Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
M S
ASSACHUSETTS  TATE 
M F C
EDICAID  RAUD  ONTROL 
U : 2015 O R  
NIT    NSITE  EVIEW
 
 
Suzanne Murrin 
Deputy Inspector General 
For Evaluation and Inspections 
 
June 2016 
OEI-07-15-00390   
   
EXECUTIVE SUMMARY:  MASSACHUSETTS STATE MEDICAID FRAUD 
CONTROL UNIT:  2015 ONSITE REVIEW 
OEI-07-15-00390 
 
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 Massachusetts Unit in October 2015.  We based 
our review on an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; (2) financial 
documentation for fiscal years (FYs) 2012 through 2014; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Units 
management; (6) a sample of files for cases that were open in FYs 2012 through 2014; 
and (7) observation of Unit operations. 
 
WHAT WE FOUND 
The Unit was generally in compliance with applicable laws, regulations, and policy 
transmittals.  For FYs 2012 through 2014, the Massachusetts Unit reported 49 criminal 
convictions, 72 civil judgments and settlements, and combined criminal and civil 
recoveries of $182 million.  We noted that the Massachusetts Unit has developed 
successful partnerships with other agencies and clinical experts to investigate and 
prosecute pharmacy cases, and streamlined a number of administrative processes using a 
customized intranet. 
 
We identified two areas where the Unit should improve its performance.  Specifically, the 
Unit should better ensure that all case files contain documentation of periodic supervisory 
reviews, and report all convictions and adverse actions to Federal partners within 
required timeframes.    
 
WHAT WE RECOMMEND  
We recommend that the Massachusetts Unit monitor the implementation of its new 
policies and processes for (1) documenting periodic supervisory reviews results, and (2) 
ensuring that all convictions and adverse actions are reported to Federal partners within 
required timeframes.  The Unit concurred with both of our recommendations.   
   
   
 
 
TABLE OF CONTENTS 
 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................5 
For FYs 2012 through 2014, the Massachusetts Unit reported  
49 criminal convictions, 72 civil judgments and settlements,  
and combined criminal and civil recoveries of $182 million ..........5 
Eighteen percent of the case files lacked required  
documentation of periodic supervisory reviews; however, 
supervisors documented opening and closing of most cases ...........6 
The Unit did not report all convictions and adverse actions to 
Federal partners within required timeframes ...................................7 
Other observation:  The Unit has developed successful  
partnerships with other agencies and clinical experts to  
investigate and prosecute pharmacy cases .......................................9 
Other observation:  The Unit has streamlined a number of 
administrative processes using a customized intranet ...................10 
Conclusion and Recommendations ............................................................12 
Unit Comments and Office of Inspector General Response ..........13 
Appendixes ................................................................................................14 
A:  2012 Performance Standards ...................................................14 
B:  Massachusetts State Medicaid Fraud Control Unit Referrals  
by Referral Source for FYs 2012 Through 2014 ...........................18 
C:  Investigations Opened and Closed By Provider Category  
for FYs 2012 Through 2014 ..........................................................19 
D:  Detailed Methodology .............................................................21 
E:  Point Estimates and 95-Percent Confidence Intervals Based 
on Reviews of Case Files ...............................................................25 
F:  Unit Comments .........................................................................26 
Acknowledgments......................................................................................28 
   
   
OBJECTIVE 
To conduct an onsite review of the Massachusetts State Medicaid Fraud 
Control Unit (MFCU or Unit). 
BACKGROUND  
The mission of MFCUs is to investigate and prosecute Medicaid provider 
fraud and patient abuse or neglect under State law.1  The SSA requires 
each State to operate a MFCU, unless the Secretary of Health and Human 
Services (HHS) determines that operation of a Unit would not be 
cost-effective because minimal Medicaid fraud exists in a particular State 
and 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) 2015, the 
50 Units collectively reported 1,553 convictions, 795 civil settlements or 
judgments, and approximately $745 million in recoveries.5, 6 
Units must meet a number of requirements established by the SSA and 
Federal regulations.  For example, each Unit must: 
  be a single, identifiable entity of State government, distinct from 
the single State Medicaid agency;7   
  develop a formal agreement, such as a memorandum of 
understanding (MOU), which describes the Units relationship 
with the State Medicaid agency;8 and   
                        ____________________________________________________________ 
1 Social Security Act (SSA)  1903(q).  Regulations at 42 CFR  1007.11(b)(1) add that 
the Units responsibilities may include reviewing complaints of misappropriation of 
patients private funds in residential health care facilities. 
2 SSA  1902(a)(61).   
3 North Dakota and the territories of American Samoa, Guam, the Northern Mariana 
Islands, Puerto Rico, and the U.S. Virgin Islands have not established Units. 
4 SSA  1903(q)(6); 42 CFR 1007.13. 
5 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2015. 
Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on April 13, 2016.   
6  All FY references in this report are based on the Federal FY (October 1 through     
September 30). 
7 SSA  1903(q)(2); 42 CFR  1007.5 and 1007.9(a). 
8 42 CFR  1007.9(d).  
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  1 
   
