Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
I   S M F
DAHO  TATE  EDICAID  RAUD 
 
C U :  
  ONTROL  NIT  
 
2012 O R  
  NSITE  EVIEW
 
Stuart Wright 
Deputy Inspector General for 
Evaluation and Inspections 
 
April 2013 
OEI-09-12-00220   
   
IDAHO STATE MEDICAID FRAUD CONTROL UNIT:  
2012 ONSITE REVIEW 
OEI-09-12-00220 
 
WHY WE DID THIS STUDY  
The Office of Inspector General (OIG) oversees all State Medicaid Fraud Control Units 
(MFCU or Unit) with respect to Federal grant compliance.  As part of this oversight, 
OIG annually reviews and certifies all Units.  In addition, OIG conducts onsite reviews of 
selected States.  These reviews assess Unit performance in accordance with the 12 MFCU 
performance standards and monitor Unit compliance with Federal grant requirements, 
laws, and regulations.   
 
HOW WE DID THIS STUDY 
We analyzed data from seven sources:  (1) a review of documentation, policies, and 
procedures related to the Units operations, staffing, and caseload; (2) a review of 
financial documentation; (3) structured interviews with key stakeholders; (4) a survey of 
Unit staff; (5) structured interviews with the Units management and selected staff; (6) an 
onsite review of case files; and (7) an onsite review of Unit operations. 
 
WHAT WE FOUND 
Our analysis of collected data from fiscal years (FY) 2009 through 2011 shows that the 
Unit reported recoveries of $5 million, Unit convictions and civil judgments and 
settlements increased, and the Unit opened 326 cases.  Unit case files consistently 
contained documentation of supervisory approval to open and close cases, documentation 
of at least one supervisory review, and documentation of additional, periodic supervisory 
reviews.  The Unit lacked adequate safeguards to secure case files, however.  In addition, 
the Unit had not fully updated its policies and procedures manual to reflect its current 
operations and had not updated its memorandum of understanding (MOU) with Idahos 
State Medicaid agencythe Department of Health and Welfare (DHW)to reflect 
current law and practice.  Except for case file security and an MOU stipulation that the 
Unit may be charged for data requests, we found no evidence of noncompliance with 
applicable laws, regulations, and policy transmittals. 
 
WHAT WE RECOMMEND 
We recommend that the Idaho Unit:  (1) ensure that case files are secured against 
unauthorized access and/or removal and create adequate policies or procedures for 
securing case files and other documentation containing personally identifiable 
information, (2) revise its policies and procedures manual to reflect current Unit 
operations, and (3) revise its MOU with DHW to reflect current law and practice.  The 
Unit concurred with all three of our recommendations. 
 
 
 
 
 
 
   
TABLE OF CONTENTS 
 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................7 
From FY 2009 through FY 2011, the Unit reported recoveries       
of $5 million, Unit convictions and civil judgments and  
settlements increased, and the Unit opened 326 cases .....................7 
Ninety-eight percent of case files contained documentation of 
supervisory approval to open and close cases ..................................8 
Ninety-one percent of case files contained documentation of at 
least one supervisory review and 89 percent contained 
documentation of additional, periodic supervisory reviews ............9 
The Unit lacked adequate safeguards to secure case files ...............9 
The Units policies, procedures, and MOU with DHW were 
outdated ............................................................................................9 
Other Observation:  Investigative Checklist and Case Plan .......... 11 
Conclusion and Recommendations ............................................................12 
Unit Comments and Office of Inspector General Response ..........13 
Appendixes ................................................................................................14 
A:  Performance Standards for Medicaid Fraud Control Units .....14 
B:  Referrals of Provider Fraud and Patient Abuse and Neglect     
to the Idaho Medicaid Fraud Control Unit by Source, Fiscal    
Years 2009 Through 2011 ..............................................................18 
C:  Investigations Opened and Closed by Provider Category       
and Case Type, Fiscal Years 2009 Through 2011 ..........................19 
D:  Case File Review Population, Sample Size Counts, and 
Confidence Interval Estimates .......................................................21   
E:  Unit Comments.........................................................................23 
Acknowledgments......................................................................................25 
 
 
 
 
 
 
   
   
 
OBJECTIVE 
To conduct an onsite review of the Idaho State Medicaid Fraud Control 
Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse and 
neglect under State law.1  Pursuant to Title XIX of the SSA, each State 
must maintain a certified Unit unless the Secretary of Health and Human 
Services (HHS) determines that operation of a Unit would not be 
cost-effective because (1) minimal Medicaid fraud exists in that State; and 
(2) the State has other, adequate safeguards to protect Medicaid 
beneficiaries from abuse and neglect.2  Currently, 49 States and the District 
of Columbia (States) have created such Units.3  In fiscal year 
(FY) 2011,4 combined Federal and State grant expenditures for the Units 
totaled $208.6 million, of which Federal funds represented 
$156.7 million.5  That year, the 50 Units employed 1,833 individuals.6  
Each Unit must employ an interdisciplinary staff that consists of at least an 
investigator, an auditor, and an attorney to carry out its duties and 
responsibilities in an effective and efficient manner.7  The staff reviews 
complaints provided by the State Medicaid agency and other sources and 
determines their potential for criminal prosecution and/or civil action.  
Collectively, in FY 2011, the 50 Units reported 1,230 convictions and 
906 civil settlements or judgments.  That year, the Units reported 
recoveries of approximately $1.7 billion.8 
 
