U.S. Department of Health and Human Services 
 
 
Office of Inspector General 
 
 
 
 
New Mexico Medicaid Fraud 
Control Unit: 2020 Review 
 
 
Suzanne Murrin 
Deputy Inspector General 
for Evaluation and Inspections 
September 2021, OEI-06-20-00550  U.S. Department of Health and Human Services 
O  ffice of Inspector General 
 
Report in Brief 
 
Se ptember 2021, OEI-06-20-00550 
 
New Mexico Medicaid Fraud Control Unit: 2020 
Unit Case Outcomes 
Federal fiscal years (FYs) 20172019 
Review  
  24 indictments 
  13 convictions   What OIG Found 
Key Takeaway 
  44 civil settlements and  We identified several factors that contributed 
judgments  The New Mexico MFCUs  to the MFCUs low case outcomes during  
  $7 million in recoveries with  case outcomes were low  FYs 20172019.  The Unit experienced 
$5.4 million from global*  compared to those of  significant turnover of management and staff, 
civil cases, $1.6 million from  similarly sized MFCUs during  which hampered its operations and 
nonglobal civil cases, and  FYs 20172019.  We found  performance.  The Unit did not take sufficient 
$25,000 from criminal cases  significant turnover of Unit  steps to ensure that it received quality 
management and staff that  referrals from the State Medicaid agency and 
Unit Snapshot 
contributed to inadequate  other sources, and we found significant 
The New Mexico Medicaid Fraud  referrals, investigative  investigative delays; both factors affected the 
Control Unit (MFCU or Unit) is  delays, limited collaboration  Units case outcomes.  Further, the Unit did 
located within the New Mexico  with Federal partners, and  not maintain regular communication and 
Office of the Attorney General.  insufficient case  worked few cases jointly with Federal 
documentationall of which  partners.  Unit management practices also 
The Unit has a total of 
affected the Units case  resulted in inconsistent periodic supervisory 
22 employees across its main office 
outcomes.  This report  reviews and documentation in Unit case files. 
in Albuquerque and satellite offices 
provides the MFCU with 
in Las Cruces and Santa Fe.  Additionally, we identified areas in which the 
recommendations designed 
Unit should improve its compliance with 
Why OIG Did This Review  to address these issues and  Federal regulations.  We found that the Unit 
improve its case outcomes. 
The Office of Inspector General  did not report all convictions and adverse 
(OIG) administers the MFCU grant  actions to Federal partners within the 
awards, annually recertifies each  appropriate timeframes.  Further, the Units memorandum of understanding 
Unit, and oversees the Units  (MOU) with the State Medicaid agency lacked procedures by which the Unit 
performance in accordance with  would receive managed care referrals.  Finally, we found that the Unit did not 
the requirements of the grant.  As  exclude costs associated with non-MFCU activities from its Federal 
part of this oversight, OIG conducts  reimbursement request. 
periodic reviews of Units and issues  What OIG Recommends   
public reports of its findings. 
We recommend that the Unit (1) develop and implement an action plan to 
reduce turnover of management and staff and to ensure continuity of Unit 
OIG conducted this review of the 
operations should turnover occur; (2) develop and implement an action plan to 
New Mexico MFCU to examine the 
ensure that the Unit receives adequate quality referrals of fraud and patient 
Units operations and to identify 
abuse or neglect; (3) ensure that investigations are completed within the 
and address factors that 
appropriate timeframes and that delays are documented; (4) improve 
contributed to the Units low case 
communication and seek more opportunities to investigate cases jointly with 
outcomes during FYs 20172019.   
Federal partners; (5) ensure that supervisory reviews of case files are conducted 
*Global recoveries derive from civil  periodically and documented in accordance with Unit policy; (6) ensure that all 
settlements or judgments involving the  convictions and adverse actions are reported to Federal partners within the 
U.S. Department of Justice and a group  appropriate timeframes; (7) revise the Units MOU with the State Medicaid 
of State MFCUs and are facilitated by  agency to establish procedures by which the Unit will receive fraud referrals 
the National Association of Medicaid 
from managed care organizations; and (8) ensure that costs associated with 
Fraud Control Units. 
non-MFCU activities are excluded from the Units Federal reimbursement 
  request.  The Unit concurred with all eight recommendations.   
   
TABLE OF CONTENTS 
 
 
  
BACKGROUND  1 
CASE OUTCOMES  7 
FINDINGS  9 
The Unit experienced significant turnover of management and staff during FYs 20172019,  9 
which hampered its operations and performance  
The Unit did not take sufficient steps to ensure that it received quality referrals from the State  10 
Medicaid agency and other sources, which limited the number of cases with successful 
outcomes 
The Unit had significant investigative delays, which affected its case outcomes  12 
The Unit did not maintain regular communication and worked few cases jointly with Federal  13 
partners 
Unit management practices resulted in inconsistent periodic supervisory reviews and  15 
documentation in Unit case files 
The Unit did not report all convictions and adverse actions to Federal partners within the  16 
appropriate timeframes 
The Units MOU with the State Medicaid agency generally reflected current practice, policy,  17 
and legal requirements with the exception of a regulatory requirement regarding procedures 
for the receipt of managed care referrals 
Three Unit professional staff temporarily performed non-MFCU duties, and the Unit did not  17 
exclude the associated costs from claimed Unit expenditures 
CONCLUSION AND RECOMMENDATIONS   19 
Develop and implement an action plan to reduce turnover of management and staff and to  19 
ensure continuity of Unit operations should turnover occur 
Develop and implement an action plan to ensure that the Unit receives adequate quality  20 
referrals of fraud and patient abuse or neglect 
Ensure that investigations are completed within the appropriate timeframes and that delays  20 
are documented in the case files 
Improve communication and seek more opportunities to investigate cases jointly with Federal  20 
partners 
Ensure that supervisory reviews of case files are conducted periodically and documented in  21 
accordance with Unit policy 
Ensure that all convictions and adverse actions are reported to Federal partners within the  21 
appropriate timeframes 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550    Revise the Units MOU with the State Medicaid agency to establish procedures by which the  21 
Unit will receive referrals of potential fraud from managed care organizations 
Ensure that costs associated with non-MFCU activities are excluded from the Units Federal  21 
reimbursement request 
UNIT COMMENTS AND OIG RESPONSE  22 
APPENDICES   24 
A.  Performance Assessment  24 
B.  New Mexico MFCU Referrals Received, by Source, for FYs 20172019  29 
C.  Detailed Methodology  30 
D.  Point Estimates and 95-Percent Confidence Intervals of Case File Reviews  33 
E.  Unit Comments  34 
ACKNOWLEDGMENTS AND CONTACT  38 
ABOUT THE OFFICE OF INSPECTOR GENERAL  39 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550     
 
BACKGROUND 
 
 
Objective 
To examine the operations of the New Mexico Medicaid Fraud Control Unit (MFCU 
or Unit) and identify factors contributing to the Units low case outcomes.    
Medicaid Fraud Control Units 
The function of MFCUs is to investigate Medicaid provider fraud and patient abuse or 
neglect and to prosecute those cases under State law or refer them to other 
prosecuting offices.1  By Federal law, a MFCU is a single, identifiable entity of State 
government; must be separate and distinct from the State Medicaid agency; and 
employs one or more investigators, attorneys, and auditors.2  Each State must operate 
a MFCU or receive a waiver.3  MFCUs operate in all 50 States, the District of Columbia, 
Puerto Rico, and the U.S. Virgin Islands.4    
Each Unit receives a Federal grant award equivalent to 90 percent of total 
expenditures for new Units and 75 percent for all other Units.5  In Federal fiscal 
year (FY) 2020, combined Federal and State expenditures for the Units totaled 
$306 million, with a Federal share of $229 million.6  
 