   
  have either statewide authority to prosecute cases or formal 
procedures to refer suspected criminal violations to an agency with 
such authority.9   
MFCU Funding 
Each MFCU is funded jointly by its State and the Federal government. 
Federal funding for the MFCUs is provided as part of the Federal 
Medicaid appropriation, but it is administered by OIG.10  Each Unit 
receives Federal financial participation equivalent to 75 percent of its total 
expenditures, with State funds contributing the remaining 25 percent.11  In 
FY 2015, combined Federal and State expenditures for the Units totaled 
$251 million, $188 million of which represented Federal funds.12   
Administration and Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to administer the 
MFCU grant program.13  To receive Federal reimbursement, each Unit must 
submit an initial application to OIG for approval and be recertified each year 
thereafter.    
In annually recertifying the Units, OIG evaluates Unit compliance with 
Federal requirements and adherence to performance standards.  The Federal 
requirements for Units are contained in the SSA, regulations, and policy 
guidance.14  In addition, OIG has published 12 performance standards that it 
uses to assess whether a Unit is effectively performing its responsibilities.15  
The standards address topics such as staffing, maintaining adequate referrals, 
and cooperation with Federal authorities.  Appendix A contains the 
Performance Standards.     
OIG also performs periodic onsite reviews of the Units, such as this review 
of the Massachusetts 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 2015. 
Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on April 13, 2016.     
13 The SSA authorizes the Secretary of HHS to award grants to the Units; the Secretary 
delegated this authority to the OIG.   
14 On occasion, OIG issues policy transmittals to provide guidance and instructions to 
MFCUs.   
15 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/files/Performance%20Standards.pdf on May 22, 2015.  On 
June 1, 2012, OIG published a revision of the performance standards at  
77 Fed. Reg. 32645.  Because our review covered FYs 2012 through 2014, we applied 
the standards published on June 1, 2012. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  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.  
Massachusetts MFCU 
The Unit, a division of the Massachusetts Office of the Attorney General, 
investigates and prosecutes cases of Medicaid fraud and patient abuse or 
neglect.  To investigate and prosecute such cases, the Unit employed 
46 staff as investigators, attorneys, auditors, nurse investigators, 
paralegals, and administrative staff during the time of our onsite review.16  
The Massachusetts Unit had total expenditures of approximately 
$5.4 million in combined State and Federal funds in FY 2015.17   
The Unit is broadly organized into two groups, investigators (which 
includes the Unit auditors) and attorneys.  The investigators and auditors 
report to either an investigations supervisor, or directly to the Chief of 
Investigations.  The three investigations supervisors also report to the 
Chief of Investigations.  The Unit employs two Managing Assistant 
Attorneys General (AAGs).  The attorneys report to one of the Managing 
AAGs, the Unit director, or the Unit Deputy Chief.  The Chief of 
Investigations, the Managing AAGs, and the Deputy Chief all report to the 
Unit director.  The second Managing AAG manages the Units global 
cases. 
Referrals.  The Unit receives referrals from a variety of sources, including 
the State Medicaid agency, a hotline, and private citizens.  Appendix B 
depicts Unit referrals by referral source for FYs 2012 through 2014.  For 
each referral received, Unit staff perform an initial review.  The results of 
the initial review of each referral are discussed at a weekly management 
meeting.  The Unit director and Chief of Investigations, in consultation 
with other Unit staff, decide whether to open a case based on each referral.   
Periodic Supervisory Reviews.  The Unit conducts periodic supervisory 
reviews on each open case.  The Unit Policy and Procedures Manual requires 
supervisory review of each case at least quarterly, but according to the Unit 
director, the Unit strives to review each case monthly.  During these reviews, 
the assigned investigator or attorney and appropriate supervisor discuss the 
                        ____________________________________________________________ 
16 In the Massachusetts Unit, four staff were designated as auditors at the time of our 
review. Although the title of each of these four staff was Investigator or Senior 
Investigator, the Director explained that their duties fulfilled the auditor function. 
17 OIG, MFCU Statistical Data for Fiscal Year 2015, February 2016.   
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  3 
   
   
progress made on each case and plan the next steps for pursuing the case.  
The reviews are noted in the Units online tracking system. 
The Chief of Investigations also meets with each investigator periodically to 
discuss progress on cases.  The frequency of these case meetings ranges 
from weekly to monthly, depending on the experience of the investigator.   
Appendix C contains details on opened and closed investigations. 
Previous Onsite Review 
In 2010, OIG published a report regarding its onsite review of the 
Massachusetts Unit.18  OIG found that the Massachusetts Unit did not 
maintain interim investigative memoranda, which note the progress of 
investigations, in official case files.  Our 2015 onsite review found no further 
evidence that the Unit did not document the progression of its investigations. 
METHODOLOGY 
Data Collection and Analysis 
We conducted the onsite review in October 2015.  We based our review on 
an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; 
(2) financial documentation for FYs 2012 through 2014; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
interviews with the Units management; (6) a sample of files for cases that 
were open in FYs 2012 through 2014; and (7) observation of Unit 
operations.  We also used these data sources to determine if any issues 
related to findings from the previous OIG onsite review persisted.  
Appendix 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. 
   
