Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
K S M
ENTUCKY  TATE  EDICAID 
 
 
F C U :
RAUD  ONTROL  NIT       
2017 O R  
  NSITE  EVIEW
 
Suzanne Murrin 
Deputy Inspector General 
 
September 2017 
OEI-06-17-00030   
   
EXECUTIVE SUMMARY - KENTUCKY STATE MEDICAID FRAUD CONTROL 
UNIT:  2017 ONSITE REVIEW  
OEI-06-17-00030 
 
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 Kentucky Unit in January 2017.  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) 2014 through 2016; (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 2014 through 2016; 
and (7) observation of Unit operations. 
 
WHAT WE FOUND 
For FYs 2014 through 2016, the Unit reported 52 criminal convictions; 49 civil 
judgments and settlements; and combined criminal and civil recoveries of approximately 
$121 million.  Our review found that the Kentucky Unit was generally in compliance 
with applicable laws, regulations, and policy transmittals.  The Unit maintained proper 
fiscal control of its resources.  The Unit collaborated with other government and industry 
stakeholders to encourage effective referrals of fraud, and appointed an executive advisor 
to mentor and support staff.  We identified one area where the Unit should improve its 
operations:  timeliness of reporting.  The Unit did not report all convictions or adverse 
actions to Federal partners within the appropriate timeframes. 
 
WHAT WE RECOMMEND  
We recommend that the Kentucky Unit implement processes to ensure that it reports 
convictions and adverse actions to Federal partners within the appropriate timeframes.  
The Unit concurred with our recommendation. 
 
 
   
   
TABLE OF CONTENTS 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................6 
For FYs 2014 through 2016, the Kentucky Unit reported              
52 criminal convictions; 49 civil judgments and settlements; 
and combined criminal and civil recoveries of approximately 
$121 million .....................................................................................6 
The Unit did not report all convictions or adverse actions to 
Federal partners within the appropriate timeframes ........................7 
The Unit maintained proper fiscal control of its resources ..............8 
Other observation:  The Unit collaborated with other government 
and industry stakeholders to encourage effective referrals of  
fraud .................................................................................................8 
Other observation:  The Unit appointed an executive advisor 
to mentor and support staff ..............................................................9 
Conclusion and Recommendations ............................................................10 
            Unit Comments and Office of Inspector General Response .......... 11 
Appendixes ................................................................................................12 
A:  2012 Performance Standards ...................................................12 
B:  Referrals to the Kentucky MFCU by Referral Source for 
FYs 2014 Through 2016 ................................................................16 
C:  Investigations Opened and Closed by the Kentucky MFCU 
by Case Type for FYs 2014 Through 2016 ....................................17 
D:  Detailed Methodology .............................................................18 
E:  Unit Comments.........................................................................21 
Acknowledgments......................................................................................23  
   
OBJECTIVES 
To conduct an onsite review of the Kentucky 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 Social Security 
Act (SSA) requires each State to operate a MFCU, unless the Secretary of 
Health and Human Services determines that operation of a Unit would not 
be cost-effective because minimal Medicaid fraud exists in a particular 
State and 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 
provider fraud and patient abuse or neglect to determine their potential for 
criminal prosecution and/or civil action.  In fiscal year (FY) 2016, the 
50 Units collectively reported 1,564 convictions; 998 civil settlements and 
judgments; and approximately $1.9 billion 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 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 2016. 
Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on April 4, 2017.   
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).  
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      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 the Department of 
Health and Human Services (HHS) Office of Inspector General (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 2016, combined Federal and State expenditures for the 
Units totaled nearly $258 million, $194 million of which represented 
Federal funds.12 
Oversight of the MFCU Program 
The Secretary of Health and Human Services 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 Units compliance with 
Federal requirements and their 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 Kentucky 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 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2016. 
Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on March 28, 2017.   
13 The SSA authorizes the Secretary of HHS to award grants to the Units;                   
(SSA  1903(a)(6)); the Secretary delegated this authority to the OIG.   
14 On occasion, OIG issues policy transmittals to provide guidance and instructions to 
MFCUs.   
15 77 Fed. Reg. 32645 (June 1, 2012).  Accessed at http://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/files/Performance%20Standards.pdf on February 28, 2017.   
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      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. 
OIG provides additional oversight including the collection and dissemination 
of performance data, training, and technical assistance.  
Kentucky MFCU 
The Kentucky Unit is located within Kentuckys Office of the Attorney 
General and has the authority to investigate and prosecute cases of 
Medicaid fraud and patient abuse or neglect.  To investigate and prosecute 
such cases, the Unit employs investigators, attorneys, and members of a 
fraud investigations support team, which includes auditors, healthcare data 
administrators, and nurse consultants/inspectors.  The Units management 
is composed of a director, assistant director/litigation manager, 
investigator manager, investigator supervisors, and a fraud investigations 
support team manager. 
At the time of our January 2017 onsite review, the Units 28 employees 
were located in 6 offices.  The main office is in the State capital, 
Frankfort, which is where we conducted our onsite review.  The Units 
five branch offices are in western Kentucky (Louisville and 
Bowling Green) and eastern Kentucky (Monticello, Alexandria, and 
Prestonsburg).  The Kentucky Unit spent approximately $3.4 million in 
combined State and Federal funds in FY 2016.16  
Referrals.  The Unit receives most of its fraud referrals from the States 
Cabinet for Health and Family Services (CHFS) OIG and most of its 
patient abuse and neglect referrals from the Department for Community 
Based Services (DCBS).17  The Unit also receives referrals from other 
sources, such as private citizens and law enforcement agencies.  
Appendix B lists Unit referrals by source for FYs 2014 through 2016. 
Prior to submitting a fraud referral to the Unit, CHFS-OIG conducts a 
preliminary investigation and meets with the Unit, together with the 
                        ____________________________________________________________ 
16 OIG, MFCU Statistical Data for Fiscal Year 2016.  Accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2016-statistical-chart.pdf on February 22, 2017.   
17 CHFS-OIG is the regulatory and licensing agency for all health care and long-term care 
facilities and is responsible for the prevention, detection, and investigation of fraud, 
waste, mismanagement, and misconduct.  Accessed at http://chfs.ky.gov/os/oig/  on 
March 28, 2017.  DCBS includes Adult and Child Protection Services.  Both agencies are 
located within CHFS, along with the Department for Medicaid Services (DMS), 
Kentuckys Medicaid agency.            
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      3   
   