1 Social Security Act (SSA)  1903(q). 
2 SSA  1902(a)(61).  Regulations at 42 CFR 1007.11(b)(1) add that the Units 
responsibilities may include reviewing complaints of misappropriation of patients 
private funds in residential health care facilities. 
3 North Dakota and the territories of American Samoa, Guam, the Northern Mariana 
Islands, Puerto Rico, and the U.S. Virgin Islands have not established Units. 
4 The Office of Inspector General (OIG) had not yet published final FY 2012 figures at 
the time of this report. 
5 All FY references in this report are based on the Federal FY (October 1 through 
September 30). 
6 OIG, State Medicaid Fraud Control Units Fiscal Year 2011 Grant Expenditures and 
Statistics.  Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/ on 
April 16, 2012. 
7 SSA  1903(q)(6) and 42 CFR 1007.13. 
8 OIG, State Medicaid Fraud Control Units Fiscal Year 2011 Grant Expenditures and 
Statistics.  Pursuant to 42 CFR  1007.17, Units report the total amount of recovered 
funds in their annual reports to OIG.   
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  1 
   
   
Units are required to have either statewide authority to prosecute cases or 
formal procedures to refer suspected criminal violations to an office with 
such authority.9  In Idaho and 43 other States, the Units are located with 
offices of State Attorneys General that have this authority.  In the 
remaining six States, the Units are located in other State agencies;10 
generally, such Units must refer cases to offices with prosecutorial 
authority.  Additionally, each Unit must be a single, identifiable entity of 
State government, distinct from the State Medicaid agency, and each Unit 
must develop a formal agreemente.g., a memorandum of understanding 
(MOU)that describes the Units relationship with that agency.11  
Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to both annually 
certify the Units and administer grant awards to reimburse States for a 
percentage of their costs of operating them.12  All Units are currently funded 
by the Federal Government on a 75-percent matching basis, with the States 
contributing the remaining 25 percent.13  To receive Federal reimbursement, 
each Unit must submit an initial application to OIG.14  OIG reviews the 
application and notifies the Unit if it is approved and the Unit is certified.  
Approval and certification are valid for a 1-year period; the Unit must be 
recertified each year thereafter.15   
Pursuant to Title XIX of the SSA, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.16  
OIG developed and issued 12 performance standards to define the criteria 
that OIG applies in assessing whether a Unit is effectively carrying out 
statutory functions and meeting program requirements.17  Examples include 
maintaining an adequate caseload through referrals from several sources, 
 
9 SSA  1903(q)(1). 
10 In States with a Unit, the Unit shares responsibility for protecting the integrity of the 
Medicaid program with the section of the State Medicaid agency that functions as the 
Program Integrity Unit.  Some States also employ a Medicaid Inspector General who 
conducts and coordinates fraud, waste, and abuse activities for the State agency. 
11 SSA  1903(q)(2) and 42 CFR  1007.9(d).  
12 The portion of funds reimbursed to States by the Federal Government for its share of 
expenditures for the Federal Medicaid program, including the MFCUs, is referred to as 
Federal Financial Participation. 
13 SSA  1903(a)(6)(B).  
14 42 CFR  1007.15(a). 
15 42 CFR  1007.15(b) and (c). 
16 SSA  1902(a)(61). 
17 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov on 
November 22, 2011.  Since the time of our onsite data collection (May 2012), OIG has 
published a revision of the performance standards, 77 Fed. Reg. 32645 (June 1, 2012).  
The performance standards referred to in this report are from 1994 and were in effect at 
the time of our review. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  2 
   
   
maintaining an annual training plan for all three of the professional 
disciplines (i.e., for auditors, investigators, and attorneys), and establishing 
policy and procedures manuals to reflect the Units operations.  See 
Appendix A for a complete list of the performance standards. 
Idaho Unit  
The Unit was founded in 2007; this is its first onsite review. 
The Unit is an autonomous entity within the Criminal Law Division of the 
Idaho Office of the Attorney General and has the authority to prosecute 
Medicaid fraud and patient abuse and neglect cases.  At the time of our 
review, the Units nine employees were located in the State capital of 
Boise.  The Unit Director directly supervises all Unit employees and acts 
as the Chief Attorney.   
The Unit receives provider fraud referrals from the State Medicaid 
agencythe Idaho Department of Health and Welfare (DHW)and from 
Federal agencies, such as OIG.  The Unit receives patient abuse and 
neglect referrals from DHWs Bureau of Facility Standards and Bureau of 
Long-Term Care.  Idaho State statute18 requires the Unit to refer all patient 
abuse and neglect allegations it receives to Adult Protective Services of 
the Idaho Commission on Aging.19  The Unit receives patient abuse and 
neglect and provider fraud referrals from other State and local agencies 
and through a Medicaid Fraud Report Form available on the Idaho 
Attorney General Web site.20  During the review period, the Unit 
automatically opened all referrals as cases upon receipt.  However, 
beginning in September 2011, the Unit changed its policy to open cases 
only after management accepts them for further investigation.  For 
additional information on Unit referrals, see Appendix B. 
The Units Chief Investigator screens all referrals the Unit receives,21 
researches the referred complaints, and provides recommendations to the 
Unit Director on whether to pursue the cases further.  The Unit Director 
decides whether to proceed with the investigations or refer the cases to 
another agency and notifies the Criminal Law Division Chief of his/her 
decision.22  For additional information on the Units opened and closed 
 