                        ____________________________________________________________ 
18 OIG, Onsite Review of the Commonwealth of Massachusetts Medicaid Fraud Control 
Unit, March 2010.   
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FINDINGS 
Our review of the Massachusetts Unit found that it was generally in 
compliance with applicable laws, regulations, and policy transmittals.  The 
Unit reported 49 criminal convictions and 72 civil judgements and 
settlements.  It also reported combined criminal and civil recoveries of 
$182 million, and recovered more than $11 in combined Federal and State 
expenditures for every $1 spent in the review period.   
We identified two areas where the Unit should improve its operations.  
Specifically, the Unit should better ensure that all case files contain 
documentation of periodic supervisory reviews, and report all convictions 
and adverse actions to Federal partners within required timeframes.   
For FYs 2012 through 2014, the Massachusetts Unit 
reported 49 criminal convictions, 72 civil judgments 
and settlements, and combined criminal and civil 
recoveries of $182 million 
For FYs 2012 through 2014, the Unit reported 49 criminal convictions and 
72 civil judgments and settlements.  See Table 1 for yearly convictions 
and civil judgments and settlements.  Of the Units 49 convictions over the 
3-year period, 42 involved provider fraud and 7 involved patient abuse and 
neglect.   
Table 1:  Massachusetts MFCU Criminal Convictions and Civil 
Judgments and Settlements, FYs 20122014 
3-Year 
Outcomes  FY 2012  FY 2013  FY 2014  Total 
Criminal Convictions  11  17  21  49 
Civil Judgments and Settlements  19  32  21  72 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
The Unit reported criminal and civil recoveries totaling $182 million for 
FYs 2012 through 2014.  Sixty-eight percent of the Units recoveries were 
obtained from global settlements during the period of our review.19  See 
Table 2 for the Massachusetts Units yearly recoveries and expenditures.   
 
   
                        ____________________________________________________________ 
19 Global cases are civil false claims actions involving the U.S. Department of Justice 
and a group of State MFCUs.  The National Association of Medicaid Fraud Control Units 
facilitates the settlement of global cases. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  5 
   
   
Table 2:  Massachusetts MFCU Recoveries and Expenditures,                  
FYs 20122014 
Type of Recovery  FY 2012  FY 2013  FY 2014  3-Year Total 
Global Civil  $47,548,936  $26,209,559  $50,327,005  $124,085,500 
Nonglobal Civil  $44,379,513  $2,514,310  $5,288,196  $52,182,018  
Criminal  $227,034  $884,124  $4,639,474  $5,750,632 
     Total           
$92,155,483  $29,607,993  $60,254,675  $182,018,150 
Recoveries 
     Total 
$5,456,458  $5,271,067  $5,470,721  $16,198,246 
Expenditures 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
Eighteen percent of the case files lacked required 
documentation of periodic supervisory reviews; 
however, supervisors documented opening and 
closing of most cases 
Eighteen percent of the case files that required periodic supervisory 
reviews lacked documentation of such reviews.  Performance Standard 
7(a) states that supervisory reviews should be conducted periodically and 
noted in the case file.  Further, the Units policy requires a review of each 
case at least quarterly.20  Pursuant to this policy, the Managing AAG or 
Chief of Investigations notes each supervisory review on the Units 
intranet.  Periodic supervisory reviews ensure timely completion of cases 
and may identify potential issues during the investigation. 
Although some case files lacked documentation of periodic supervisory 
reviews, most case files contained documentation of supervisory approval 
to open and close the cases.  Eighty-eight percent of the Units case files 
included documentation of supervisory approval to open the cases.  All of 
the Units closed cases included documentation of supervisory approval to 
close the case.21  Performance Standard 5(b) states that Unit supervisors 
should approve the opening and closing of cases.  The Units policy also 
requires that opening and closing documents be maintained in case files.22 
Supervisory approval to open cases indicates that Unit supervisors are 
monitoring the intake of cases, thereby facilitating progress in the 
                        ____________________________________________________________ 
20 MA MFCU Policy and Procedures Manual, B-4 Supervisory Reviews, p. 12. 
21 All closed case files in our sample included documentation of supervisory approval to 
close the cases.  However, we cannot be certainbecause of sampling errorthat all of 
the Units closed case files in the review period included this documentation.   As a 
statistical matter, we are 95-percent confident that at least 96.2 percent of the closed cases 
in the population had documentation of supervisory approval to close the case. 
22 MA MFCU Policy and Procedures Manual, B1-Case Opening Procedures and  
B2-Case Closing Procedures, p. 11. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  6 
   