Department for Medicaid Services (DMS), to discuss potential referrals.18  
Within 1 week after meeting with the Unit, CHFS-OIG refers a list of 
cases to the Unit.  The Unit management decides which referrals, if any, 
the Unit will accept and open as cases.   
The Unit receives referrals of patient abuse and neglect from DCBS 
through a shared electronic system, from which the Unit downloads every 
day.  When the Unit downloads a referral, an investigations supervisor 
conducts a preliminary analysis to determine whether a full investigation 
is warranted.  The Unit director and the investigations manager then 
review the analysis to decide whether to proceed with a full investigation. 
Investigations.  The Unit uses the following team approach to investigate 
cases.  Once the Unit decides to open a case, the Unit management assigns 
an investigator, an attorney, and a member of the fraud investigations 
support team.  The Unit management rotates weekly meetings among the 
Units branch offices to discuss the progress and prioritization of cases.  
Unit policy requires that all investigative activities and team meetings be 
documented and maintained in the Units electronic case-management 
system.  Appendix C illustrates opened and closed investigations by case 
type for FYs 2014 through 2016.  
Previous Onsite Review 
In 2010, OIG conducted an onsite review of the Kentucky Unit.  OIG 
found that Unit supervisors did not conduct periodic reviews of 
investigative case files to monitor the progress of investigations.  OIG 
recommended that the Unit supervisors conduct regularly scheduled 
reviews of investigative case files and maintain supervisory notes of these 
reviews.  The Unit concurred with these recommendations.  Our 2017 
onsite review found that Unit supervisors conducted periodic investigative 
case file reviews.  
METHODOLOGY 
Data Collection and Analysis 
We conducted the onsite review in January 2017.  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 2014 through 2016; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
                        ____________________________________________________________ 
18 According to the MOU between DMS and the Unit, DMS delegated to CHFS-OIG the 
exclusive authority to conduct preliminary investigations for the Medicaid program for 
the purpose of detecting, preventing, and substantiating fraud and abuse.  Kentucky 
Revised Statutes 194A.030(1)(c)(1) and 205.8453.  DMS also designated CHFS-OIG as 
the exclusive referral agency. 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      4   
   
interviews with the Units management; (6) a sample of files for cases that 
were open in FYs 2014 through 2016; and (7) observation of Unit 
operations.  Appendix D provides details of our methodology. 
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. 
   