 
 
1 SSA  1903(q)(3).  Regulations at 42 CFR 1007.11(b) add that the Units responsibilities may include 
reviewing complaints of misappropriation of patients private funds in Medicaid-funded health care 
facilities and board and care facilities.  As of December 27, 2020, MFCUs may also receive Federal 
financial participation to investigate and prosecute abuse or neglect of Medicaid beneficiaries in a 
noninstitutional or other setting.  Consolidated Appropriations Act, 2021, Public Law 116-260, Division 
CC, Section 207. 
2 SSA  1903(q). 
3 SSA  1902(a)(61). 
4 The territories of American Samoa, Guam, and the Northern Mariana Islands have not established Units. 
5 SSA  1903(a)(6).  For a Units first 3 years of operation, the Federal government contributes 90 percent 
of funding and the State contributes 10 percent of Unit funding.  Thereafter, the Federal government 
contributes 75 percent and the State contributes 25 percent. 
6 OIG analysis of MFCUs FY 2020 reporting of expenditures.  The Federal FY 2020 was from  
October 1, 2019, through September 30, 2020. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Background | 1
     
OIG Grant Administration and Oversight of MFCUs 
The Office of Inspector General (OIG) administers the grant award to each Unit and 
oversees Units.7, 8  As part of its oversight, OIG recertifies each Unit annually and 
conducts periodic reviews or inspections.   
In its annual recertification review, OIG examines the Units reapplication, the Units 
case statistics, and questionnaire responses from Unit stakeholders.  Through the 
recertification review, OIG assesses a Units performance, as measured by the 
following: its adherence to published performance standards;9  its compliance with 
applicable laws, regulations, and OIG policy transmittals;10 and its case outcomes.  
See Appendix A for the 12 performance standards and OIGs assessment of the New 
Mexico MFCUs adherence to those standards.   
OIG further assesses Units performance through periodic reviews of selected Units.  
OIG selects Units for these reviews on the basis of an annual risk assessment of all 
Units.  Each of OIGs reviews may identify findings and result in recommendations for 
improvement.  OIG may also make observations on Unit operations and practices, 
including identifying beneficial practices that may be useful to share with other Units.  
In addition, OIG provides training and technical assistance to Units, as appropriate, 
both during the review and on an ongoing basis.   
New Mexico MFCU 
The New Mexico MFCU, also known as the Medicaid Fraud and Elder Abuse Division, 
is located within the New Mexico Office of the Attorney General.  The MFCU has a 
main office in Albuquerque and satellite offices in Las Cruces and Santa Fe.  The Unit 
has the authority to prosecute Medicaid fraud and patient abuse and neglect cases.11  
In September 2020, the Unit had 22 employees: 8 investigators, including 2 Special 
Agents in Charge and 2 nurse investigators; 4 attorneys, including the MFCU director; 
 
7 As part of grant administration, OIG receives from Units and examines financial information, such as 
budgets and quarterly and final Federal Financial Reports, that detail MFCU income and expenditures.  
8 The Social Security Act authorizes the Secretary of Health and Human Services to award grants (SSA  
1903(a)(6)) and to certify and annually recertify the Units (SSA  1903(q)).  The Secretary delegated these 
authorities to OIG in 1979. 
9 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  OIG developed the 
performance standards in conjunction with the MFCUs, and the standards were originally published at 
59 Fed. Reg. 49080 (Sept. 26, 1994). 
10 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  Policy 
transmittals can be found at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/.  
11 At the time of our review, the Units authority to receive Federal financial participation to investigate 
and prosecute patient abuse and neglect cases was limited to allegations arising in facility settings.  As of 
December 27, 2020, MFCUs can also receive Federal financial participation to investigate and prosecute 
abuse or neglect of Medicaid beneficiaries in a noninstitutional or other setting.  Consolidated 
Appropriations Act, 2021, Public Law 116-260, Division CC, Section 207. 
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OEI-06-20-00550  Background | 2
     
4 forensic auditors; 2 internet security specialists; 1 outreach and training coordinator; 
and 3 support staff, including legal and administrative assistants.  During our review 
period of FYs 20172019, the Unit spent approximately $8 million (with a State share 
of approximately $2 million).  
Referrals.  The Unit reported receiving fraud referrals from several sources, 
including the State Medicaid agency and private citizens, during FYs 20172019.  The 
Unit reported receiving most of its referrals of patient abuse and neglect from Adult 
Protective Services (APS), located within the New Mexico Aging and Long-Term 
Services Department.  APS is the State agency responsible for investigating reports of 
suspected abuse, neglect, and exploitation of vulnerable adults.12  Additionally, in 
FY 2017, OIG approved the New Mexico MFCU to engage in data mining, which 
allows the Unit to identify fraud through analysis of Medicaid claims data.13, 14  See 
Appendix B for a list of Unit referrals by source for FYs 20172019.   
When the Unit receives a referral of fraud or patient abuse or neglect, one of the 
Units administrative assistants completes an intake form for the referral.  Unit 
managers meet on a weekly basis to review each referral and determine whether to 
assign a preliminary investigation.15  If the managers determine that the referral is 
outside of the Units jurisdiction or otherwise decide not to proceed with the referral, 
the Unit may forward it to another agency.   
Investigations and Prosecutions.  Once the Unit accepts a referral for 
preliminary investigation, it enters the information into the Units case management 
system and Unit managers assign the referral to an investigator.  Per Unit policy, a 
referral accepted for preliminary investigation must be assigned to an investigator 
within 1 month of the Units receipt of the referral.  Unit policy also states that the 
preliminary investigation period for referrals of fraud and patient abuse or neglect 
should be no longer than 180 days from the date of assignment, during which the 
investigator determines whether there is sufficient evidence to warrant a formal 
investigation.   
At the end of the preliminary investigation, the investigator prepares a form that 
indicates whether the referral should be closed or opened as a case, which the Special 
Agent in Charge and the Unit director or deputy director review and sign.  If the Unit 
 
12 New Mexico Aging and Long-Term Services Department, Adult Protective Services.  Accessed at 
http://www.nmaging.state.nm.us/Adult_ProtectiveServices.aspx on April 5, 2021. 
13 Data mining is the practice of electronically sorting Medicaid or other relevant data, including but not 
limited to the use of statistical models and intelligent technologies, to uncover patterns and relationships 
within that data to identify aberrant utilization or billing, or other practices that are potentially fraudulent. 
14 On May 17, 2013, HHS issued the final rule "State Medicaid Fraud Control Units; Data Mining" (78 Fed. 
Reg. 29055).  This rule permits Federal financial participation in costs of data mining if certain criteria are 
satisfied.  MFCUs must submit data mining applications to OIG for approval. 
15 At the time of our review, the Unit management intake team consisted of the director, deputy director, 
outreach and training coordinator, and Special Agents in Charge. 
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OEI-06-20-00550  Background | 3
     
determines that a formal investigation is warranted, the investigator develops an 
investigative plan and discusses the plan with the Special Agent in Charge before 
beginning the investigation.   
Upon completion of the formal investigation, the investigator presents the findings 
and evidence to the Unit attorney assigned to the case.  If the attorney determines 
that there is sufficient evidence to support either civil or criminal prosecution, the 
attorney will submit a memorandum to the Unit director proposing prosecution.  
New Mexico Medicaid Program 
The New Mexico Medicaid program is administered by the New Mexico Human 
Services Department (HSD) and provides health coverage for approximately 
756,000 beneficiaries enrolled in the program.16  In FY 2020, New Mexicos Medicaid 
expenditures were approximately $6.6 billion.17  HSD administers the States Medicaid 
fee-for-service and managed care programs.18  There are three Medicaid managed 
care organizations (MCOs) in the State of New Mexico.19  As of September 2020, 
96 percent of New Mexicos Medicaid beneficiaries received their services through 
these 3 MCOs.20 
Medicaid Program Integrity.  The HSD-OIG functions as the State Medicaid 
Program Integrity Unit, and its mission is to prevent and detect fraud, waste, and 
abuse in the HSD public assistance programs and internal operations.  The HSD-OIG 
is composed of three bureaus that are responsible for processing allegations, 
conducting preliminary investigations, and providing investigative support and 
internal audits.21  The States MCOs also have a role in program integrity.  Each MCO 
 