   
investigation.  Supervisory approval of case closures helps ensure the 
timely completion and resolution of cases.   
During FY 2014 (toward the end of our review period), the Unit 
implemented a new, streamlined method of documenting periodic 
supervisory reviews and supervisory approvals to open and close cases 
through their intranet site.  According to Unit staff, this new method 
greatly improved the process of documenting these reviews.  However, 
because the new process was implemented near the end of the review 
period, few sampled cases were required to have periodic reviews.  
Therefore, we could not verify whether the new process resulted in 
documentation of more periodic supervisory reviews. 
The Unit did not report all convictions and adverse 
actions to Federal partners within required timeframes 
The Unit did not report all convictions to OIG for the purpose of program 
exclusion or all adverse actions to the National Practitioner Data Bank 
(NPDB) within the required timeframes.  The Unit director explained that, 
for part of the review period, the Unit was using an old reporting process 
that did not result in all convictions being reported to OIG in a timely 
manner.  However, in January 2013, the Unit instituted a new reporting 
process to address this issue.  With regard to NPDB reporting, the Unit 
director explained that the Unit was not aware of the requirement to report 
adverse actions to NPDB within 30 days until September 2013.  In March 
2014, the Unit began tracking reporting of adverse actions to NPDB through 
the new process as well.   
The Unit did not report all convictions to OIG within required 
timeframes. 
The Unit did not report 21 of its 49 convictions to OIG within 30 days of 
sentencing as required by Federal regulations.  Table 3 shows how many 
days after sentencing these convictions were reported to OIG.  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.  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. 
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Table 3:  Number of Convictions Reported to OIG After Required Timeframe 
Federal Partner  Convictions Reported  Convictions Reported  Convictions Reported  Total Convictions 
Reported To  Within 31 to 60 Days  Within 61 to 90 Days  More Than 90 Days  Reported More Than 
After Sentencing  After Sentencing  After Sentencing  30 Days After Sentencing  
OIG  8  2  11  21 
Source:  OIG analysis of Unit convictions and dates reported to OIG, 2016. 
Unit management explained that many of the convictions that were reported 
late occurred prior to implementation of its new reporting process in 
January 2013.  The new process provides multiple opportunities for 
tracking, documenting, and communicating about convictions.  These 
opportunities include: 
  submission of court activity reports by Unit attorneys after every 
court appearance.  The court activity reports detail actions taken in 
court and indicate the next scheduled court event.  These reports are 
submitted to the Unit director and the Units support staff.  They 
ensure that the Units support staff who are responsible for 
reporting convictions to OIG have current court information on all 
active cases. 
  preparation of biweekly reports by all Unit attorneys and 
investigators.  The biweekly reports describe significant activities, 
including convictions, from the past two weeks, and significant 
activities expected in the next two weeks.  These reports are 
reviewed at several levels, including supervisors, the Deputy Chief, 
and the Unit director. 
  weekly meetings between Unit management and support staff to 
discuss a wide variety of issues, including conviction reporting.   
The Unit director reported that 25 of the Units 29 convictions obtained 
since the implementation of the new process were reported in a timely 
manner.  The new processes are documented in the Units policy and 
procedures manual.23 
The Unit did not report most of its adverse actions to NPDB 
within required timeframes. 
The Unit did not report 45 of its 49 convictions to NPDB within 30 days of 
the adverse action.  Federal regulations require that Units report any 
adverse actions generated as a result of investigations or prosecutions of 
                        ____________________________________________________________ 
23 MA MFCU Policy and Procedures Manual, D2-Court Activity Reports, p. 18 and  
F5-Bi-Weekly Reports, p. 24. 
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healthcare providers to the NPDB.24  Performance Standard 8(g) also states 
that the Unit should report qualifying cases to NPDB.25  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 
healthcare employment with an organization that is not aware of their 
adverse actions. 
Table 4:  Number of Convictions Reported to NPDB After Required Timeframe 
Federal Partner  Convictions Reported  Convictions Reported  Convictions Reported  Total Convictions 
 
Reported To Within 31 to 60 Days  Within 61 to 90 Days  More Than 90 Days  Reported More Than 
       
After the Action After the Action After the Action 30 Days After the Action 
   
NPDB 2  0  43  45
 
Source:  OIG analysis of Unit convictions and dates reported to NPDB, 2016.
Unlike delays in reporting convictions to OIG for exclusion, delays in 
reporting adverse actions to NPDB occurred because the Unit was unaware 
of the requirement to report to NPDB within 30 days.  According to the Unit 
director, the Unit learned of the NPDB reporting requirement in a 
September 2013 webinar OIG hosted.  In March 2014, the Unit began 
including the reporting of adverse actions to NPDB in their new process for 
reporting convictions described above.  The new reporting process provides 
multiple opportunities for documentation and communication help ensure 
the timely reporting of adverse actions to NPDB.   
Other observation: The Unit has developed successful 
partnerships with other agencies and clinical experts 
to investigate and prosecute pharmacy cases 
The Unit has developed successful partnerships with other agencies and 
effective methods of accessing specialized expertise in its investigation and 
prosecution of pharmacy cases, including cases involving the 
overprescription and/or abuse of opioids.  The Unit developed these 
relationships in response to the recent rise in problems with opioid abuse in 
Massachusetts.  In March 2014, Massachusetts Governor declared a public 
                        ____________________________________________________________ 
24 45 CFR  60.5.   
25 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 2012 through 2014); therefore, we reviewed the reporting of adverse 
actions under NPDB requirements.  78 Fed. Reg. 20473 (April 5, 2013).  Examples of 
final adverse actions include, but are not limited to, convictions, civil judgments (but not 
civil settlements), and program exclusions.  See SSA  1128E(g)(1) and 45 CFR  60.3. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  9 
   