18 Idaho Statute Title 39, Chapter 53, Adult Abuse, Neglect, and Exploitation Act. 
19  However, the Unit may still investigate these allegations on its own, without waiting 
for action from Adult Protective Services or local law enforcement. 
20 Complainants use this form to refer both provider fraud and patient abuse and neglect 
cases to the Unit online.  The Unit received 35 Medicaid Fraud Report Form referrals in 
FYs 20092011. 
21 The Unit occasionally will open cases that were not formally referred by an outside 
source.  For example, a case may be brought to the Units attention by the media. 
22 The Criminal Law Division Chief within the Idaho Office of the Attorney General 
supervises the Unit Director. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  3 
   
   
investigations, including a breakdown by case type and provider category, 
see Appendix C. 
The Unit may open a case and pursue it through a variety of actions, 
including criminal prosecution, civil action, or a combination of the two.  
The Unit may close a case for a variety of reasons, including, but not 
limited to, resolving it through criminal and/or civil action or referring it 
to another agency.   
METHODOLOGY 
We analyzed data from seven sources:  (1) a review of documentation, 
policies, and procedures related to the Units operations, staffing, and 
caseload for FYs 2009 through 2011; (2) a review of financial 
documentation for FYs 2009 through 2011; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with 
the Units management and selected staff; (6) an onsite review of case 
files that were open in FYs 2009 through 2011; and (7) an onsite review of 
Unit operations.  
We analyzed data from all seven sources to describe the caseload and 
assess the performance of the Unit.  We also analyzed the data to identify 
any opportunities for improvement and any instances in which the Unit 
did not meet the performance standards or was not operating in 
accordance with laws, regulations, and policy transmittals.23  In addition, 
we noted any practices that appeared to benefit the Unit.  We based these 
observations on statements from Unit staff, data analysis, and our own 
judgment.  We did not independently verify the effectiveness of these 
practices, but included the information because it may be useful to other 
Units in their operations. 
We conducted the onsite review in May 2012. 
Data Collection and Analysis 
Review of Unit Documentation.  We reviewed documentation, policies, 
and procedures related to the Units operations, staffing, and cases, 
including its annual reports, quarterly statistical reports, and responses to 
recertification questionnaires.  We also reviewed the Units data 
describing how it investigates and prosecutes Medicaid cases.  Data 
collected included information such as the number of referrals received by 
the Unit and the number of investigations opened and closed.   
Review of Financial Documentation.  We reviewed Unit financial 
practices to determine compliance with applicable laws and regulations 
 
23 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov.  
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  4 
   
   
and to determine the need for additional internal controls.  Prior to the 
onsite review, we reviewed the Units financial policies and procedures, 
its response to an internal control questionnaire, and MFCU grant-related 
documents such as financial status reports.  During the onsite review, we 
examined a sample of the Units purchase and travel transactions.  In 
addition, we examined a sample of time and effort records, vehicle 
records, and the equipment inventory.   
Interviews With Key Stakeholders.  We conducted structured interviews 
with six individual stakeholders among four agencies who were familiar 
with Unit operations.  Specifically, we interviewed DHWs Medicaid 
Program Integrity Supervisor; DHWs Bureau of Facility Standards Chief; 
an Assistant U.S. Attorney based in Boise; the Criminal Law Division 
Chief; an OIG Special Agent based in Boise; and an Assistant Special 
Agent in Charge for OIGs Region IX, which includes the State of Idaho.  
These interviews focused on the Units interaction with external agencies, 
Unit operations, opportunities for improvement, and any practices that 
appeared to benefit the Unit and that may be useful to other Units in their 
operations. 
Survey of Unit Staff.  We conducted an electronic survey of all applicable 
Unit staff.24  We requested and received responses from six nonmanagerial 
staff members, for a 100-percent response rate.25  Our questions focused 
on operations of the Unit, opportunities for improvement, and practices 
that appeared to benefit the Unit and that may be useful to other Units in 
their operations.  The survey also sought information about the Units 
compliance with applicable laws, regulations, and policy transmittals.   
Interviews With Unit Management and Selected Staff.  We conducted 
structured interviews with the Units Director (Chief Attorney), Chief 
Investigator, and an auditor.  We asked them to provide us with additional 
information necessary to better understand the Units operations, identify 
opportunities for improvement, identify practices that appeared to benefit 
the Unit and that may be useful to other Units in their operations, and 
clarify information obtained from other data sources.  
Onsite Review of Case Files.  We selected a simple random sample of      
100 case files from the 329 cases26 that were open at any point from 
FY 2009 through FY 2011.  The design of this sample allowed us to 
 
24 We did not survey one of the Units nonmanagerial auditors because we interviewed 
that auditor onsite. 
25 This report uses the terms management and supervisors interchangeably.  
Nonmanagement employees are Unit staff members who have no supervisory 
authority. 
26 This figure includes cases opened before FY 2009 that remained open at some point 
during FYs 20092011. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  5 
   
   
estimate the percentage of all 329 cases with various characteristics at the 
95-percent confidence level.  We reviewed these 100 sampled case files 
and the Units processes for monitoring the status and outcomes of cases.  
From these 100 case files, we selected another simple random sample of 
50 for a more in-depth review of potential issues.  This second-phase 
sample allowed us to conduct a more comprehensive review of case files 
to identify other potential issues from a qualitative perspective.  For 
population and sample size counts, as well as confidence interval 
estimates, see Appendix D. 
Onsite Review of Unit Operations.  While onsite, we reviewed the Units 
operations.  Specifically, we observed intake of referrals, data analysis 
operations, security of data and case files, and the general functioning of 
the Unit.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.27 
 
27 Full text of these standards is available online at http://www.ignet.gov/pande/ 
standards/oeistds11.pdf.  
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  6 
   