16 CMS, Monthly Medicaid & CHIP Application, Eligibility Determination, and Enrollment Reports & Data, 
September 2020.  Accessed at https://www.medicaid.gov/medicaid/national-medicaid-chip-program-
information/medicaid-chip-enrollment-data/monthly-medicaid-chip-application-eligibility-
determination-and-enrollment-reports-data/index.html on June 23, 2021. 
17 OIG, MFCU Statistical Data for FY 2020.  Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-
units-mfcu/expenditures_statistics/fy2020-statistical-chart.pdf on April 5, 2021.  
18 New Mexico Human Services Department, Providers Overview.  Accessed at 
https://www.hsd.state.nm.us/providers/Default.aspx on April 5, 2021.  
19 The three MCOs in New Mexico are Blue Cross Blue Shield of New Mexico, Presbyterian Health Plan, 
and Western Sky Community Care.  Accessed at https://www.hsd.state.nm.us/wp-
content/uploads/PressRelease/2f473c14ee654f868b5a25b3cfd15a6d/Procurement_press_release_1.pdf 
on April 5, 2021. 
20 Kaiser Family Foundation reported that approximately 727,421 beneficiaries were enrolled in New 
Mexico MCOs in September 2020.  Kaiser Family Foundation, Growth in Medicaid MCO Enrollment during 
the COVID-19 Pandemic.  Accessed at https://www.kff.org/coronavirus-covid-19/issue-brief/growth-in-
medicaid-mco-enrollment-during-the-covid-19-pandemic/ on April 5, 2021. 
21 The HSD-OIGs three bureaus are the Investigations Bureau, the Internal Review Bureau, and the 
Central Office.  New Mexico Human Services Department, Office of Inspector General.  Accessed at 
https://www.hsd.state.nm.us/about_the_department/office_of_inspector_general/ on January 14, 2021. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Background | 4
     
is responsible for notifying the HSD-OIG of suspected fraud, waste, or abuse within  
5 business days of identification, and conducting preliminary investigations within  
12 months.  If the HSD-OIG determines that a referral meets the criteria for credible 
allegation of fraud, it sends the referral to the MFCU for further investigation.  
Previous OIG Report and Oversight 
In 2015, OIG issued a report following its 2014 onsite review of the Unit.22  OIG found 
that (1) a Unit supervisor approved the opening and closing of almost all case files, 
but 42 percent lacked documentation of periodic supervisory reviews; (2) 32 percent 
of case files had unexplained investigation delays of a year or more; (3) the Unit did 
not always refer sentenced individuals to OIG or adverse actions to the National 
Practitioner Data Bank (NPDB) within an appropriate timeframe; (4) the Units 
memorandum of understanding (MOU) with the State Medicaid agency did not reflect 
current law and practice, and the Units policies and procedures manual was 
incomplete; and (5) the Unit incorrectly reported program income and inappropriately 
claimed expenditures for indirect costs. 
OIG made four recommendations to the Unit.  OIG recommended that the Unit  
(1) ensure that periodic supervisory reviews are documented in Unit case files;  
(2) ensure that any investigation delays are limited to situations imposed by resource 
constraints or other exigencies; (3) ensure that it reports all relevant information to 
OIG and the NPDB within an appropriate timeframe; and (4) revise its policies and 
procedures manual to reflect current Unit operations.   
By August 2015, OIG considered all four recommendations to have been 
implemented by the Unit.  The Unit began using a form to indicate in the case file that 
a supervisory review had been conducted and drafted a policy and procedures to 
describe the process for conducting and documenting these reviews.  As part of this 
process, the Unit began discussing and documenting in the case files any reason for 
delays in the investigation and prosecution of a case.  The Unit also implemented a 
policy and procedures outlining the reporting of convictions and adverse actions to 
OIG and the NPDB.  Finally, the Unit revised its policies and procedures manual to 
reflect its current operations.  
Methodology 
We conducted a review of the New Mexico Unit in September 2020.  Our review 
covered the 3-year period of FYs 20172019.  Due to the COVID-19 pandemic, we 
were unable to conduct the review onsite as planned; instead, we conducted the 
review remotely through a virtual format.  The review team consisted of OIG 
 
22 OIG, New Mexico State Medicaid Fraud Control Unit: 2014 Onsite Review, OEI-09-14-00240, February 
2015. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Background | 5
     
evaluators, OIG agents, a grant oversight analyst, and a director from another State 
MFCU.   
The primary purpose of the review was to follow up on issues that OIG identified 
through its ongoing administration and oversight activities.  Our pre-review analysis 
identified the Units low case outcomes as an area of concern.  The analysis showed 
that the New Mexico MFCUs case outcomes were among the lowest when compared 
to those of similarly sized MFCUs during FYs 20172019.  We focused our data 
collection and analysis on identifying factors contributing to low case outcomes and 
ways to help the Unit improve its case outcomes.   
We also examined the Units operations and adherence to the 12 performance 
standards and applicable Federal laws, regulations, and policy transmittals.  In 
examining the Units operations and performance, we applied the published MFCU 
performance standards listed in Appendix A, but we did not assess every performance 
indicator for each of the 12 standards.  See Appendix C for a detailed methodology.   
We based our review on an analysis of data from seven sources: (1) Unit 
documentation, such as policies and procedures; (2) structured interviews with key 
stakeholders; (3) structured interviews with Unit managers and selected staff;  
(4) review of a random sample of case files that were open at any point during the 
review period; (5) referrals received by the Unit; (6) review of all convictions submitted 
to OIG for program exclusion and all adverse actions submitted to the NPDB during 
the review period; and (7) documentation associated with the Units fiscal controls.  
Standards 
OIG conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.  
These inspections differ from other OIG evaluations in that they support OIGs direct 
administration of the MFCU grant program but are subject to the same internal 
quality controls as are other OIG evaluations, including internal and external peer 
review.
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Background | 6
     
 
CASE OUTCOMES
 
The New Mexico Unit reported low case outcomes for FYs 20172019, with  
24 indictments, 13 convictions, and 44 civil settlements and judgments.23  Of the 
13 convictions, 11 involved provider fraud and 2 involved patient abuse or neglect.  
The Units total numbers of indictments, fraud convictions, and patient abuse or 
neglect convictions were low compared to those of other similarly sized MFCUs 
during FYs 20172019.24  Specifically, when compared to MFCUs with similar staff 
sizes, the New Mexico Unit had the lowest numbers of indictments and fraud 
convictions and the second lowest number of patient abuse or neglect convictions. 
 
The Unit reported $7 million in total recoveries for FYs 20172019.  Of the $7 million 
in total recoveries, global civil recoveries represented approximately $5.4 million or 
77 percent of the Units total recoveries during the review period.  The remaining 
recoveries which came from the Units criminal and nonglobal civil casework totaled 
$1.6 million during the 3-year review period.  The New Mexico Unit had the least total 
criminal and nonglobal civil recoveries of all MFCUs with similar staff sizes.  See 
Exhibit 1 on the next page for the sources of the New Mexico Units recoveries.   
   
