed surveys from 130, or 99 percent.  The survey 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.   
Structured Interviews with Unit Management and Selected Staff.  We 
conducted structured interviews with the Units director, deputy director, 
four chief attorneys, five law enforcement captains, and chief auditor.  We 
also conducted group interviews of the Units 15 law enforcement 
lieutenants by geographic location.  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 
______________________________________________________ 
32 We did not survey the MFCU director, deputy director, or other regional supervisors 
whom we interviewed remotely or onsite.  We also did not survey two employees who 
began employment within 2 weeks of the date we conducted our survey. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   21 
     
   
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 1,548 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 155 cases that were categorized as global. 
We then selected a simple random sample of 100 cases from the remaining 
1,393 cases.  From the initial sample of 100 case files, we selected a 
further simple random sample of 50 files for an OIG investigator to 
conduct an indepth review of selected issues, such as the timeliness of 
investigations and case development. 
Fifteen sampled cases were not reviewed.  Fourteen cases were labeled by 
the Unit as civil fraud cases; however, they were global cases.  The 
fifteenth case was a case file number opened for the purpose of conducting 
data mining activities; however, this case did not represent a case worked 
by the Unit.  After excluding the ineligible cases, we reviewed 85 total 
case files.   
Because there were 15 ineligible cases in the 100 sampled cases, it is possible 
that there could be other ineligible cases in the population.  Therefore, we 
estimated (1) the total number of eligible case files, and (2) the number of 
eligible closed case files, as shown in Table D-1. 
Table D-1:  Estimates of the Population of Eligible Case Files 
Sampled  Population 
95-percent 
Estimate Description  Case  of Eligible 
Confidence Interval 
Files  Case Files 
Total eligible case files  85  1,184  1,0691,270 
Eligible closed case files  63  878  755980 
Source:  OIG analysis of Florida MFCU case files, 2015. 
Using the results of our review of the sampled case files, we reported two 
estimates related to the subpopulation of eligible case files and one estimate 
related to the subpopulation of eligible closed case files.  The point estimates 
and their 95-percent confidence intervals are in Appendix E. 
Onsite Review of Unit Operations.  During our September 2015 site visit, 
we observed the Units offices and meeting spaces; the security of data 
and case files; location of select equipment; and the general functioning of 
the Unit.  We also determined whether the Unit referred sentenced 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   22 
     
   
individuals to OIG for program exclusion and whether the Unit reported 
adverse actions to the NPDB.  
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.33   
   
______________________________________________________ 
33 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   23 
     
   
APPENDIX E 
Table E-1:  Point Estimates and 95-Percent Confidence 
Intervals Based on Reviews of Case Files 
95-Percent Confidence 
Sample  Point  Interval for Percentages 
Estimate Characteristic 
Size   Estimate 
Lower  Upper 
Limit  Limit 
Case files that did not contain documentation of 
85  42.4%  32.0%  53.2% 
periodic supervisory review 
Case files that contained documentation of 
85  98.8%  93.8%  99.9% 
supervisory approval for opening 
Case files that contained documentation of 
63  100.0%  94.4%  100.0% 
supervisory approval for closing 
Source:  OIG analysis of Florida MFCU case files, 2015. 
 
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   24 
     
   
APPENDIX F 
Unit Comments 
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   25 
     
   
   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   26 
     
   
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, and Jennifer King, Deputy Regional Inspector General; 
and in consultation with Richard Stern, Director of the Medicaid Fraud 
Policy and Oversight Division. 
Tricia Fields, of the Kansas City regional office, served as the project 
leader for this study.  Other Office of Evaluation and Inspections staff who 
conducted the review include Conswelia McCourt and Dennis J. Tharp.  
Other Medicaid Fraud Policy and Oversight Division staff who 
participated in the review include Susan Burbach.  Office of Investigations 
staff also participated in the review.  Office of Audit Services staff who 
conducted a financial review include Deana Baggett and Beverly Farley.  
Central office staff who contributed include Kevin Farber, Lonie Kim, and 
Joanne Legomsky.   
Florida State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00340)                                   27 
     
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.