   
FINDINGS 
From FY 2009 through FY 2011, the Unit reported 
recoveries of $5 million, Unit convictions and civil 
judgments and settlements increased, and the Unit 
opened 326 cases  
From FY 2009 through FY 2011, the Unit reported total criminal and civil 
recoveries28 of $5 millionan annual average of $1.7 million (see 
Table 1).  Of the $5 million in recoveries, the Unit attributed $4.8 million 
to civil recoveries and $225,000 to criminal recoveries.  The Units annual 
average expenditures for FYs 2009 through 2011 were $647,000.29   
Table 1:  Idaho MFCU Reported Recovered Funds, FYs 2009 Through 2011 
3-Year  Annual 
FY 2009  FY 2010  FY 2011 
  Total  Average 
Reported Criminal 
$20,185  $28,764  $176,152  $225,101  $75,034 
Recoveries 
Reported Civil 
$985,219  $2,597,964  $1,190,879  $4,774,062  $1,591,354 
Recoveries 
Total Reported 
$1,005,404  $2,626,728  $1,367,031  $4,999,163  $1,666,388 
Recoveries 
Total 
$596,666  $646,119  $699,273  $1,942,058  $647,353 
Expenditures 
Source:  OIG analysis of Unit Quarterly Statistical Reports, FYs 2009 through 2011. 
From FY 2009 through FY 2011, Unit convictions and civil 
judgments and settlements increased 
From FY 2009 through FY 2011, the Unit obtained 15 convictions and 
23 civil judgments and settlementsan annual average of 5 convictions 
and 7.7 civil judgments and settlements (see Table 2).   
 
 
 
 
 
28 Unit-reported recoveries include only the State share of funds recovered from 
multi-State, or global, civil false claims cases, both those worked directly by the Unit 
and those worked by staff from other Units.  The Unit-reported civil recoveries do not 
include the Federal share of recoveries allotted to the Idaho Unit from global cases 
involving the U.S. Department of Justice and other State MFCUs.   
29 The Unit provided data on reported expenditures in response to an OIG data request on 
February 3, 2012.  The figures presented in this paragraph are rounded. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  7 
   
   
Table 2:  Unit Convictions and Civil Judgments and/or Settlements, 
FYs 2009 Through 2011 
3-Year  Annual 
FY 2009  FY 2010  FY 2011 
  Total  Average 
Convictions  2  5  8  15  5 
Civil Judgments and/or Settlements  3  9  11  23  7.7 
Source:  OIG analysis of Unit Quarterly Statistical Reports, FYs 2009 through 2011. 
 
The Units convictions increased during the review periodfrom two in 
FY 2009 to eight in FY 2011.  The Units civil judgments and settlements 
also increased during the review periodfrom 3 in FY 2009 to 11 in 
FY 2011. 
From FY 2009 through FY 2011, the Unit opened 326 cases 
From FYs 2009 through 2011, the Unit opened an average of 109 cases 
annuallyan average of 93 provider fraud and 16 patient abuse and 
neglect cases.  From FYs 2009 through 2011, the Unit closed an average 
of 97 cases annuallyan average of 82 provider fraud and 15 patient 
abuse and neglect cases.30  From FYs 2009 through 2011, the Unit 
received an average of 106 referrals annuallyan average of 95 provider 
fraud and 11 patient abuse and neglect referrals. 
Ninety-eight percent of case files contained 
documentation of supervisory approval to open and 
close cases 
According to Performance Standard 6(b), Unit supervisors should approve 
the opening and closing of cases to ensure a continuous case flow and the 
timely completion of cases.  Supervisory approval to open and close cases 
demonstrates that Unit supervisors are monitoring the intake of cases and 
the timeliness of case resolutions, thereby promoting the efficiency and 
effectiveness of Unit staff.  Based on our review of 100 case files, the Unit 
documented supervisory approval to both open and close cases in 
98 percent of the case files. 
 
 
 
 
 
30 Closures include multiple cases opened before FY 2009. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  8 
   
   
Ninety-one percent of case files contained 
documentation of at least one supervisory review and 
89 percent contained documentation of additional, 
periodic supervisory reviews 
According to Performance Standard 6(c), supervisory reviews should be 
conducted periodically and noted in the case file to ensure timely case 
completion.31  Based on our review of 100 case files, 91 percent of Unit 
case files contained documentation indicating at least one supervisory 
review and 89 percent contained documentation indicating additional, 
periodic supervisory reviews. 
The Unit lacked adequate safeguards to secure case 
files 
According to Performance Standard 1, a Unit will conform to all 
applicable statutes, regulations and policy transmittals.  Pursuant to 
Federal regulations, a Unit must prevent the misuse of information under 
the Units control by safeguarding the privacy rights of witnesses, 
victims, and informants.32  A Unit must also safeguard the identities of 
suspects when the allegations are unsubstantiated, unless such identities 
are already in the public record or the individuals clearly consented to the 
release of their private information.  Unit case files containing personally 
identifiable information were not secured from access by non-MFCU 
personnel.  Although individuals must use a coded access card to enter the 
Units general office space, several Attorney General Criminal Law 
Division entities share this office space, and non-MFCU personnel can 
gain access to areas where case files are stored on open, accessible 
shelves.  These vulnerabilities have created the possibility that personally 
identifiable information could be removed from the premises undetected.  
Since our onsite review, the Unit has provided documentation 
demonstrating that the case files have been properly secured. 
The Units policies, procedures, and MOU with DHW 
were outdated 
Although the Unit updated its policies and procedures manual in 
February 2012, the Unit Director stated that the investigative checklist had 
not been incorporated into the written manual.  In addition, the Unit did 
not have adequate policies or procedures for securing case files and other 
 