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      5   
   
FINDINGS 
For FYs 2014 through 2016, the Kentucky Unit 
reported 52 criminal convictions; 49 civil judgments 
and settlements; and combined criminal and civil 
recoveries of approximately $121 million 
For FYs 2014 through 2016, the Unit reported 52 criminal convictions and 
49 civil judgments and settlements.  Exhibit 1 provides details of the 
Units yearly convictions and civil judgments and settlements.  Of the 
Units 52 convictions over the 3-year period, 29 involved provider fraud 
and 23 involved patient abuse or neglect. 
Exhibit 1:  Kentucky MFCU Criminal Convictions and Civil Judgments and 
Settlements, FYs 20142016 
3-Year 
Outcomes  FY 2014  FY 2015  FY 2016  Total 
Criminal Convictions  19  15  18  52 
Civil Judgments and Settlements  19  14  16  49 
Source:  OIG analysis of Unit-submitted data, 2017. 
The Unit reported criminal and civil recoveries of approximately 
$121 million for FYs 2014 through 2016ranging from $3.8 million to 
$69 million over the 3 years (shown in Exhibit 2).  During the 3-year 
review period, global19 cases accounted for 21 percent of the Units 
recoveries. 
Exhibit 2:  Kentucky MFCU Recoveries and Expenditures, FYs 20142016 
Type of Recovery  FY 2014  FY 2015  FY 2016  3-Year Total 
Global Civil  $4,534,964  $2,511,192  $23,279,694  $30,325,850 
Nonglobal Civil  $63,718,239   $853,496   $24,224,083   $88,795,818  
Criminal  $1,141,776   $387,035   $130,634   $1,659,445  
Total Recoveries  $69,394,979   $3,751,723   $47,634,411   $120,781,113  
Total Expenditures  $2,989,940  $3,393,619  $3,408,063  $9,791,622 
 
Source:  OIG analysis of Unit-submitted data, 2017.
                        ____________________________________________________________ 
19 Global cases are civil False Claims Act cases that are litigated in Federal courts by 
the U.S. Department of Justice and involve a group of MFCUs.  The National 
Association of Medicaid Fraud Control Units facilitates the settlement of global cases on 
behalf of the States.  Global cases accounted for 88 of the Units 416 cases over the 
3-year period. 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      6   
   
The Unit did not report all convictions or adverse 
actions to Federal partners within the appropriate 
timeframes 
The Unit did not report all convictions or adverse actions to OIG and the 
National Practitioner Data Bank (NPDB) within the appropriate timeframes 
required by these entities.  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 resulting from prosecutions of health care providers to the NPDB 
within 30 calendar days from the date of the adverse action.20,  21  
The Unit reported 35 percent of its convictions to OIG after the 
appropriate timeframes 
The Unit reported 35 percent of its convictions (18 of 52) to OIG more than 
30 days after sentencing.  Exhibit 3 illustrates the number of days after 
sentencing that the Unit reported these convictions to OIG.  Late reporting 
of convictions to OIG delays the initiation of the program exclusion 
process, which may result in improper payments to providers by Medicare 
or other Federal health care programs or possible harm to beneficiaries.   
Exhibit 3:  Number of Late Convictions Reported to Federal Partners 
Convictions or  Convictions or  Convictions  or 
Total Convictions  
Federal Partner  Adverse Actions  Adverse Actions  Adverse Actions 
or Adverse Actions  
Reported To  Reported 130   Reported 31-60  Reported More Than 
Reported Late  
Days Late  Days Late  60 Days Late 
OIG (Convictions)  8  2  8  18 
NPDB (Adverse Actions)  0  3  1  4 
Source:  OIG analysis of Unit convictions and dates reported to OIG and NPDB, 2017. 
  
The Unit also reported adverse actions to NPDB, but reported 
36 percent of these actions later than the 30 days required 
As required, the Unit reported 11 adverse actions to the NPDB.  However, it 
reported 4 of these adverse actions more than 30 days after the action 
occurred.  Exhibit 3 illustrates the number of days after the adverse actions 
                        ____________________________________________________________ 
20 45 CFR  60.5.  Examples of adverse actions include criminal convictions; civil 
judgements (but not civil settlements); exclusions; and other negative actions or findings. 
21 Performance Standard 8(g) states that the Unit should report qualifying cases to the 
Healthcare Integrity & Protection Databank [HIPDB], the National Practitioner Data 
Bank, or successor data bases.  The HIPDB and the NPDB were merged during our 
review period (FYs 2013 through 2015); therefore, we reviewed the reporting of adverse 
actions under NPDB requirements.  See 78 Fed. Reg. 20473 (April 5, 2013). 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      7   
   