 
23 OIG provides information on MFCU operations and outcomes, but it does not direct or encourage 
MFCUs to investigate or prosecute a specific number of cases.  MFCU investigators and prosecutors 
should apply professional judgment and discretion in determining which criminal and civil cases to 
pursue. 
24 We compared the New Mexico MFCU to similarly sized MFCUs with staff sizes that ranged from                     
21 to 39 employees; the New Mexico MFCU had a staff of 22 employees.  Although comparison across 
similarly sized MFCUs provides context for the case outcomes of a particular MFCU, many factors other 
than the size of a MFCUs staff can affect case outcomes. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Case Outcomes | 7   
Exhibit 1: The Unit reported combined civil and criminal recoveries of  
$7 million during FYs 20172019. 
 
Source: OIG analysis of Unit statistical data FYs 20172019. 
   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Case Outcomes | 8   
 
 FINDINGS 
 
 
The New Mexico MFCUs case outcomes were low compared to those of similarly 
\
sized MFCUs during FYs 20172019; this review focused on identifying factors that 
limited case outcomes.  We found that the primary cause for the low case outcomes 
during our review period was the frequent turnover of management and staff, which 
disrupted and negatively affected many aspects of Unit operations.  We also identified 
several areas of potential improvement for which we are issuing recommendations.  
Finally, we assessed the Units adherence to each of the 12 MFCU performance 
standards outlined in Appendix A of the report.   
The Unit experienced significant turnover of management and 
staff during FYs 20172019, which hampered its operations and 
performance  
While neither the number of staff for which the Unit was approved nor the number of 
staff that the Unit employed was low in relation to the States Medicaid program 
expenditures, the Unit experienced significant turnover in both management and staff 
positions during our review period.  Although the Units staffing levels were relatively 
constant with 23 employees at the end of FY 2017 and 21 employees at the end of 
FYs 2018 and 2019, we found that a total of 27 staff members left the Unit during the 
3-year period.  The departing staff included 8 attorneys, 2 of whom were Unit 
directors; 11 investigators; 1 auditor; and 7 administrative staff.25  Some of the staff 
who left the Unit were new hires and stayed with the Unit only for a short period.  See 
Exhibit 2 on the next page for a depiction of the total number of staff who joined the 
Unit and the total number of staff who left the Unit, by profession, during  
FYs 20172019.  As a result of the frequent turnover of staff, most of the Units 
attorneys and investigators had been employed with the Unit for approximately  
3 years or less at the time of our review.  However, most of the Units newly hired staff 
had extensive experience relevant to their respective professions. 
 
 
 
 
 
25 One of the Unit directors who departed served in an interim capacity. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 9   
Exhibit 2: During our review period, 27 staff were hired, 27 staff departed, 
and only 6 staff remained constant. 
 
Source: Unit-provided documentation. 
In interviews, Unit management and staff attributed the turnover to circumstances 
such as employees leaving for other professional opportunities or because of changes 
in their personal lives.  We did not identify any additional causes for the frequent 
turnover during our review period. 
Unit management and staff reported that turnover negatively impacted the Units 
operations and performance.  Unit staff reported that management turnover led to 
inconsistency in leadership styles, which disrupted Unit operations.  Further, most Unit 
directors did not stay with the Unit long enough to invest in long-term improvements, 
and thus potentially impeded the Units success.  We found that the turnover of both 
managers and staff negatively affected many aspects of Unit operations, including 
quality of referrals, timeliness of Unit investigations, collaboration with Federal 
partners, and consistency of supervisory reviews.  We found that these factors in turn 
contributed to the Units low case outcomes.   
The Unit did not take sufficient steps to ensure that it received 
quality referrals from the State Medicaid agency and other 
sources, which limited the number of cases with successful 
outcomes  
Performance Standard 4 states that a Unit should take steps to maintain an adequate 
volume and quality of referrals from the State Medicaid agency and other sources.  
During FYs 20172019, the Unit received 1,014 fraud referrals and 640 referrals of 
patient abuse or neglect, which was similar to the total numbers of such referrals 
received by similarly sized Units during the same timeframe.  Although the Unit 
received an adequate number of referrals, Unit management and staff explained that 
the referrals that the Unit received from its stakeholders were typically of poor quality 
or outside of the Units jurisdiction or authority.  For example, while the State 
Medicaid agency should be a significant source of fraud referrals, Unit management 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 10   
reported that many of the referrals from the Medicaid agency involved allegations of 
personal care services (PCS) fraud for which the expected investigative costs 
outweighed possible recoveries or the allegations had occurred several years prior, 
thus affecting the Units ability to obtain necessary evidence and successfully 
prosecute the cases.26  Further, although APS was the largest source of referrals of 
patient abuse and neglect, Unit managers reported opening very few of those as 
cases because most of the referrals involved allegations that were outside of the 
Units authority.  The Unit managers explained that the APS referrals typically involved 
allegations of patient abuse or neglect that occurred outside of the facility setting, for 
which the Unit could not receive Federal financial participation during the review 
period.   
Despite the Units concerns regarding the quality of 
referrals, the Unit did not provide sufficient feedback  Performance Standard 4(b): 
A Unit should provide 
to the State Medicaid agency, APS, or other referral 
periodic feedback to the 
sources to improve the quality of the referrals it 
State Medicaid agency and 
received during our review period.  We found that the 
other referral sources on the 
frequent turnover of Unit management and staff 
adequacy of both the 
disrupted the Units relationships with the referral 
volume and quality of its 
sources and affected its ability to conduct outreach 
referrals.  
efforts to improve the quality of referrals.  One of the 
Unit managers explained that in the past, the Unit had productive relationships with 
the referral agencies, but with the frequent change in leadership, the Unit had to 
rebuild those relationships each time new management came on board.  In an 
interview with staff of the New Mexico Department of Health, which houses the State 
survey and certification agency, staff reported having limited knowledge about the 
MFCUs authority to investigate allegations of patient abuse or neglect and therefore 
rarely forwarding referrals to the Unit.  One of the Units stakeholders said that it 
would be helpful if the MFCU provided outreach and feedback regarding the types of 
referrals the Unit would like to receive.   
Because of the Units limited outreach and feedback to stakeholders during the review 
period, we found that it opened only a small percentage of those referrals as 
investigations, which limited the number of cases available for the Unit to investigate 
and prosecute.  Specifically, the Unit opened cases for 9 percent of fraud referrals and 
4 percent of patient abuse or neglect referrals, while on average, similarly sized 
MFCUs opened cases for 58 percent of fraud referrals and 42 percent of patient abuse 
or neglect referrals.    
After our review period, the Unit took steps to improve the quality of referrals.  The 
Unit hired an outreach and training coordinator.  The Unit assigned the coordinator, 
who previously worked at the State Medicaid agency, to assist in educating and 
establishing relationships with stakeholders to improve the quality of referrals.  The 
 