31 For the purposes of this report, supervisory approval to open and close a case does not 
constitute a supervisory review.  Periodic supervisory review indicates that a supervisor 
reviewed a case more than once between the cases opening and closing. 
32 42 CFR  1007.11(f); OIG State Fraud Policy Transmittal 99-02, Public Disclosure 
Requests and Safeguarding of Privacy Rights (December 22, 1999). 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  9 
   
   
documentation containing personally identifiable information.  Moreover, 
the Units MOU with DHW had not been updated to reflect recent legal 
changes that allow the Unit to refer any provider under investigation of a 
credible fraud allegation to DHW for payment suspension.  In addition, the 
Units MOU with DHW33 stipulates that the Unit may be charged for data 
requests to the DHW Medicaid Program Integrity Unit, contrary to Federal 
regulations.34 
The Unit had not updated its policies and procedures manual to 
reflect current Unit operations 
According to Performance Standard 3, a Unit should establish policies and 
procedures for its operations, which should be included in a policies and 
procedures manual.  According to Unit management, the manual needs to 
be revised to incorporate the use of the investigative checklist.  In 
addition, the manual does not incorporate adequate policies and 
procedures for securing case files and other documentation containing 
personally identifiable information from unauthorized access and/or 
removal. 
The Unit had not updated its MOU with DHW to reflect current 
law and practice 
According to Performance Standard 10, Units should periodically review 
their MOUs with the State Medicaid agency to ensure that they reflect 
current law and practice.  As required by Federal regulations, 35 the Unit had 
an MOU with DHW.  However, the MOU did not reflect recent legal 
changes that allow the Unit to refer any provider under investigation for a 
credible fraud allegation to DHW for payment suspension.36  
In addition, Federal regulations require that the State Medicaid agency 
promptly fulfill any data request from a Unit without charge,37 and that State 
Medicaid agency obligations to the Unit must be included in the 
MOU between the Unit and DHW.38  However, the MOU between the Unit 
and DHW stipulates that if a charge is incurred by DHW [as a result of 
fulfilling a data request for the Unit], then such charges will be reimbursed 
by the [Unit].39  In addition, the MOU stipulates that Unit requests for 
information will be assigned equal priority to similar requests from 
 
33 Memorandum of Understanding between the Idaho Office of Attorney General and the 
Idaho Department of Health and Welfare,  III(A&B). 
34 42 CFR  455.21(a)(2)(i). 
35 42 CFR  1007.9(d). 
36 42 CFR  455.23 and 1007.9(e).   
37 42 CFR  455.21(a)(2)(i).  
38 42 CFR  1007.9(d). 
39 Memorandum of Understanding between the Idaho Office of Attorney General and the 
Idaho Department of Health and Welfare,  III(A&B). 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  10 
   
   
DHW staff, provided the data does not have to be specially retrieved.40  
Neither MOU stipulation complies with Federal regulations, which state 
that Unit data requests must be fulfilled promptly, regardless of retrieval 
difficulty, and without charge.  The Unit Director indicated that the Unit has 
never been charged by DHW for data, and that Unit data requests were 
completed promptly by DHW. 
Other Observation:  Investigative Checklist and Case 
Plan 
According to Performance Standard 6, a Unit should have a continuous 
case flow and complete its cases in a reasonable time.  According to Unit 
management and staff, the implementation of an investigative checklist in 
February 2010 benefitted the Units case flow.  The investigator assigned 
to each case uses the checklist as an investigation guide, and Unit 
supervisors use the checklist to ensure that personnel follow appropriate 
investigation policies and procedures and that all investigation steps are 
completed.  In addition, Unit attorneys discuss the investigative case 
plan of each case with the investigator assigned to the case prior to the 
Units monthly staff meetings.  Each investigative case plan is then 
reviewed by the Unit Director.  The investigative case plan contains the 
overall investigation and prosecution strategy for each case, describes how 
far the case has progressed, and lists which documents should be included 
in the case files.  
 
40 Ibid.,  III(C). 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  11 
   
   
CONCLUSION AND RECOMMENDATIONS 
From FY 2009 through FY 2011, the Unit obtained 15 convictions and 
23 civil judgments or settlements, reported recoveries of $5 million, and 
opened 326 cases.  Unit convictions and civil judgments and settlements 
increased during the review period.  Unit supervisors consistently 
approved the opening and closing of cases, and case files consistently 
contained documentation of periodic supervisory reviews.  The Unit took 
steps to ensure timely case completion by implementing an investigative 
checklist and investigative case plan.  Finally, the Unit exercised proper 
fiscal control over its resources.  
Other opportunities for improvement exist.  Specifically, Unit case files 
were not secured against potential unauthorized access or removal.  The 
Units policies and procedures manual had not been updated to reflect all 
current Unit operations.  Finally, the Units MOU with DHW was not 
updated to reflect recent legal changes that allow the Unit to refer any 
provider under investigation of a credible fraud allegation to DHW for 
payment suspension, and the MOU allowed for the Unit to be charged by 
DHW for data requests, contrary to Federal regulations.  With the 
exceptions of case file security and the MOU stipulation that the Unit may 
be charged for data requests, our review of compliance issues found no 
evidence of significant noncompliance with applicable laws, regulations, 
or policy transmittals. 
We recommend that the Idaho Unit: 
Ensure That Its Case Files Are Secure 
The Unit should store its case files and other documentation containing 
personally identifiable information in a locked room or in locked storage 
cabinets.  Since our onsite review, the Unit has provided documentation 
demonstrating that the case files have been properly secured. 
Revise Its Policies and Procedures Manual To Reflect Current 
Unit Operations  
The Unit should revise its policies and procedures manual to include the 
investigative checklist and develop policies and procedures for securing 
case files and other documentation containing personally identifiable 
information.   
Revise Its MOU With DHW To Reflect Current Law and Practice 
The Unit should revise its MOU with DHW to specify that the Unit may 
refer any provider suspected of fraud for payment suspension to DHW and 
to describe the procedures for this type of referral.  In addition, the Unit 
should revise its MOU with DHW to remove the stipulation that the Unit 
may be charged for data requests. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  12 
   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Unit concurred with the three report recommendations. 
Regarding our first recommendation, the Unit secured its case files by 
moving the files into a locked room. 
Regarding our second recommendation, the Unit revised its policies and 
procedures to include the investigative checklist and developed policies 
and procedures for securing case files and other documentation containing 
personally identifiable information. 
Regarding our third recommendation, the Unit is working with DHW to 
complete a revised MOU by October 5, 2013. 
The full text of the Units comments is provided in Appendix E.  We did 
not make any changes to the report as a result of the Units comments. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  13 
   