that the Unit reported them to NPDB.  The NPDB is intended to restrict the 
ability of physicians, dentists, and other health care practitioners to move 
from State to State without disclosure or discovery of previous medical 
malpractice and adverse actions.  If a Unit fails to report adverse actions to 
the NPDB, individuals may be able to find new health care employment 
with an organization that is not aware of the adverse actions made against 
them.   
Unit managers explained that the Unit relied solely on one administrative 
staff member to report convictions to OIG and adverse actions to the NPDB, 
which caused delays when that staff member was out of the office or 
working on other projects.    
The Unit maintained proper fiscal control of its 
resources  
The Unit maintained proper fiscal control of its resources during the 
review period, in accordance with the terms of Performance Standard 11.  
The Units financial documentation indicated that the Units requests for 
reimbursement for FYs 2014 through 2016 represented allowable, 
allocable, and reasonable costs.  In addition, the Unit maintained adequate 
internal controls relating to accounting, budgeting, personnel, 
procurement, property, and equipment.  
Other observation:  The Unit collaborated with other 
government and industry stakeholders to encourage 
effective referrals of fraud 
The Unit reported several collaborative efforts with DMS, CHFS-OIG, 
and the five Kentucky managed care organizations (MCOs) to encourage 
effective referrals of fraud.22  The Unit stated that these efforts improved 
the quality, completeness, and timeliness of referrals from these 
government and industry stakeholders. 
The Unit participated in two monthly meetings with DMS and 
CHFS-OIG.  The purpose of the first meeting was to discuss CHFS-OIGs 
investigations of potential fraud referrals.  The Unit reported that these 
meetings helped ensure that referrals from CHFS-OIG were complete and 
timely, and assisted the Unit in determining whether to accept or decline a 
referral. 
                        ____________________________________________________________ 
22 DMS contracts with MCOs to provide or arrange for healthcare services on a Statewide 
or community basis.  These healthcare services generally include all primary, specialty, 
and acute medical care.  MCOs are paid a fixed prospective payment, referred to as a 
capitated rate, for each Medicaid beneficiary enrolled with the MCO.  MCOs must meet 
other Federal requirements.  See 42 CFR  438.2. 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      8   
   
The Unit reported that the purpose of the second monthly meeting with 
DMS and CHFS-OIG was to discuss management issues shared across the 
three agencies, which often included discussion of the referral and 
investigation processes.  For example, the three agencies recently 
identified ways for streamlining case closings to increase recoupment 
from inappropriate payments identified during investigations.  According 
to the Unit, these meetings fostered familiarity with how each agency 
operates, which improved communication and collaboration among the 
three agencies. 
Additionally, the Unit, DMS, and CHFS-OIG met quarterly with 
representatives from the following:  the Special Investigations Units of 
each of the five Kentucky MCOs; the U.S. Attorneys Offices; and (often) 
HHS OIG.  These meetings were used to provide training on the elements 
of an effective referral, discuss potential referrals, and share investigative 
information and resources.  Unit managers reported that the discussion 
helped MCOs understand the particular information that the Unit needed 
from the MCOs investigations, which improved the quality of the 
referrals.  The Unit also reported that the meetings helped identify 
providers who were under investigation by multiple agencies, which 
improved collaboration on those cases. 
Other observation:  The Unit appointed an executive 
advisor to mentor and support staff  
The Unit created a position for an executive advisor, who is appointed at 
the discretion of the Unit director and approved by the Office of the 
Attorney General.  The executive advisorcurrently, an attorneyhas a 
key role in the Units training program and supports the Unit by assisting 
attorneys in developing litigation skills and mentoring new attorneys.  The 
executive advisor also serves as a co-chair on cases, providing input and 
support to the team in developing the cases. 
   
   
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      9   
   
CONCLUSION AND RECOMMENDATIONS 
Our review found that the Kentucky Unit was generally in compliance 
with applicable laws, regulations, and policy transmittals.  For FYs 2014 
through 2016, the Unit reported 52 criminal convictions; 49 civil 
judgments and settlements; and combined criminal and civil recoveries of 
approximately $121 million.  The Unit maintained proper fiscal control of 
its resources.  The Unit collaborated with other government and industry 
stakeholders to encourage effective referrals of fraud, and appointed an 
executive advisor to mentor and support staff. 
We identified one area in which the Unit should improve its operations:  
timeliness of reporting.  The Unit did not report all convictions or adverse 
actions to Federal partners within the appropriate timeframes.  
We recommend that the Kentucky Unit:  
Implement processes to ensure that it reports convictions and 
adverse actions to Federal partners within the appropriate 
timeframes  
The Unit should implement processes to ensure that it reports convictions 
to OIG within 30 days of sentencing and adverse actions to NPDB within 
30 days of the action.  Such processes could include designating backup 
staff to report convictions and adverse actions to Federal partners when the 
primary staff member for such reporting is out of the office or working on 
other projects.  The Unit could also implement automated reminders that 
alert the Unit staff to report convictions and adverse actions to Federal 
partners.  
 
 
 
 
 
 
 
 
 
 
 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      10   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Kentucky Unit concurred with our recommendation.  The Unit stated 
that it has implemented safeguards to ensure that it reports convictions and 
adverse actions to Federal partners within 30 days of sentencing or 
adverse action.  These safeguards include sending calendar reminders to 
the employee responsible for reporting convictions to Federal partners, 
placing the 30-day reporting deadline on the Units master calendar, and 
appointing an additional employee to serve as a backup when the 
employee responsible for reporting convictions is out of the office or 
working on other projects.  Additionally, the Unit stated that the Unit 
director and case attorney now monitor the reporting of convictions to 
ensure that submissions are within the 30-day period. 
OIG anticipates that the Units planned actions will implement our 
recommendation.  OIG requests that the Unit provide documentation to 
demonstrate that it has implemented the described actions. 
The full text of the Units comments is provided in Appendix E. 
 