26 We observed that the Unit worked on a disproportionate number of cases involving PCS providers.  For 
information regarding how referrals may have affected Unit case mix and case outcomes, see page 26. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 11   
Unit also reported that it had implemented algorithms to identify fraud through  
in-house analysis of Medicaid claims data.  In FY 2017, the Unit requested and 
received OIG approval to conduct data mining to identify vulnerabilities and detect 
fraud, but the Unit did not generate any cases through data mining during our 3-year 
review period.  However, in FY 2020, the Unit generated eight cases through its data 
mining efforts. 
The Unit had significant investigative delays, which affected its 
case outcomes 
According to Performance Standard 5, a Unit should take steps to maintain a 
continuous case flow and to complete cases in an appropriate timeframe based on 
the complexity of the cases.  Our review of a sample of Unit case files that were open 
at any point during FYs 20172019 identified significant delays in the Units 
preliminary and formal investigations.  Lengthy investigations can result in Unit failure 
to meet the appropriate statutes of limitations and allow continued commission of 
fraud and/or patient abuse or neglect.  Investigative delays can also impact the Units 
ability to obtain and use credible witness testimony and affect the prosecutorial 
viability of Unit cases, reducing the likelihood of convictions and appropriate 
sentencing.   
The Unit did not always complete preliminary investigations 
timely in accordance with its policy  
Unit policy states that the Unit should conduct all preliminary investigations within 
180 days and determine whether a formal investigation is warranted.  For comparison, 
Federal investigators are generally required to complete preliminary investigations 
within 45 days of referral receipt, and in OIGs experience, other MFCUs typically 
attempt to complete preliminary investigations within 3060 days of referral receipt.   
Despite the Units unusually long preliminary phase, the Unit did not complete the 
preliminary investigation for most cases within the 180-day timeframe.  Specifically, 
we found in 66 percent of case files that the Units preliminary investigations were 
open longer than 180 days.27  In some cases, the preliminary investigations were open 
for several years, which can be problematic and particularly concerning if the cases 
involve patient abuse or neglect.  We observed that cases could have been opened as 
soon as a Medicaid nexus was established.  Unit management attributed the lengthy 
preliminary investigations to staff turnover and described how one referral that had 
 
27 For the purposes of our case file review, we reviewed cases that were open at some point during  
FYs 20172019.  We did not review a representative sample of all referrals opened for preliminary 
investigation, and therefore we did not formally assess the timeframe of all preliminary investigations 
conducted during our review period.  
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OEI-06-20-00550  Findings | 12   
been open as a preliminary investigation for 2.5 years had been reassigned 5 times 
due to investigators leaving the Unit. 
Staff turnover and inefficient processes caused significant delays 
in the Units formal investigations  
Our case file review also found significant delays in the Units formal investigations.  
Specifically, we found that 51 percent of case files had significant delays during the 
formal investigation stage.  The investigative delays ranged from 6 months to 4 years.  
In reviewing the case files, we found that few cases contained documentation 
explaining the cause(s) of the delays.  However, Unit managers reported to us that 
similar to the preliminary investigations, the delays during the formal investigations 
were largely due to staff turnover.   
Some of the Units processes also contributed to investigative delays.  We found that 
the Unit did not always reassign cases immediately when an investigator left the Unit 
and did not consistently prioritize cases on the basis of age, and therefore some of 
the older cases fell further behind.  When investigators left the Unit, Unit managers 
usually waited to reassign those cases until the vacancies were filled.  However, staff 
noted that even after the Unit filled vacancies, there were often investigative delays 
because of the steep learning curve, particularly for Medicaid fraud investigations, 
that required new employees to spend time on training and becoming familiar with 
their case assignments before they could actively begin investigating cases.  Further, 
the lack of documentation explaining the reasons for the investigative delays made it 
difficult for new investigators to become familiar with the status of the cases that the 
Unit had reassigned to them.   
We also found inefficiencies in the Units case management processes that may have 
contributed to investigative delays.  We found that it was sometimes difficult to locate 
documents, such as interview reports and data analysis, in Unit case files.  We also 
found that there was a lack of consistency in documentation of investigative activities 
and few standardized documentation forms.  Inconsistent documentation in the case 
files can make it difficult for new investigators to become familiar with the status of 
cases upon assignment and can cause investigative delays.  On the basis of our 
observations, during and after our review, we provided the Unit with technical 
assistance to enhance consistency and completeness of its case files. 
The Unit did not maintain regular communication and worked 
few cases jointly with Federal partners  
Performance Standard 8 states that a Unit should cooperate with OIG and other 
Federal agencies in the investigation and prosecution of Medicaid and other health 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 13   
care fraud.28  We found that the Unit did not 
Performance Standard 8(a): 
communicate regularly and worked few cases jointly 
A Unit should communicate 
with Federal partners during FYs 20172019.   on a regular basis with OIG 
Specifically, we found that the Unit investigated only  and other Federal agencies 
9 cases jointly with OIG and 6 cases with the U.S.  investigating or prosecuting 
Attorneys Office during the 3-year period.   health care fraud in the State. 
According to OIG agents, with the exception of the 
Units attendance at the biannual joint health care task force meetings, which OIG 
agents also attended, the Unit rarely communicated with OIG. 
The OIG agents and officials in both the civil and criminal divisions of the U.S. 
Attorneys Office attributed the limited communication and collaboration with the 
Unit to the frequent turnover of Unit management and staff.  One OIG agent, who 
reported having a good working relationship with one of the Units supervisory 
investigators, explained that it was difficult to maintain ongoing relationships with 
Unit investigators because of the frequent departure and replacement of Unit staff.  
OIG agents and Unit staff also indicated that the geographic distance between the 
OIG office and the Units offices further limited collaboration.  In addition, the Units 
case mix contained a disproportionate amount of fraud cases involving personal care 
services, which are cases that typically do not involve Federal partners.  See page 26 in 
Appendix A for further information about the Units case mix.   
Increased communication and collaboration with Federal partners who also 
investigate or prosecute health care fraud in the State, such as OIG, the U.S. Attorneys 
Office, the Drug Enforcement Agency (DEA), and the Federal Bureau of Investigation 
(FBI), could result in additional fraud referrals to the MFCU and more joint cases, 
which could improve the Units case outcomes.  Further, working more cases jointly 
with Federal partners could create more opportunities for the Unit to access and 
share resources (e.g., equipment and personnel) more effectively with other law 
enforcement agencies.  OIG agents reported that joint casework could also provide 
the Unit with guidance and training opportunities from other agencies that could be 
particularly helpful for newer staff and for complex Medicaid fraud cases.  The agents 
expressed an interest in collaborating more regularly with the Unit on complex cases 
and encouraged the Unit to reach out to OIG to work jointly on cases.  Officials in the 
U.S. Attorneys Office also stated that they were open to enhancing their relationship 
with the Unit. 
Although Federal partners expressed an interest in improving collaboration with the 
Unit, they raised concerns about the potential impact of a recently enacted State 
statute on future joint casework with the Unit.  The new statute, which went into effect 
in January 2020, requires the State Medicaid agency to provide written notice to 
providers of preliminary findings of overpayment before reaching a final 
 
28 Effective May 21, 2019, 42 CFR  1007.11(e)(3) requires the Unit to establish a practice of regular Unit 
meetings or communication with OIG investigators and Federal prosecutors.   
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OEI-06-20-00550  Findings | 14   
determination of overpayment or a credible allegation of fraud.29  When the Medicaid 
agency identifies a credible allegation of fraud, it is generally required to suspend 
payments to the provider and refer the allegation to the MFCU for further 
investigation.  However, the MFCU may specifically request that a payment 
suspension not be imposed on the provider because such a payment suspension may 
compromise or jeopardize the investigation.30  Federal partners expressed concerns 
that notifying providers of a preliminary finding of overpayment as required by the 
State statute could jeopardize an investigation.  Given the potential challenges 
introduced by the new statute, there may be a disincentive for the Unit and its Federal 
partners to work jointly on cases.  
Unit management practices resulted in inconsistent periodic 
supervisory reviews and documentation in Unit case files 
According to Performance Standard 7(a), supervisory reviews should be conducted 
periodically, consistent with Unit policies and procedures, and noted in the case files.  
Although the Unit had a policy for the frequency of periodic supervisory reviews
every 60 days or more frequentlywe found that most of 
the Units case files did not contain consistent 
documentation of such reviews.31  For cases that were 
open longer than 60 days, 82 percent of the case files did 
not contain documentation of periodic supervisory 
reviews consistent with Unit policy.  Of these case files,  
76 percent did not contain documentation of supervisory 
reviews every 60 days (i.e., the supervisory reviews were 
conducted less frequently), and 7 percent did not contain 
documentation of any supervisory review.  See Appendix 
D for an expanded list of case file review point estimates 
and confidence intervals.   
Despite having a policy in place for conducting periodic supervisory reviews, Unit staff 
reported that turnover in the management positions led to inconsistency in 
leadership styles that disrupted the Units supervisory review practices.  Staff 
explained that when new Unit managers came on board, they did not conduct or 
document the supervisory reviews consistently.  Although the case files often lacked 
documentation, staff reported that they would informally ask questions and discuss 
their cases with the Unit supervisors.   
Periodic supervisory reviews of case files are important because they provide an 
opportunity for Unit managers to provide case oversight, promote engagement 
 