   
APPENDIX A 
Performance Standards for Medicaid Fraud Control Units 
(Unit)41  
1.  A Unit will be in conformance with all applicable statutes, 
regulations and policy transmittals.  In meeting this standard, the 
Unit must meet, but is not limited to, the following requirements: 
a.  The Unit professional staff must consist of permanent employees 
working full-time on Medicaid fraud and patient abuse matters. 
b.  The Unit must be separate and distinct from the single State 
Medicaid agency. 
c.  The Unit must have prosecutorial authority or an approved formal 
procedure for referring cases to a prosecutor. 
d.  The Unit must submit annual reports, with appropriate 
certifications, on a timely basis. 
e.  The Unit must submit quarterly reports on a timely basis. 
f.  The Unit must comply with the Americans with Disabilities Act, 
the Equal Employment opportunity requirements, the Drug Free 
workplace requirements, Federal lobbying restrictions, and other 
such rules that are made conditions of the grant. 
2.  A Unit should maintain staff levels in accordance with staffing 
allocations approved in its budget.  In meeting this standard, the 
following performance indicators will be considered: 
a.  Does the Unit employ the number of staff that was included in the 
Unit's budget as approved by the Office of Inspector General 
(OIG)? 
b.  Does the Unit employ the number of attorneys, auditors, and 
investigators that were approved in the Unit's budget? 
c.  Does the Unit employ a reasonable size of professional staff in 
relation to the State's total Medicaid program expenditures?  
d.  Are the Unit office locations established on a rational basis and are 
such locations appropriately staffed? 
3.  A Unit should establish policies and procedures for its operations, 
and maintain appropriate systems for case management and case 
tracking.  In meeting this standard, the following performance 
indicators will be considered: 
 
41 59 Fed. Reg. 49080 (Sept. 26, 1994).  These performance standards were in effect at 
the time of our review and precede the performance standards published in June 2012. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  14 
   
   
a.  Does the Unit have policy and procedure manuals? 
b.  Is an adequate, computerized case management and tracking 
system in place? 
4. A Unit should take steps to ensure that it maintains an adequate 
workload through referrals from the single State agency and other 
sources.  In meeting this standard, the following performance 
indicators will be considered: 
a.  Does the Unit work with the single State Medicaid agency to 
ensure adequate fraud referrals? 
b.  Does the Unit work with other agencies to encourage fraud 
referrals? 
c.  Does the Unit generate any of its own fraud cases? 
d.  Does the Unit ensure that adequate referrals of patient abuse 
complaints are received from all sources? 
5.  A Units case mix, when possible, should cover all significant 
provider types.  In meeting this standard, the following performance 
indicators will be considered: 
a.  Does the Unit seek to have a mix of cases among all types of 
providers in the State? 
b.  Does the Unit seek to have a mix of Medicaid fraud and Medicaid 
patient abuse cases? 
c.  Does the Unit seek to have a mix of cases that reflect the 
proportion of Medicaid expenditures for particular provider 
groups? 
d.  Are there any special Unit initiatives targeting specific provider 
types that affect case mix? 
e.  Does the Unit consider civil and administrative remedies when 
appropriate? 
6.  A Unit should have a continuous case flow, and cases should be 
completed in a reasonable time.  In meeting this standard, the 
following performance indicators will be considered: 
a.  Is each stage of an investigation and prosecution completed in an 
appropriate time frame? 
b.  Are supervisors approving the opening and closing of 
investigations?  
c.  Are supervisory reviews conducted periodically and noted in the 
case file? 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  15 
   
   
7.  A Unit should have a process for monitoring the outcome of cases.  
In meeting this standard, the following performance indicators will be 
considered: 
a.  The number, age, and type of cases in inventory. 
b.  The number of referrals to other agencies for prosecution. 
c.  The number of arrests and indictments. 
d.  The number of convictions. 
e.  The amount of overpayments identified. 
f.  The amount of fines and restitution ordered. 
g.  The amount of civil recoveries. 
h.  The numbers of administrative sanctions imposed. 
8.  A Unit will cooperate with the OIG and other federal agencies, 
whenever appropriate and consistent with its mission, in the 
investigation and prosecution of health care fraud.  In meeting this 
standard, the following performance indicators will be considered: 
a.  Does the Unit communicate effectively with the OIG and other 
Federal agencies in investigating or prosecuting health care fraud 
in their State? 
b.  Does the Unit provide OIG regional management, and other 
Federal agencies, where appropriate, with timely information 
concerning significant actions in all cases being pursued by the 
Unit? 
c.  Does the Unit have an effective procedure for referring cases, 
when appropriate, to Federal agencies for investigation and other 
action? 
d.  Does the Unit transmit to the OIG, for purposes of program 
exclusions under section 1128 of the Social Security Act, reports 
of convictions, and copies of Judgment and Sentence or other 
acceptable documentation within 30 days or other reasonable time 
period? 
9.  A Unit should make statutory or programmatic recommendations, 
when necessary, to the State government.  In meeting this standard, 
the following performance indicators will be considered: 
a.  Does the Unit recommend amendments to the enforcement 
provisions of the State's statutes when necessary and appropriate to 
do so? 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  16 
   