   
health emergency related to opioid addiction; and in December 2015, the 
Massachusetts Medical Society called the opioid crisis the Societys top 
priority.26   
Unit staff reported that their strong, cooperative relationship with the Drug 
Enforcement Administrations (DEAs) Diversion Program led to the Units 
successful prosecutions of cases involving drug diversion and illegal 
prescription of opioids.  DEA has the ability to efficiently obtain original 
prescriptions from pharmacies, a time- and resource-intensive task that is 
necessary to investigate and prosecute illegal prescribing.  The partnership 
also helps identify new cases; the Unit has opened several investigations 
based on DEA referrals of suspect pharmacies and prescribers.  DEA 
performs pharmacy inspections, and therefore has ample information on 
prescribing doctors and their employees.   
The Unit also cooperates with the Norfolk County Overdose Death Review 
Team, which performs periodic reviews of all deaths from opiate drug 
overdoses.  A working group of staff from the county and other State police 
and licensing agencies conduct these reviews.  The team reviews the 
prescription histories of county residents who die from overdoses of opiate 
drugs to identify providers and pharmacies who may be involved in abusive 
or illegal prescribing.  Unit staff also identified their relationship with the 
Norfolk County working group as a rich source of referrals and 
investigative information.  For example, the working group may identify 
abusive practices by a prescriber or pharmacy already under investigation 
by the Unit and provide information to the Unit that helps support their 
case. 
Additionally, Unit staff reported that they gain access to specialized 
expertise on prescribing and the pharmaceutical industry by employing 
students from local pharmacy schools as interns.  The pharmacy interns use 
their expertise to review pharmacy claims and identify recipients who 
receive Medicaid-paid prescription drugs, but who do not have claims for 
office visits or other healthcare services from the prescribers of those drugs.  
Unit staff reported that the interns contribute significantly to the Units 
pharmacy cases, but cost the Unit little in terms of budget and resources.  
Other observation:  The Unit has streamlined a 
number of administrative processes using its intranet  
The Unit has streamlined several administrative processes through its 
intranet.  Unit staff reported that the improvements to these processes have 
                        ____________________________________________________________ 
26 Massachusetts Medical Society, 2015 Interim Meeting: Presidents Report, December 
4, 2015.  Accessed online at http://www.massmed.org/Governance-and-
Leadership/House-of-Delegates/Interim-Meeting/2015-Interim-Meeting--President-s-
Report/#.VxEqx032bcs on April 15, 2016. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  10 
   
   
helped the Unit ensure timely progression of cases and effective 
investigation and prosecution of fraud and abuse.  
The Unit tracks and documents periodic supervisory case reviews through 
the intranet site. Each manager has a folder on the intranet for each staff 
person supervised; reviews of the cases assigned to each staff person are 
noted in that persons folder.  When a manager notes a case review, the 
intranet automatically sends an email to the Units support staff.   The 
support staff then update the Units case management system to reflect the  
case review conducted.27  
Another process the Unit has streamlined through its intranet is supervisory 
review and approval of opening and closing memos.  When each case is  
opened and closed, the staff assigned to it draft a memorandum explaining 
why the case should be opened, or why it is ready to be closed.  When Unit 
staff upload a draft memorandum to the intranet, it is automatically routed 
to the appropriate supervisor(s) for review.  When each supervisor approves 
the memorandum, the intranet records those approvals.   
The Unit has also streamlined a number of other administrative processes 
through the intranet, including:  requesting criminal history information, 
requesting data from the State Medicaid agency, managing staff leave  
requests, and populating calendars with scheduled leave and court 
appearances. Finally, the intranet also provides links to useful resources,  
such as the Units Policy and Procedures Manual and administrative forms.   
   
____________________________________________________________ 
27 The Unit implemented this  process near the end of the review period; thus, our case file  
review results  do not  reflect any improvements in documentation of  periodic reviews that  
resulted from the new process. 
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CONCLUSION AND RECOMMENDATIONS 
Our review of the Massachusetts Unit found that it was generally in 
compliance with applicable laws, regulations and policy transmittals.  The 
Unit reported obtaining 49 criminal convictions and 72 civil judgments 
and settlements during the review period.  The Unit also reported 
combined criminal and civil recoveries of $182 million, and recovered 
more than $11 in combined Federal and State expenditures for every 
$1 spent in the review period.  The Massachusetts Unit has developed 
successful partnerships and effective methods of accessing expertise to 
investigate and prosecute pharmacy cases, and streamlined a number of 
administrative processes using its customized intranet. 
We identified two areas where the Unit should improve its operations.  
Specifically, the Unit should better ensure that all case files contain 
documentation of periodic supervisory reviews, and should report all 
convictions and adverse actions to Federal partners within required 
timeframes. 
We recommend that the Massachusetts Unit:  
Monitor implementation of its new policies and 
process for documenting periodic supervisory reviews  
The Unit already has implemented new policies and a related process to 
ensure that periodic supervisory case reviews are documented.  To ensure 
the new policies and related process are working as intended, the Unit 
could review a sample of its own case files to determine if the changes 
produce the required documentation.  If the Unit finds that some reviews 
are not being documented, it should further revise to its process to ensure 
the documentation of all periodic supervisory reviews. 
Monitor implementation of its new policies and 
process to ensure all convictions and adverse actions 
are being reported to Federal partners within required 
timeframes  
The Unit already has implemented new policies and a related process to 
ensure that convictions are reported to OIG within 30 days and adverse 
actions are reported to NPDB within 30 days.  To ensure the new policies 
and related process are working as intended, the Unit could periodically 
review its own reporting to determine if all convictions and adverse 
actions being reported to both OIG and NPDB in a timely manner.  If  
these reviews indicate that some convictions or adverse actions are not 
being reported within required time frames, the Unit should further revise 
its processes to ensure the timeliness of all reporting to Federal partners. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  12 
   
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Massachusetts Unit concurred with both of our recommendations.   
Regarding the first recommendation, the Unit stated that it will continue to 
use its intranet to facilitate documentation of supervisory reviews.  The 
Unit also will monitor the effectiveness of the system through periodic 
self-reviews. 
Regarding the second recommendation, the Unit stated that it will monitor 
its policies and procedures that are intended to ensure compliance with 
adverse action reporting requirements and that it has added this as a 
discussion item to its weekly meetings with support staff. 
The Units comments are provided in Appendix F. 
 