29 NM Stat.  27-11-7 (2019). 
30 42 CFR  455.23(e). 
31 According to the Units policies and procedures manual, updated in 2014, supervisory case reviews 
should be conducted once every 2 months, or at least once every 60 days. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 15   
between Unit staff and managers, and help ensure timely completion of 
investigations.  Regular case file reviews can also constitute on-the-job training and 
development opportunities for new investigators, and consistent documentation of 
these reviews can help newly assigned investigators more quickly become familiar 
with the status of cases, particularly if they are taking over a case from a staff member 
who left the Unit.  
The Unit did not report all convictions and adverse actions to 
Federal partners within the appropriate timeframes 
According to Performance Standard 8(f), a Unit should transmit to OIGwithin  
30 days of sentencingreports of all convictions so that convicted individuals can be 
excluded from Federal health care programs.32  Although the Unit had procedures in 
place for reporting its convictions to OIG within 30 days of sentencing, the Unit did 
not report 3 of its 9 convictions within the appropriate timeframe.  Specifically, the 
Unit reported 1 conviction to OIG within 31 to 60 days after sentencing and 
2 convictions more than 90 days after sentencing.  We found that near the end of our 
3-year review period (around May 2019), the Unit stopped submitting documentation 
to OIGs Exclusions Portal.   
In interviews, Unit managers explained that the departure of one of the Units staff 
members, who had been assigned to submit convictions to OIG, disrupted the Units 
submissions because the remaining staff were unfamiliar with the process.  Unit 
managers also reported that delays in court procedures resulted in late submissions 
to OIG.  After our review period, OIG provided technical assistance to the Unit to aid 
in the submission of any outstanding convictions to the Exclusions Portal.  Late 
reporting of convictions to OIG delays the initiation of the program exclusion process, 
which may result in improper payments to providers by the Medicaid program or 
other Federal health care programs as well as possible harm to beneficiaries.   
Federal regulations also require Units to report any adverse actions resulting from 
investigations or prosecutions of health care providers to the NPDB within 30 calendar 
days of the date of the final adverse action.33, 34  Although the Unit had procedures in 
place for reporting adverse actions to the NPDB, the Unit did not report 6 of its  
9 adverse actions to the NPDB within the appropriate timeframe.  Of the 6 adverse 
 
32 Effective May 21, 2019, 42 CFR  1007.11(g) requires the Unit to transmit information on convictions 
within 30 days of sentencing, or as soon as practicable, if the Unit encounters delays in receiving the 
necessary information from the court.  Convictions include those obtained by either Unit prosecutors or 
non-Unit prosecutors in any case investigated by the Unit.  
33 45 CFR  60.5.  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).  
34 Performance Standard 8(g) states that the Unit should report qualifying cases to the Healthcare 
Integrity & Protection Databank [HIPDB], the NPDB, or successor data bases.  The HIPDB and the NPDB 
merged in 2013; therefore, OIG reviewed the reporting of adverse actions under NPDB requirements.  
See 78 Fed. Reg. 20473 (April 5, 2013).   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 16   
actions submitted late, 4 were submitted within 31 to 60 days after sentencing and 
2 were submitted more than 90 days after sentencing.   
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 action taken against them.  
The Units MOU with the State Medicaid agency generally 
reflected current practice, policy, and legal requirements with 
the exception of a regulatory requirement regarding procedures 
for the receipt of managed care referrals   
The New Mexico Office of the Attorney General and the State Medicaid agency had 
an MOU in place that was executed in February 2020.  The MOU generally reflected 
current practice, policy, and legal requirements with the exception of the regulatory 
requirement that the Unit and the State Medicaid agency establish procedures by 
which the Unit will receive referrals of potential fraud from MCOs, if applicable.35   
MFCU regulations effective on May 21, 2019, require the Unit and the Medicaid 
agency to agree to establish procedures by which the Unit will receive referrals of 
potential fraud from MCOs either directly or through the Medicaid agency.36  We 
found that the New Mexico Units MOU did not include procedures by which the Unit 
would receive MCO referrals.  During our review, the Unit director expressed her 
intent to revise the MOU to include such procedures. 
Three Unit professional staff temporarily performed non-MFCU 
duties, and the Unit did not exclude the associated costs from 
claimed Unit expenditures 
Federal regulations state that a Unit may request Federal reimbursement only for 
costs attributable to the establishment and operation of the Unit.37  Although OIG 
guidance permits Unit staff to temporarily engage in non-MFCU activities, the Unit 
must document and maintain records of the time spent on these activities, and 
 
35 42 CFR  1007.9(d)(3)(iv). 
36 Ibid. 
37 42 CFR  1007.19(d). 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 17   
exclude the time from the Units claimed expenditures for purposes of Federal 
reimbursement.38  
We found that in May 2018 and November 2019, a total of three Unit staff members 
performed activities that were not MFCU-related and that the Unit had not excluded 
the appropriate portion of the staff members salaries from claimed Unit expenditures.  
In this case, the Unit staff members assisted another division of the Attorney Generals 
Office with the execution of search warrants.  Although the Unit documented and 
maintained records of the time spent on non-MFCU activities, it did not exclude the 
14 total hours (equaling a Federal share of $433) from its reimbursement request for 
the staff members salaries.  After our review, the Unit returned the Federal share of 
the associated costs.  
 
38 OIG, OIG State Fraud Policy Transmittal Number 2014-1.  Accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/policy_transmittals/State%20Fraud%20Policy%20Transmittal%20No%20%202014-1.pdf on April 5, 
2021. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Findings | 18   
CONCLUSION AND RECOMMENDATIONS 
 
 
 
 
 
The New Mexico MFCUs case outcomes were low compared to those of similarly 
sized MFCUs during FYs 20172019.  We identified several factors that contributed to 
 the low case  outcomes during the 3-year review period, many of  which related to the 
Units frequent turnover of management and staff.  We make several 
recommendations below that are designed to improve Unit operations and improve 
case outcomes. 
Through our review, we found that staff turnover disrupted and negatively affected 
many aspects of Unit operations.  The Unit did not take sufficient steps to ensure that 
it received quality referrals from the State Medicaid agency and other sources, which 
limited its number of cases with successful outcomes.  The Unit also had significant 
investigative delays that affected its case outcomes.  The Unit did not maintain regular 
communication and worked few cases jointly with Federal partners.  Further, Unit 
management practices resulted in inconsistent periodic supervisory reviews and 
documentation in Unit case files, which potentially affected the progression of cases.   
Additionally, we identified areas in which the Unit should improve its compliance with 
Federal regulations.  We found that the Unit did not report all convictions and adverse 
actions to Federal partners within the appropriate timeframes.  We also found that the 
Units MOU with the State Medicaid agency lacked procedures by which the Unit 
would receive managed care referrals.  Lastly, we found that the Unit did not exclude 
costs associated with non-MFCU activities from its Federal reimbursement request.   
To address the issues identified in this report and further improve Unit operations, we 
make eight recommendations to the New Mexico MFCU.  OIG is also prepared to 
provide further technical assistance, and if necessary, to conduct follow-up to ensure 
that the recommendations are adequately implemented. 
We recommend that the New Mexico MFCU: 
1.  Develop and implement an action plan to reduce turnover of 
management and staff and to ensure continuity of Unit 
operations should turnover occur 
The Unit should examine in detail any possible institutional reasons for its low 
employee retention and develop an action plan to address the findings in this report 
regarding management and staff turnover.  The plan should include provisions for 
improving employee retention as well as provisions for ensuring continuity of Unit 
operations and processes if the Unit experiences turnover in the future.  In designing 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Conclusion and Recommendations | 19 
   