 
 
   
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APPENDIX A 
2012 Performance Standards23  
1.  A UNIT CONFORMS WITH ALL APPLICABLE STATUTES, REGULATIONS, AND POLICY DIRECTIVES, 
INCLUDING: 
A.  Section 1903(q) of the Social Security Act, containing the basic requirements for operation of a MFCU; 
B.  Regulations for operation of a MFCU contained in 42 CFR part 1007; 
C.  Grant administration requirements at 45 CFR part 92 and Federal cost principles at 2 CFR part 225; 
D.  OIG policy transmittals as maintained on the OIG Web site; and  
E.  Terms and conditions of the notice of the grant award. 
2.  A UNIT MAINTAINS REASONABLE STAFF LEVELS AND OFFICE LOCATIONS IN RELATION TO THE 
STATES MEDICAID PROGRAM EXPENDITURES AND IN ACCORDANCE WITH STAFFING 
ALLOCATIONS APPROVED IN ITS BUDGET.   
A.  The Unit employs the number of staff that is included in the Units budget estimate as approved by OIG. 
B.  The Unit employs a total number of professional staff that is commensurate with the States total Medicaid 
program expenditures and that enables the Unit to effectively investigate and prosecute (or refer for 
prosecution) an appropriate volume of case referrals and workload for both Medicaid fraud and patient abuse 
and neglect. 
C.  The Unit employs an appropriate mix and number of attorneys, auditors, investigators, and other 
professional staff that is both commensurate with the States total Medicaid program expenditures and that 
allows the Unit to effectively investigate and prosecute (or refer for prosecution) an appropriate volume of case 
referrals and workload for both Medicaid fraud and patient abuse and neglect. 
D.  The Unit employs a number of support staff in relation to its overall size that allows the Unit to operate 
effectively. 
E.  To the extent that a Unit maintains multiple office locations, such locations are distributed throughout the 
State, and are adequately staffed, commensurate with the volume of case referrals and workload for each 
location. 
3.  A UNIT ESTABLISHES WRITTEN POLICIES AND PROCEDURES FOR ITS OPERATIONS AND 
ENSURES THAT STAFF ARE FAMILIAR WITH, AND ADHERE TO, POLICIES AND PROCEDURES.   
A.  The Unit has written guidelines or manuals that contain current policies and procedures, consistent with 
these performance standards, for the investigation and (for those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect.  
B.  The Unit adheres to current policies and procedures in its operations. 
C.  Procedures include a process for referring cases, when appropriate, to Federal and State agencies.  
Referrals to State agencies, including the State Medicaid agency, should identify whether further investigation 
or other administrative action is warranted, such as the collection of overpayments or suspension of payments. 
D.  Written guidelines and manuals are readily available to all Unit staff, either online or in hard copy. 
E.  Policies and procedures address training standards for Unit employees. 
4.  A UNIT TAKES STEPS TO MAINTAIN AN ADEQUATE VOLUME AND QUALITY OF REFERRALS FROM 
THE STATE MEDICAID AGENCY AND OTHER SOURCES.   
A.  The Unit takes steps, such as the development of operational protocols, to ensure that the State Medicaid 
agency, managed care organizations, and other agencies refer to the Unit all suspected provider fraud cases.  
Consistent with 42 CFR 1007.9(g), the Unit provides timely written notice to the State Medicaid agency when 
referred cases are accepted or declined for investigation. 
B.  The Unit provides periodic feedback to the State Medicaid agency and other referral sources on the 
adequacy of both the volume and quality of its referrals. 
                        ____________________________________________________________ 
23 77 Fed. Reg. 32645, June 1, 2012. 
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C.  The Unit provides timely information to the State Medicaid or other agency when the Medicaid or other 
agency requests information on the status of MFCU investigations, including when the Medicaid agency 
requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii). 
D.  For those States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and 
neglect cases, the Unit takes steps, such as the development of operational protocols, to ensure that pertinent 
agencies refer such cases to the Unit, consistent with patient confidentiality and consent.  Pertinent agencies 
vary by State but may include licensing and certification agencies, the State Long Term Care Ombudsman, and 
adult protective services offices.  
E.  The Unit provides timely information, when requested, to those agencies identified in (D) above regarding 
the status of referrals. 
F.  The Unit takes steps, through public outreach or other means, to encourage the public to refer cases to the 
Unit. 
5.  A UNIT TAKES STEPS TO MAINTAIN A CONTINUOUS CASE FLOW AND TO COMPLETE CASES IN 
AN APPROPRIATE TIMEFRAME BASED ON THE COMPLEXITY OF THE CASES. 
A.  Each stage of an investigation and prosecution is completed in an appropriate timeframe. 
B.  Supervisors approve the opening and closing of all investigations and review the progress of cases and take 
action as necessary to ensure that each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
C.  Delays to investigations and prosecutions are limited to situations imposed by resource constraints or other 
exigencies.   
6.  A UNITS CASE MIX, AS PRACTICABLE, COVERS ALL SIGNIFICANT PROVIDER TYPES AND 
INCLUDES A BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.   
A.  The Unit seeks to have a mix of cases from all significant provider types in the State. 
B.  For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
C.  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. 
D.  The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors.  Special Unit initiatives may focus on specific provider types. 
E.  As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7.  A UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER AND DEVELOPS A CASE 
MANAGEMENT SYSTEM THAT ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.   
A.  Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B.  Case files include all relevant facts and information and justify the opening and closing of the cases. 
C.  Significant documents, such as charging documents and settlement agreements, are included in the file.  
D.  Interview summaries are written promptly, as defined by the Units policies and procedures. 
E.  The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
F.  The Unit has an information management system that allows for the monitoring and reporting of case 
information, including the following:  
1.  The number of cases opened and closed and the reason that cases are closed. 
2.  The length of time taken to determine whether to open a case referred by the State Medicaid agency or other 
referring source. 
3.  The number, age, and types of cases in the Units inventory/docket 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      13   
   