   
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  13 
   
   
APPENDIX A 
2012 Performance Standards28  
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. 
                        ____________________________________________________________ 
28 77 Fed. Reg. 32645, June 1, 2012. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  14 
   
   
C.  The Unit provides timely information to the State Medicaid or other agency when the Medicaid or other 
agency requests information on the status of MFCU investigations, including when the Medicaid agency 
requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii). 
D.  For those States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and 
neglect cases, the Unit takes steps, such as the development of operational protocols, to ensure that pertinent 
agencies refer such cases to the Unit, consistent with patient confidentiality and consent.  Pertinent agencies 
vary by State but may include licensing and certification agencies, the State Long Term Care Ombudsman, and 
adult protective services offices.  
E.  The Unit provides timely information, when requested, to those agencies identified in (D) above regarding 
the status of referrals. 
F.  The Unit takes steps, through public outreach or other means, to encourage the public to refer cases to the 
Unit. 
5. A UNIT TAKES STEPS TO MAINTAIN A CONTINUOUS CASE FLOW AND TO COMPLETE CASES IN AN 
APPROPRIATE TIMEFRAME BASED ON THE COMPLEXITY OF THE CASES. 
A.  Each stage of an investigation and prosecution is completed in an appropriate timeframe. 
B.  Supervisors approve the opening and closing of all investigations and review the progress of cases and take 
action as necessary to ensure that each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
C.  Delays to investigations and prosecutions are limited to situations imposed by resource constraints or other 
exigencies.   
6.  A UNITS CASE MIX, AS PRACTICABLE, COVERS ALL SIGNIFICANT PROVIDER TYPES AND 
INCLUDES A BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.   
A.  The Unit seeks to have a mix of cases from all significant provider types in the State. 
B.  For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
D.  As part of its case mix, the Unit maintains a balance of fraud and patient abuse and neglect cases for those 
States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and neglect cases. 
C.  The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors.  Special Unit initiatives may focus on specific provider types. 
E.  As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7.  A UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER AND DEVELOPS A CASE 
MANAGEMENT SYSTEM THAT ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.   
A.  Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B.  Case files include all relevant facts and information and justify the opening and closing of the cases. 
C.  Significant documents, such as charging documents and settlement agreements, are included in the file.  
D.  Interview summaries are written promptly, as defined by the Units policies and procedures. 
E.  The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
F. The Unit has an information management system that allows for the monitoring and reporting of case 
information, including the following:  
1. The number of cases opened and closed and the reason that cases are closed. 
2.  The length of time taken to determine whether to open a case referred by the State Medicaid agency or other 
referring source. 
3.  The number, age, and types of cases in the Units inventory/docket 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  15 
   
   
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. 
 
 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  16 
   
   
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.  
   
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  17 
   
   
APPENDIX B 
Massachusetts State Medicaid Fraud Control Unit Referrals by 
Referral Source for FYs 2012 Through 2014 
  FY 2012  FY 2013  FY 2014 
Abuse &  Patient  Abuse &  Patient  Abuse &  Patient 
Referral Source  Fraud  Fraud  Fraud 
Neglect  Funds  Neglect  Funds  Neglect  Funds 
Medicaid agency   
69  0  0  18  0  0  0  0  0 
PI/SURS29 
Medicaid agency  
0  0  0  24  0  0  65  0  0 
other 
Managed care 
0  0  0  0  0  0  1  0  0 
organizations 
State survey and 
8  1,014  1  2  986  1  3  1,176  0 
certification agency 
Other State 
12  0  0  2  0  0  4  0  0 
agencies 
Licensing board  0  0  0  0  0  0  4  0  0 
Law enforcement  2  0  0  14  2  0  6  1  0 
Office of Inspector 
5  2  0  2  0  0  2  0  0 
General 
Prosecutors  1  0  0  0  0  0  2  0  0 
Providers  6  0  0  4  0  0  0  0  0 
Provider 
0  0  0  0  0  0  0  0  0 
associations 
Private health 
1  0  0  2  0  0  0  0  0 
insurer 
Long-term-care 
0  0  0  0  0  0  0  0  0 
ombudsman 
Adult protective 
0  0  0  1  1  0  0  0  0 
services 
Private citizens  54  0  0  116  2  0  102  1  0 
MFCU hotline  178  0  0  78  14  0  149  36  0 
Self-generated  5  0  0  3  0  0  1  0  0 
Other  12  0  0  6  0  0  5  0  1 
   Total  353  1,016  1  272  1,005  1  344  1,214  1 
   Annual Total  1,370  1,278  1,559 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
                        ____________________________________________________________ 
29 The abbreviation PI stands for program integrity; the abbreviation SURS stands for 
Surveillance and Utilization Review Subsystem. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  18 
   