the plan, the Unit should consult with OIG and address recommendations 2 through  
6 below. 
2. Develop and implement an action plan to ensure that the 
Unit receives adequate quality referrals of fraud and patient 
abuse or neglect  
The Unit should develop and implement a plan for conducting outreach efforts and 
providing education to referral sources, such as the State Medicaid agency, APS, and 
the Department of Health, to ensure that the Unit receives adequate quality referrals.  
As part of these efforts, the Unit should provide periodic feedback to the referral 
sources on the quality of their referrals, including the types of referrals the Unit would 
like to receive and helpful information to include in a quality referral.  The Unit should 
also consider incorporating education on quality referrals into its in-house training to 
ensure that all Unit staff have the same expectations and can provide the same 
feedback to the referral sources.  Additionally, to the extent possible, the Unit should 
continue to utilize its data mining authority to generate additional cases. 
3. Ensure that investigations are completed within the 
appropriate timeframes and that delays are documented in 
the case files  
To avoid investigative delays and disruption to Unit casework, the Unit should take 
steps to ensure timely completion of preliminary and formal investigations and 
develop a process for quickly reassigning and prioritizing cases if turnover occurs.  
The Unit should also consider reducing the current 180-day preliminary investigation 
timeframe.   
In addition, the Unit should improve access to case information and ensure that 
investigative activities, including any delays, are documented consistently in the case 
files.  The Unit should also ensure that investigative delays are limited to situations 
imposed by resource constraints or other exigencies.   
4. Improve communication and seek more opportunities to 
investigate cases jointly with Federal partners 
The Unit should build relationships and establish regular meetings or communication 
with OIG and other Federal agencies investigating or prosecuting health care fraud in 
the State, such as DEA, the FBI, and the U.S. Attorneys Office.  The Unit should also 
seek more opportunities, as appropriate, to conduct casework jointly with Federal 
partners, although doing so may be challenging given the new statute.  Increased 
communication and collaboration with Federal partners could result in additional 
fraud referrals to the Unit and more joint cases, both of which could improve the 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Conclusion and Recommendations | 20 
   
Units case outcomes.  To improve communication and increase joint casework, the 
Unit could inquire about receiving training from OIGs Office of Investigations and the 
U.S. Attorneys Office.   
5. Ensure that supervisory reviews of case files are conducted 
periodically and documented in accordance with Unit policy  
The Unit should ensure that supervisory reviews of case files are conducted 
periodically, consistent with Unit policy, and documented in the case files.  The Unit 
could consider implementing automatic reminders to ensure that reviews are 
conducted according to Unit policy and that documentation is maintained in the case 
files.  
6. Ensure that all convictions and adverse actions are reported 
to Federal partners within the appropriate timeframes 
The Unit should ensure that it consistently reports all convictions to OIG within 30 
days of sentencing and all adverse actions to the NPDB within 30 days of the action, 
or as soon as practicable if the Unit encounters delays in receiving the necessary 
information from the court.  The Unit could train staff in reporting convictions and 
adverse actions to Federal partners and could implement automated reminders to 
alert Unit staff about when to report the convictions or adverse actions.   
7. Revise the Units MOU with the State Medicaid agency to 
establish procedures by which the Unit will receive referrals of 
potential fraud from MCOs 
To ensure compliance with Federal regulations, the Unit should revise its MOU with 
the State Medicaid agency to establish procedures by which the Unit will receive 
referrals of potential fraud from MCOs either directly or through the Medicaid 
agency.  
8. Ensure that costs associated with non-MFCU activities are 
excluded from the Units Federal reimbursement request 
The Unit should ensure that it excludes all future costs not related to the 
establishment or operations of the Unit from its MFCU grant reimbursement 
requests.  For example, the Unit should consider incorporating processes for 
appropriately tracking and excluding unallowable costs into its policies and 
procedures manual and should train Unit management and staff on the costs that are 
allowable under the MFCU grant.  
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Conclusion and Recommendations | 21 
   
 
UNIT COMMENTS AND OIG RESPONSE 
 
 
The New Mexico MFCU concurred with all eight of our recommendations, but 
expressed that it faces challenges that may impact the Units performance.  OIG will 
seek to work with the Unit to address these challenges and to implement the 
recommendations in this report. 
First, the Unit concurred with our recommendation to develop and implement an 
action plan to reduce turnover of management and staff and to ensure continuity of 
Unit operations should turnover occur.  The Unit reported that it has developed an 
action plan to improve management and staff retention.  As part of this plan, the Unit 
is developing procedures for recruitment, onboarding, cross-training, and in-house 
Medicaid training, as well as conducting regularly scheduled meetings with Unit staff.  
The Unit also reported that the New Mexico Office of the Attorney General is now 
part of the New Mexico State personnel system.  The Unit stated that this change will 
assist the Unit in implementing the employee retention plan by ensuring that 
nondirector Unit employees may only be removed for cause, thus providing staff with 
increased job security and stability.  
Second, the Unit concurred with our recommendation to develop and implement an 
action plan to ensure that the Unit receives adequate quality referrals of fraud and 
patient abuse or neglect.  The Unit reported that it has implemented an action plan to 
improve relationships with potential referral sources such as State and Federal 
agencies.  The Unit reported that the plan includes conducting regularly scheduled 
meetings with potential referral sources and providing them with a written description 
of the types of cases the Unit will pursue.  The Unit also reported that it has worked 
with State partners to improve the quality of referrals by ensuring that referrals are 
within the Units authority and contain sufficient information and requisite support to 
aid in conducting an investigation.  Moreover, the Unit noted that it has implemented 
a procedure to notify referral sources of the reason(s) it may decline to open specific 
referrals as investigations.  Additionally, the Unit reported hiring an intake manager 
and outreach coordinator, who has developed outreach materials to provide to 
potential referral sources.   
Third, the Unit concurred with our recommendation to ensure that investigations are 
completed within the appropriate timeframes and that delays are documented in the 
case files.  The Unit reported that in 2020, its management began reviewing, 
documenting, and assigning all referrals and complaints within 1 week of receipt.  The 
Unit also reported that Unit managers now review open investigations during weekly 
and quarterly team meetings to track case progression and address delays in a timely 
manner. 
Fourth, the Unit concurred with our recommendation to improve communication and 
seek more opportunities to investigate cases jointly with Federal partners.  The Unit 
reported that it has begun meeting regularly with the Assistant U.S. Attorney in 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Unit Comments and OIG Response | 22   
Albuquerque and is working with the FBIs health care fraud unit and DEA.  The Unit 
also reported that it has implemented a new case deconfliction and parallel 
proceedings process that it plans to use together with data mining to identify and 
propose potential joint investigations to Federal partners.  
Fifth, the Unit concurred with our recommendation to ensure that supervisory reviews 
of case files are conducted periodically and documented in accordance with Unit 
policy.  The Unit reported that its new data management system helps the Unit ensure 
that supervisory reviews are consistently and efficiently documented.  The Unit noted 
that it will amend its policy to reflect the current practice of documenting supervisory 
reviews at least every 90 days.  The Unit also reported that supervisors conduct a  
180-day review management meeting for all open referrals to promote awareness of 
pending deadlines.  
Sixth, the Unit concurred with our recommendation to ensure that all convictions and 
adverse actions are reported to Federal partners within the appropriate timeframes.  
The Unit reported that it has instituted monthly status meetings to promote timely 
reporting to the OIG and the NPDB.  The Unit also reported that in 2020, Unit staff 
received training on the proper reporting protocol and have cross-trained to ensure 
consistency in reporting in the event of turnover.  
Seventh, the Unit concurred with our recommendation to revise the Units MOU with 
the State Medicaid agency to establish procedures by which the Unit will receive 
referrals of potential fraud from MCOs.  The Unit reported that the Unit director is 
working with the State Medicaid agency on amendments to establish procedures by 
which the Unit will receive referrals of potential fraud from the MCOs. 
Eighth, the Unit concurred with our recommendation to ensure that costs associated 
with non-MFCU activities are excluded from the Units Federal reimbursement 
request.  The Unit reported that it recently briefed staff on the proper procedure for 
conducting work outside of the Unit and will remind staff on a quarterly basis in the 
Units monthly staff meetings.  The Unit also reported that it has informed 
management within the Attorney Generals Office of these requirements.   
This summary is based on the Units comments (see Appendix E) and additional 
follow-up with Unit management. 
 