4.  The number of referrals received by the Unit and the number of referrals by the Unit to other agencies. 
5.  The number of cases criminally prosecuted by the Unit or referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending prosecutions. 
6.  The number of criminal convictions and the number of civil judgments. 
7.  The dollar amount of overpayments identified. 
8.  The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil judgments or prefiling settlements. 
8.  A UNIT COOPERATES WITH OIG AND OTHER FEDERAL AGENCIES IN THE INVESTIGATION AND 
PROSECUTION OF MEDICAID AND OTHER HEALTH CARE FRAUD.   
A.  The Unit communicates on a regular basis with OIG and other Federal agencies investigating or prosecuting 
health care fraud in the State. 
B.  The Unit cooperates and, as appropriate, coordinates with OIGs Office of Investigations and other Federal 
agencies on cases being pursued jointly, cases involving the same suspects or allegations, and cases that have 
been referred to the Unit by OIG or another Federal agency.  
C.  The Unit makes available, to the extent authorized by law and upon request by Federal investigators and 
prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the 
Medicaid program. 
D.  For cases that require the granting of extended jurisdiction to investigate Medicare or other Federal health 
care fraud, the Unit seeks permission from OIG or other relevant agencies under procedures as set by those 
agencies.  
E.  For cases that have civil fraud potential, the Unit investigates and prosecutes such cases under State 
authority or refers such cases to OIG or the U.S. Department of Justice. 
F.  The Unit transmits to OIG, for purposes of program exclusions under section 1128 of the Social Security Act, 
all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
G.  The Unit reports qualifying cases to the Healthcare Integrity & Protection Databank, the National Practitioner 
Data Bank, or successor data bases. 
9.  A UNIT MAKES STATUTORY OR PROGRAMMATIC RECOMMENDATIONS, WHEN WARRANTED, TO 
THE STATE GOVERNMENT.   
A.  The Unit, when warranted and appropriate, makes statutory recommendations to the State legislature to 
improve the operation of the Unit, including amendments to the enforcement provisions of the State code. 
B.  The Unit, when warranted and appropriate, makes other regulatory or administrative recommendations 
regarding program integrity issues to the State Medicaid agency and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State legislature and the State Medicaid or other 
agencies in response to recommendations.  
10.  A UNIT PERIODICALLY REVIEWS ITS MEMORANDUM OF UNDERSTANDING (MOU) WITH THE 
STATE MEDICAID AGENCY TO ENSURE THAT IT REFLECTS CURRENT PRACTICE, POLICY, AND 
LEGAL REQUIREMENTS.   
A.  The MFCU documents that it has reviewed the MOU at least every 5 years, and has renegotiated the MOU 
as necessary, to ensure that it reflects current practice, policy, and legal requirements. 
B.  The MOU meets current Federal legal requirements as contained in law or regulation, including 42 CFR  
455.21, Cooperation with State Medicaid fraud control units, and 42 CFR  455.23, Suspension of payments 
in cases of fraud. 
C.  The MOU is consistent with current Federal and State policy, including any policies issued by OIG or the 
Centers for Medicare & Medicaid Services (CMS). 
D.  Consistent with Performance Standard 4, the MOU establishes a process to ensure the receipt of an 
adequate volume and quality of referrals to the Unit from the State Medicaid agency. 
E.  The MOU incorporates by reference the CMS Performance Standard for Referrals of Suspected Fraud from 
a State Agency to a Medicaid Fraud Control Unit.                                                                                                           
 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      14   
   
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.  
   