   
b.  Does the Unit provide program recommendations to single State 
agency when appropriate? 
c.  Does the Unit monitor actions taken by State legislature or State 
Medicaid agency in response to recommendations? 
10.  A Unit should periodically review its memorandum of 
understanding (MOU) with the single State Medicaid agency and 
seek amendments, as necessary, to ensure it reflects current law 
and practice.  In meeting this standard, the following performance 
indicators will be considered: 
a.  Is the MOU more than 5 years old? 
b.  Does the MOU meet Federal legal requirements? 
c.  Does the MOU address cross-training with the fraud detection staff 
of the State Medicaid agency? 
d.  Does the MOU address the Units responsibility to make program 
recommendations to the Medicaid agency and monitor actions 
taken by the Medicaid agency concerning those recommendations? 
11. The Unit director should exercise proper fiscal control over the 
Unit resources.  In meeting this standard, the following performance 
indicators will be considered: 
a.  Does the Unit director receive on a timely basis copies of all fiscal 
and administrative reports concerning Unit expenditures from the 
State parent agency? 
b.  Does the Unit maintain an equipment inventory? 
c.  Does the Unit apply generally accepted accounting principles in its 
control of Unit funding? 
12. A Unit should maintain an annual training plan for all 
professional disciplines.  In meeting this standard, the following 
performance indicators will be considered: 
a.  Does the Unit have a training plan in place and funds available to 
fully implement the plan? 
b.  Does the Unit have a minimum number of hours training 
requirement for each professional discipline, and does the staff 
comply with the requirement? 
c.  Are continuing education standards met for professional staff? 
d.  Does the training undertaken by staff aid to the mission of the 
Unit? 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  17 
   
   
APPENDIX B 
Referrals of Provider Fraud and Patient Abuse and Neglect to 
the Idaho Medicaid Fraud Control Unit by Source, Fiscal 
Years 2009 Through 2011 
Table B-1:  Total Medicaid Fraud Control Unit Fraud and Abuse Referrals 
and Annual Average 
Annual 
  Case Type  FY 2009  FY 2010  FY 2011  3-Year Total 
Average 
Patient Abuse and Neglect  13  7  13  33  11 
 
Provider Fraud  105  90  90  285  95 
 
  Total  118  97  103  318  106 
 
Source:  Office of Inspector General (OIG) analysis of Idaho Fraud Control Unit (Unit) Quarterly Statistical Reports, 
   
fiscal years (FY) 2009 through 2011.
 
Table B-2:  Unit Referrals, by Referral Source 
 
 
FY 2009  FY 2010  FY 2011 
   
Abuse  Abuse  Abuse  Percentage 
Referral 
Fraud  &  Fraud  &  Fraud  &  Total  of All 
Source 
Neglect  Neglect  Neglect  Referrals 
Private 
36  4  36  2  36  1  115  36.2 
Citizens* 
Other**  30  0  27  2  19  3  81  25.5 
Single State 
Medicaid  17  1  11  0  15  0  44  13.8 
Agency 
Unit Hotline***  10  2  11  0  10  2  35  11.0 
State Survey 
and 
0  2  0  1  1  5  9  2.8 
Certification 
Agency 
OIG  2  0  2  1  4  0  9  2.8 
Other State 
4  0  0  1  2  1  8  2.5 
Agencies 
Law 
1  2  0  0  2  0  5  1.6 
Enforcement 
Outside 
2  0  1  0  1  1  5  1.6 
Prosecutors 
Adult 
Protective  0  2  1  0  0  0  3  0.9 
Services 
Licensing 
3  0  0  0  0  0  3  0.9 
Board 
Providers  0  0  1  0  0  0  1  0.3 
Total  105  13  90  7  90  13  318  100 
Annual   
118  97  103 
Total   
Annual   
106 
Average   
Source:  OIG analysis of Unit Quarterly Statistical Reports, FYs 2009 through 2011.   
*Includes phone calls to the Units main number, emails to the Unit, and walk-in referrals. 
** Includes global National Association of Medicaid Fraud Control Units case referrals and Unit 
self-referrals. 
***Medicaid Fraud Report forms submitted to the Unit through the Idaho Attorney General Web site. 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  18 
   
   
 
APPENDIX C 
Investigations Opened and Closed by Provider Category and 
Case Type, Fiscal Years 2009 Through 2011 
Table C-1:  Total Annual Opened and Closed Investigations 
 
  Annual    
 Case Type  FY 2009  FY 2010  FY 2011  3-Year Total  Average* 
 Opened  129  95  102  326  109 
Patient Abuse and 
  28  7  12  47  16 
Neglect 
  Provider Fraud  101  88  90  279  93 
           
 
Closed  113  87  91  291  97 
 
Patient Abuse and 
26  8  11  45  15 
  Neglect 
Provider Fraud  87  79  80  246  82 
Source:  Idaho Medicaid Fraud Control Unit (Unit) response to Office of Inspector General (OIG) data request. 
*Averages in this table are rounded. 
 
Table C-2:  Total Investigations, by Case Type 
FY 2009  FY 2010  FY 2011 
Case Type 
Opened  Closed  Opened  Closed  Opened  Closed 
Patient Abuse and Neglect  28  26  7  8  12  11 
Provider Fraud  101  87  88  79  90  80 
Total  129  113  95  87  102  91 
Source:  Unit response to OIG data request. 
 
 
Table C-3:  Patient Abuse and Neglect Investigations 
 
Provider Category  FY 2009  FY 2010  FY 2011 
        
Opened  Closed  Opened  Closed  Opened  Closed 
Home Health Aides  2  0  1  3  1  1 
Nondirect Care  6  6  0  0  0  0 
Nurses/Doctors 
5  4  0  1  3  2 
Assistants/Nurse Aides 
Nursing Facilities  2  2  2  0  3  3 
Other Long-Term Care 
0  1  0  0  0  0 
Facilities 
Other  13  13  4  4  5  5 
Total  28  26  7  8  12  11 
Source:  Unit response to OIG data request. 
 