   
APPENDIX C 
Investigations Opened and Closed By Provider Category for 
FYs 2012 Through 2014 
Table C-1:  Fraud Investigations  
Provider Category  FY 2012  FY 2013  FY 2014 
Facilities  Opened  Closed  Opened  Closed  Opened  Closed 
     Hospitals  3  1  1  0  3  1 
     Nursing facilities  8  6  2  6  3  3 
     Other long-term-care  
0  0  0  0  0  0 
     facilities 
     Substance abuse treatment            
0  0  0  0  0  0 
     centers  
     Other   39  8  20  13  20  27 
   Subtotal  50  15  23  19  26  31 
Practitioners  Opened  Closed  Opened  Closed  Opened  Closed 
     Doctors of medicine or  
43  21  13  20  16  21 
     osteopathy 
     Dentists  28  24  11  10  11  15 
     Podiatrists  0  0  1  1  0  0 
     Optometrists/opticians  0  0  1  1  1  0 
     Counselors/psychologists  0  0  1  1  2  1 
     Chiropractors  2  3  0  0  0  0 
     Other   15  5  1  5  5  6 
   Subtotal  88  53  28  38  35  43 
Medical Support  Opened  Closed  Opened  Closed  Opened  Closed 
     Pharmacies  17  32  16  6  14  9 
     Pharmaceutical  
51  24  33  36  29  29 
     manufacturers 
     Suppliers of durable medical 
15  8  21  3  19  2 
     equipment and/or supplies 
     Laboratories  7  4  5  6  8  6 
     Transportation services  5  0  1  7  3  4 
     Home health care agencies  12  8  11  2  4  8 
     Home health care aides  20  16  16  17  11  13 
     Nurses, physician assistants,  
     nurse practitioners, certified   4  7  1  2  2  1 
     nurse aides 
     Radiologists  1  1  0  0  0  0 
     Medical supportother   0  0  0  0  0  0 
   Subtotal  132  100  104  79  90  72 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  19 
   
   
Table C-1 (Continued):  Fraud Investigations 
Program Related  Opened  Closed  Opened  Closed  Opened  Closed 
     Managed care   0  0  0  0  0  0 
     Medicaid program  
0  0  0  0  0  0 
     administration 
     Billing company  0  0  0  0  0  0 
     Other  0  0  0  0  0  0 
   Subtotal  0  0  0  0  0  0 
   Total Provider Categories  270  168  155  136  151  146 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
Table C-2:  Patient Abuse and Neglect Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nursing facilities  256  201  52  103  35  78 
     Other long-term-care facilities  0  0  0  0  0  0 
Nurses, physicians 
assistants, nurse    
97  90  35  46  16  44 
practitioners, certified nurse           
aides 
     Home health aides  0  0  0  0  0  0 
     Other  6  4  1  3  1  3 
   Total  359  295  88  152  52  125 
Source: OIG analysis of Unit-submitted documentation, 2016. 
 
Table C-3:  Patient Funds Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nondirect care  0  0  0  0  0  0 
Nurses, physicians 
assistants, nurse    
0  0  0  0  0  0 
practitioners, certified nurse           
aides 
     Home health aides  0  0  0  0  0  0 
     Other  1  1  1  0  0  1 
   Total  1  1  1  0  0  1 
Source: OIG analysis of Unit-submitted documentation, 2016. 
   
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  20 
   
   
APPENDIX D 
Detailed Methodology 
Data collected from the seven sources below was used to describe the 
caseload and assess the performance of the Massachusetts MFCU. 
Data Collection  
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information regarding the Units investigation of Medicaid cases, 
including information about the number of referrals the Unit received, the 
number of investigations the Unit opened and closed, the outcomes of 
those investigations, and the Units case mix.  We also collected and 
analyzed information about the number of cases that the Unit referred for 
prosecution and the outcomes of those prosecutions.   
We gathered this information from several sources, including the Units 
quarterly statistical reports, its annual reports, its recertification 
questionnaire, its policy and procedures manuals, and its MOU with the 
State Medicaid agency.  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 internal control issues or other 
issues involving use of resources. Prior to the onsite review, we reviewed 
the Units financial policies and procedures; its response to an internal 
control questionnaire; and documents (such as financial status reports) 
related to MFCU grants.  
We reviewed three purposive samples to assess the Units internal control 
of fiscal resources. All three samples were limited to the review period of 
FY 2012 through FY 2014. The three samples included the following: 
1.  To assess the Units expenditures, we selected a purposive sample 
of 24 items from the Units 2,611 expenditure transactions. We 
selected routine and nonroutine transactions representing a variety 
of budget categories and payment amounts. 
2.  To assess the Units travel expenditures, we selected a purposive 
sample of 24 items from the Units 94 travel transactions. We 
selected a variety of travel expenditure categories related to both 
in-State and out-of-State travel, such as hotel stays, airfare, and 
conference expenses. 
3.  To assess employees time and efforti.e., their work hours 
spent on various MFCU taskswe selected a sample of three pay 
periods, one from each fiscal year. We then requested and reviewed 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  21 
   