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      15   
   
APPENDIX B 
Referrals to the Kentucky MFCU by Referral Source for 
FYs 2014 Through 2016 
 
FY 2014  FY 2015  FY 2016 
Abuse/  Abuse/  Abuse/ 
Referral Source  Fraud  Fraud  Fraud 
Neglect1  Neglect  Neglect 
Medicaid agency   
3  0  0  0  1  0 
PI/SURS2 
CHFS-OIG  65  7  59  3  94  0 
Managed care 
18  0  15  0  7  0 
organizations3 
State survey and 
1  76  0  53  0  26 
certification agency 
Other State agencies  3  1  1  2  1  0 
Licensing board  1  0  1  0  0  0 
Other law enforcement  2  3  0  2  8  1 
HHS OIG  6  1  1  0  1  0 
Local prosecutors  2  0  4  1  3  0 
Providers  2  0  2  0  2  1 
Private health insurers  12  0  0  0  0  0 
Department of 
Community Based  17  3,084  16  3,048  0  2,288 
Services 
Private citizens  13  14  23  17  16  36 
MFCU hotline4  14  24  NA  NA  NA  NA 
Other  34  1  30  18  16  0 
Anonymous5  NA  NA  0  1  0  0 
   Total  193  3,211  152  3,145  149  2,352 
   Annual Total  3,404  3,297  2,501 
Source:  OIG analysis of Unit Quarterly and Annual Statistical Reports, FYs 2014-2016. 
1 The category of referrals of abuse and neglect includes referrals of misappropriation of patient funds.  
2The abbreviation PI stands for program integrity; the abbreviation SURS stands for Surveillance and Utilization Review 
Subsystem.  The Medicaid agency sends all referrals to the States CHFS-OIG to screen and investigate potential fraud.  
The Medicaid agency delegated to CHFS-OIG its authority to conduct investigations of the Medicaid program for the purpose 
of detecting, preventing, and substantiating fraud and abuse.  Kentucky Revised Statutes 194A.030(1)(c)(1) and 205.8453. 
3The managed care organizations sends all referrals to CHFS-OIG to screen and investigate potential fraud.  CHFS-OIG 
meets with the MFCU once a month to discuss these referrals.  
4 The referral source MFCU hotline was not a category reported on the FY 2015 and FY 2016 Annual Statistical Reports. 
5 The referral source Anonymous was not a category reported on the FY 2014 Quarterly Statistical Reports. 
 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      16   
   
APPENDIX C 
Investigations Opened and Closed by the Kentucky MFCU by 
Case Type for FYs 2014 Through 2016 
 
Case Type  FY 2014  FY 2015  FY 2016  3-Year Total  Annual 
Average* 
Opened  551  117  117  785  262 
Patient Abuse  88  45  40  173  58 
and Neglect 
Provider Fraud  458  72  77  607  202 
Misappropriation  5  0  0  5  2 
of Patient Funds 
Closed  64  129  83  276  92 
Patient Abuse  11  33  47  91  30 
and Neglect 
Provider Fraud  53  96  36  185  62 
Misappropriation  0  0  0  0  0 
of Patient Funds 
Source:  OIG analysis of Unit data, 2017. 
*Averages in this column are rounded. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      17   
   
APPENDIX D 
Detailed Methodology 
We used data collected from the seven sources below to describe the 
caseload and assess the performance of the Kentucky MFCU. 
Data Collection  
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information regarding the Units investigation of Medicaid cases, 
including information about the number of referrals the Unit received, the 
number of investigations the Unit opened and closed, the outcomes of 
those investigations, and the Units case mix.  We also collected and 
analyzed information about the number of cases that the Unit referred for 
prosecution and the outcomes of those prosecutions.   
We gathered this information from several sources, including the Units 
annual and quarterly statistical reports, its annual reports, its recertification 
questionnaire, its manuals of policy and procedures, and its MOU with the 
State Medicaid agency.  We requested any additional data or clarification 
from the Unit as necessary. 
Review of Unit Financial Documentation.  We reviewed the Units control 
over its fiscal resources to identify any issues involving internal controls 
or the use of resources.  Prior to the onsite review, we reviewed the Units 
financial policies and procedures; its response to a questionnaire on 
internal controls; and documents (such as financial status reports) related 
to MFCU grants. 
We reviewed three purposive samples to assess the Units internal control 
of fiscal resources.  All three samples were limited to the review period of 
FYs 2014 through 2016.  The three samples included the following: 
1.  To assess the Units expenditures, we grouped related lines in the 
transaction detail into 3,342 transactions and selected a purposive 
sample of 30 transactions for additional review.24  We purposively 
included transactions from different Federal cost categories and 
included automated as well as manual journal entries.  The dollar 
amounts of the selected transactions varied, ranging from a $76,677 
personnel expenditure to a $105 travel expenditure.  Our selections 
totaled $368,673.9, which were taken from $9,799,401.16 in 
                        ____________________________________________________________ 
24 The transaction detail reports we selected from included multiple lines relating to 
activities and accounting entries, which contributed to the Units reported expenditures.  
To determine units for our sample selection, we considered all the lines with the same 
document identifier as a transaction.   
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      18   
   