 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  19 
   
   
Table C-4:  Provider Fraud Investigations 
 
Provider Category  FY 2009  FY 2010  FY 2011 
Facilities  Opened  Closed  Opened  Closed  Opened  Closed 
Hospitals  0  2  4  3  2  3 
Nursing Facilities  2  1  2  4  4  4 
Other Long-Term Care 
2  4  3  2  3  3 
Facilities 
Substance Abuse Facilities  0  1  0  0  0  0 
Other  4  5  6  8  4  2 
Practitioners  Opened  Closed  Opened  Closed  Opened  Closed 
Chiropractors  3  2  1  0  0  1 
Counselors/ Psychologists  18  19  11  11  11  12 
Dentists  3  1  6  5  2  3 
Doctors of Medicine or 
5  6  6  7  6  5 
Osteopathy 
Optometrists/ Opticians  1  1  0  0  0  0 
Other  1  1  1  1  0  0 
Medical Support  Opened  Closed  Opened  Closed  Opened  Closed 
Durable Medical 
6  5  1  3  6  4 
Equipment Suppliers 
Home Health Care 
4  5  2  1  3  3 
Agencies 
Home Health Care Aides  14  9  4  8  24  11 
Laboratories  0  0  1  0  1  0 
Nurses/Doctors 
2  5  7  5  0  4 
Assistants/Nurse Aides 
Pharmaceutical 
17  2  12  9  10  8 
Manufacturers 
Pharmacies  6  4  1  2  4  2 
Radiologists  0  0  1  1  0  0 
Transportation Services  1  3  5  3  2  3 
Other  5  5  12  5  6  10 
Program Related  Opened  Closed  Opened  Closed  Opened  Closed 
Billing Companies  2  2  0  0  1  1 
Managed Care  3  2  0  0  1  0 
Medicaid Program 
1  1  1  1  0  0 
Administration 
Other  1  1  1  0  0  1 
Total  101  87  88  79  90  80 
 
Source:  Unit response to OIG data request.
 
 
 
 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  20 
   
   
APPENDIX D 
Case File Review Population, Sample Size Counts, and 
Confidence Interval Estimates 
Table D-1 shows population and sample counts and percentages by case 
type.  Note that both samples have percentages of case types similar to the 
general population, though sample counts for some case types are very 
small.  Because of these small sample sizes, we cannot reliably generalize 
what we found in our sample review to each case type in the population, 
and only our overall estimates project to the population of all case files.  
We estimated the 4 population values for all 329 case files from the results 
of our review of the case files selected in our simple random samples.  
Table D-2 includes the estimate descriptions, sample sizes, point 
estimates, and 95-percent confidence intervals for these four estimates.  
 
Table D-1:  Population and Sample Size Counts for Case Types 
Population Count  Sample Count*       Sample Count* 
Case Type 
and (%) n=329  and (%)  n=100  and (%)  n=50 
Closed  254 (77%)  82 (82%)  41 (82%) 
Open  75 (23%)  18 (18%)  9 (18%) 
       
Civil  55 (17%)  16 (16%)  9 (18%) 
Criminal  274 (83%)  84 (84%)  41 (82%) 
       
Global  53 (16%)  17 (17%)  10 (20%) 
Patient Abuse/Neglect  48 (15%)  15 (15%)  6 (12%) 
Provider Fraud  228 (69%)  68 (68%)  34 (68%) 
Source: The Idaho Medicaid Fraud Control Unit provided a list of all case files open during fiscal years 2009 through 
2011. 
*The Office of Inspector General generated this random sample. 
 
 
 
 
 
 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  21 
   
   
Table D-2:  Confidence Intervals for Key Case File Review Data 
Point  95-Percent Confidence 
Estimate Description  Sample Size 
Estimate  Interval 
Case Files With 
Documented Supervisory  100  98.0%  93.699.4% 
Approval for Opening 
Case Files With 
Documented Supervisory  82  97.6%  92.199.2% 
Approval for Closing 
Case Files With 
Documentation Indicating 
100  91.0%  84.595.1% 
at Least One Supervisory 
Review 
Case Files With 
Documentation Indicating 
100  89.0%  82.493.6% 
Periodic Supervisory 
Review 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  22 
   
   
APPENDIX E 
Unit Comments 
 
 
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  23 
  li 
I! 
and other documentation containing personally identifiable information.  This has been 
accomplished since receiving the draft report. 
'!'he third recommendation is tbr the MFCU to revise its Memorandum of Understanding 
with the Idaho Department of Health and Welfare (DHW) regarding procedures involving 
referrals of providers suspected offraud for payment suspicion to DHW and the removal of the 
stipulation that the Unit may be charged for data requests.  The MFCU will wo rk with the DHW 
to accomplish this by Octobct' 5, 2013. 
We look forward to working togethe.r with you and others in the U.S. Department of 
Heal th and Human Services in the future in our role of policing the Idaho Medicaid Program as 
envisioned by the ldal1o Legislature and Congress. 
;
Sincerely  i 
Kendal McDevitt 
Deputy Idaho Attorney General 
Director, Medicaid Fraud Control Unit  ; 
.l   
; 
I 
Page 2 of2 
-
Idaho State Medicaid Fraud Control Unit: 2012 Onsite Review (OEI-09-12-00220)  24  
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Timothy S. Brady, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Michael Henry, Deputy Regional Inspector General.  
Matthew DeFraga served as the lead analyst for this study.  Central office 
staff who provided support include Susan Burbach, Kevin Farber, and 
Debra Roush.  Office of Investigations staff who provided support include 
Jason Weinstock.   
Idaho State Medicaid Fraud Control Unit:  2012 Onsite Review (OEI-09-12-00220)  25 
   
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.