   
documentation (e.g., time card records) to support the time and 
effort of the MFCU staff during the selected pay periods. 
We also reviewed a purposive sample of the Units supply inventory, 
including vehicles.  Specifically, we selected and verified a purposive 
sample of 31 items from the current inventory list of 495 items maintained 
in the Units Boston office. To ensure a variety in our inventory sample, 
we included expensive items such as computers and vehicles, as well as 
less-expensive items such as flash drives and computer monitors. 
Interviews with Key Stakeholders.  In August and September 2015, we 
interviewed key stakeholders, including officials in the United States 
Attorneys Offices, the State Attorney Generals Office, and other State 
agencies that interacted with the Unit (i.e., the Medicaid Program Integrity 
Unit, the Bureau of Health Care Quality and Safety, and the Division of 
Health Professions Licensure).  We also interviewed supervisors from OIGs 
Region I offices who work regularly with the Unit.  We focused these 
interviews on the Units relationship and interaction with OIG and other 
Federal and State authorities and opportunities for improvement.  We used 
the information collected from these interviews to develop subsequent 
interview questions for Unit management. 
Survey of Unit Staff.  In September 2015, we conducted an online survey 
of all 37 nonmanagerial Unit staff within each professional discipline 
(i.e., investigators, attorneys, and nurse investigators) as well as support 
staff.  The response rate was 100 percent.  Our questions focused on 
operations of the Unit, opportunities for improvement, and practices that 
contributed to the effectiveness and efficiency of Unit operations and/or 
performance.  The survey also sought information about the Units 
compliance with applicable laws and regulations.   
Onsite Interviews with Unit Management.  We conducted structured 
interviews with the Units management during the onsite review in 
October 2015.  We interviewed the Units director, Deputy Chief, Chief of 
Investigations, Managing AAGs, and Administrative Assistant.  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. 
Onsite Review of Case Files and Other Documentation.  We requested that 
the Unit provide us with a list of cases that were open at any point during 
FYs 2012 through 2014.  This list of 1,635 cases included, but was not 
limited to, the current status of the case; whether the case was criminal, 
civil, or global; and the date on which the case was opened.  Because 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  22 
   
   
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 exclude those cases from our review of a Units case files.  
Therefore, we excluded 387 cases that were categorized as global.  We 
also excluded four cases that were opened in 2015, after the end of the 
review period.  After these exclusions, 1,244 case files remained.   
From the 1,244 cases, we selected a simple random sample of 106 cases 
for review.  From this initial sample of 106 case files, we selected a simple 
random sample of 53 files for a more indepth review of selected issues, 
such as the timeliness of investigations and case development. 
Through our case review, we determined that 2 sampled cases were global 
cases that had not been identified as globals in the case list.  Two more 
cases should have been closed prior to the beginning of the review period, 
but were not because of an administrative oversight.  These four cases 
were ineligible to be in the sample.  After excluding the ineligible cases, 
we reviewed a total of 102 sampled case files total, including 92 closed 
cases, and 79 cases that were open longer than 90 days.   
Because there were ineligible cases in the 106 sampled cases, there could 
be other ineligible cases in the population.  Therefore, we estimated: 
(1) the population of eligible case files, (2) the subpopulation of eligible 
closed case files, and (3) the subpopulation of eligible cases active and 
open longer than 90 days, as shown in Table D-1. 
Table D-1:  Estimates of the Population of Eligible Case Files and Selected 
Subpopulations 
Sampled  Population of  95-percent 
Estimate Description 
Case Files  Case Files  Confidence Interval 
Total eligible case files  102  1,197  1,1301,231 
Eligible closed case files  92  1,080  1,9841,150 
Eligible case files open longer than 
79  927  8151,023 
90 days 
Source:  OIG analysis of Massachusetts MFCU case files, 2016.  
Using the results of our review of the sampled case files, we reported one 
estimate for each of the above subpopulations.  Appendix E contains the 
point estimates and their 95-percent confidence intervals.  
Onsite Review of Unit Operations.  During our October 2015 onsite visit, 
we reviewed the Units workspace and operations.  Specifically, we 
visited the Unit headquarters in the State capital. While onsite, we 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  23 
   
   
observed the Units offices and meeting spaces, security of data and case 
files, location of select equipment, and the general functioning of the Unit. 
Data Analysis 
We analyzed data to identify any opportunities for improvement and 
instances in which the Unit did not fully meet the performance standards 
or was not operating in accordance with laws, regulations, or policy 
transmittals.30 
   
                        ____________________________________________________________ 
30 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  24 
   
   
APPENDIX E 
Point Estimates and 95-Percent Confidence Intervals Based on 
Reviews of Case Files 
95-Percent Confidence 
Sample  Point  Interval  
Estimate 
Size   Estimate 
Lower  Upper 
Percentage of case files that were open longer 
than 90 days that lacked documentation of  79  17.7%  10.2%  27.6% 
periodic supervisory review 
Percentage of case files that included 
documentation of supervisory approval for  102  88.2%  80.6%  93.7% 
opening 
Percentage of closed case files that included 
documentation of supervisory approval for  92  100%  96.2%  100% 
closing 
Source:  OIG analysis of Massachusetts MFCU case files, 2016. 
. 
   
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  25 
   
   
APPENDIX F 
Unit Comments 
 
 
 
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  26 
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ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City 
regional office, and Jennifer King, Deputy Regional Inspector General; 
and in consultation with Richard Stern, Director of the Medicaid Fraud 
Policy and Oversight Division. 
Michala Walker, of the Kansas City regional office, served as the project 
leader for this study.  Other Office of Evaluation and Inspections staff who 
conducted the study include Maria Balderas.  Other Medicaid Fraud 
Policy and Oversight Division staff who participated in the review include 
Jordan Clementi.  Office of Investigations staff also participated in the 
review.  Office of Audit Services staff who conducted a financial review 
include Michael Jones, Marilyn Carrion, and Valerie Johnson.  Other 
central office staff who contributed to this review include Kevin Farber, 
Lonie Kim, Joanne Legomsky, and Jacquelyn Towns.   
  
Massachusetts State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00390)  28 
   
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.