expenditures.25  We then requested and reviewed documentation 
supporting the selected transactions. 
2.  To assess employees time and efforti.e., their work hours spent 
on various MFCU taskswe selected a purposive sample of three pay 
periods, one from each fiscal year.  We then requested and reviewed 
documentation to support the time and effort of the MFCU staff during 
the selected pay periods. 
3.  We also reviewed a purposive sample of the Units fixed assets 
inventory.  Specifically, we selected and verified 30 of the 84 items 
from the Units inventory.  
Interviews with Key Stakeholders.  In December 2016 and January 2017, we 
interviewed key stakeholders, including officials in the U.S. Attorneys 
Offices and State agencies that interacted with the Unit, including the CHFS 
and the DMS.  We also interviewed supervisors from OIGs Region IV, who 
work regularly with the Unit.  We focused these interviews on the Units 
relationship and interaction with OIG and other Federal and State 
authorities, and we identified opportunities for improvement.  We used the 
information collected from these interviews to develop subsequent interview 
questions for Unit management. 
Survey of Unit Staff.  In December 2016, we conducted an online survey 
of the 29 nonmanagerial Unit staff within each professional discipline 
(i.e., investigators, auditors, attorneys, analysts, and nurse investigators) as 
well as support staff.  Our questions focused on Unit operations, 
opportunities for improvement, and practices that contributed to the 
effectiveness and efficiency of Unit operations and/or performance.  The 
survey also sought information about the Units compliance with 
applicable laws and regulations.   
Onsite Interviews with Unit Management.  We conducted structured onsite 
interviews with the Units management in January 2017.  We interviewed 
the current and former Unit directors, the litigations manager, the 
investigations manager, and the fraud investigations support team 
manager.  We asked these individuals to provide information related to 
(1) Unit operations, (2) Unit practices that contributed to the effectiveness 
and efficiency of Unit operations and/or performance, (3)opportunities for 
 
the Unit to improve its operations and/or performance, and 
(4) clarification regarding information obtained from other data sources. 
                        ____________________________________________________________ 
25 The transaction detail reports totaled to $3.85 less than the total expenditures claimed 
for the grant period.  This was immaterial and likely due to rounding effects over the 
3 years. 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      19   
   
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 time during 
FYs 2014 through 2016.  We requested data on the 416 cases that 
included, but were 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.  Because global cases are civil false claims actions that typically 
involve multiple agencies, such as the U.S. Department of Justice and a 
group of State MFCUs, we excluded all of those cases from our review of 
a Units case files.  Therefore, we excluded 88 cases that were categorized 
as global from the list of cases.  The remaining number of case files 
was 328.   
We then selected a simple random sample of 100 cases from the 
population of 328 cases.  From this initial sample of 100 case files, we 
selected a further simple random sample of 50 files for a more in-depth, 
qualitative review of selected issues, such as the timeliness of 
investigations and case development.  While onsite, we consulted MFCU 
staff to address any apparent issues with individual case files, such as 
missing documentation.   
Onsite Review of Unit Operations.  During our January 2017 onsite visit, 
we reviewed the Units workspace and operations.  Specifically, we 
visited the Units main office in Frankfort, Kentucky.  While onsite, we 
observed the Units offices and meeting spaces; the security of data and 
case files; the location of select equipment; and the general functioning of 
the Unit. 
Data Analysis 
We analyzed data to identify any opportunities for improvement and 
instances in which the Unit did not fully meet the performance standards 
or was not operating in accordance with laws, regulations, or policy 
transmittals.26 
 
 
 
 
 
 
                        ____________________________________________________________ 
26 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      20   
   
APPENDIX E 
Unit Comments 
 
 
 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      21   
   
 
 
 
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      22   
   
ACKNOWLEDGMENTS 
Anthony Soto McGrath served as the team leader for this study.  Others in 
the Office of Evaluation and Inspections who conducted the study include 
Ben Gaddis and Jamila Murga.  Medicaid Fraud Policy and Oversight 
Division staff who participated in the review include Frantzy Clement. 
Staff from the Office of Investigations and Office of Audit Services also 
participated in the review.  Central office staff who provided support 
include Kevin Farber and Christine Moritz.  
This report was prepared under the direction of Ruth Ann Dorrill, 
Regional Inspector General for Evaluation and Inspections in the Dallas 
regional office, and Amy Ashcraft and Petra Nealy, Deputy Regional 
Inspectors General, and in consultation with Richard Stern, Director of the 
Medicaid Fraud Policy and Oversight Division.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.   
Kentucky State Medicaid Fraud Control Unit:  2017 Onsite Review (OEI-06-17-00030)      23   
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.