 
 
   
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OEI-06-20-00550  Unit Comments and OIG Response | 23   
 
APPENDIX A  
 
 
Performance Assessment 
We assessed the New Mexico MFCUs adherence to applicable laws, 
regulations, policy transmittals, and each of the MFCU performance 
standards.  From this review, we identified eight findings (they are 
presented here and in the body of the report).  We also made 
observations about Unit operations and practices that are included in this 
appendix.  The complete MFCU performance standards, including 
performance indicators, were published at 77 Fed. Reg. 32645  
(June 1, 2012), and appear on OIGs website at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/.   
STANDARD 1  A Unit conforms with all applicable statutes, regulations, and policy 
directives. 
 
Observation  From the information we reviewed, we identified three compliance-
related concerns.  We found that the Unit did not consistently report 
 
convictions and adverse actions to Federal partners within the appropriate 
 
timeframes, which potentially delayed the process for excluding providers 
from the Federal health care programs (see page 16).  We found that the 
 
Units MOU with the State Medicaid agency lacked procedures by which 
 
the Unit would receive managed care referrals (see page 17).  Finally, we 
  found that the Unit did not exclude costs associated with non-MFCU 
  activities from its Federal reimbursement request (see page 17).  For each 
of these findings, we include recommendations in the body of the report 
 
to ensure that the Unit corrects the issues.  We also made findings and 
 
recommendations related to compliance concerns during our previous, 
onsite review of the Unit in 2014.39 
 
     
 
 
 
39 OIGs 2014 onsite review of the New Mexico Unit included five findings and four recommendations.  
Prior to the release of the report, the Unit provided OIG with an updated MOU with the State Medicaid 
agency that reflected current law and practice, and worked with OIG to correct the financial issues 
identified during the review.  As such, recommendations for these two findings were not included in the 
final report. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix A | 24   
STANDARD 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. 
 
Finding  The Unit experienced significant turnover of management and staff 
during FYs 20172019, which hampered its operations and performance.  
 
See page 9. 
 
Observation  The Unit maintained adequate staffing levels and the Units professional 
 
staff had extensive backgrounds related to their field.  Despite frequent 
   
turnover of management and staff, we found that the Units total staff 
 
levels were comparable to those of other MFCUs in relation to the States 
 
Medicaid program expenditures and remained relatively constant, ranging 
   
from 21 to 23 employees at the end of each fiscal year during our review 
 
  period.  We also found that most employees had extensive experience 
    relevant to their respective professions.  For example, the Units Special 
  Agent in Charge had been employed with the Unit for more than 16 years, 
 
and all special agents had previous experience in law enforcement.  The 
    Units nurse investigators had previously worked as nurses in medical 
 
facilities.  All Unit attorneys had previous experience in white collar or 
 
health care-related crimes.  Further, many staff previously worked with 
   
MFCU stakeholders, such as the State Medicaid agency, the FBI, the 
 
  District Attorneys Office, and local law enforcement agencies.  For 
    example, the current Unit director was previously employed as an 
  attorney at the State Medicaid agency and had existing relationships with 
staff at the agency at the time of our review.  
 
 
STANDARD 3  A Unit establishes written policies and procedures for its operations 
and ensures that staff are familiar with, and adhere to, policies and 
procedures. 
 
Observation  The Unit maintained written policies and procedures.  The Unit 
maintained a Policies and Procedures Resource Guidebook that was 
 
available to Unit staff on a shared network drive.  The manual was last 
 
updated in 2014.  The Unit also maintained discipline-specific procedures 
manuals, such as investigations and litigations guidebooks, which were 
 
updated in 2018.  Although the Unit maintained written policies and 
 
procedures for its operations, OIG observed that some policies and 
  procedures, particularly with regard to periodic supervisory reviews (see 
  page 15) and reporting convictions and adverse actions to Federal 
partners within the appropriate timeframes (see page 16), were not 
 
consistently applied by Unit management during our review period. 
 
 
 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-0 0550  Appendix A | 25 
 
   
STANDARD 4  A Unit takes steps to maintain an adequate volume and quality of 
referrals from the State Medicaid agency and other sources. 
 
Finding  The Unit did not take sufficient steps to ensure that it received quality 
referrals from the State Medicaid agency and other sources, which 
 
limited the number of cases with successful outcomes.  See page 10. 
 
S TANDARD 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. 
 
 
 
Finding  The Unit had significant investigative delays, which affected its case 
  outcomes.  See page 12. 
 
 
Observa tion  All case files contained documentation of supervisory approval of the 
  opening and closing of investigations.  According to Performance 
  
Standard 5(b), supervisors should approve the opening and closing of all 
 
   
investigations, review the progress of cases, and take action as necessary 
  to ensure that each stage of the investigation and prosecution is 
  
  completed within an appropriate timeframe.  Our review found that all of 
   
the sampled case files contained documentation of supervisory approval 
 
   of case openings and closings.  See Appendix D for the point estimates 
 
    and the confidence intervals for the case file reviews.  
  
STANDARD 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. 
     
Observation  The Units case mix included both cases of fraud and cases of patient 
  
abuse or neglect, but the Unit worked a disproportionate number of 
     
cases involving personal care services.  Of the Units 564 cases that were 
 
  open during FYs 20172019, 92 percent (518 cases) involved provider 
    fraud and 8 percent (46 cases) involved patient abuse or neglect. 
Although the Units open fraud cases covered 40 different provider types 
 
(e.g., nursing facilities and pharmacies), more than a quarter (29 percent) 
  of the Units fraud cases involved PCS agencies and attendants.  During 
  the 3-year period, all but one of the Units fraud indictments and all of its 
fraud convictions involved PCS providers.   
 
  Unit management attributed the high number of PCS fraud cases to 
stakeholders referring a disproportionate number of PCS referrals to the 
 
Unit.  While investigation of PCS fraud is important, Performance Standard 
  6(c) states that the Unit should allocate its resources among provider 
types on the basis of levels of Medicaid expenditures or other risk factors.  
 
New Mexico Medicaid Fraud Con trol Unit: 2020 Review 
OEI-06-20-00550  Appendix A | 26 
 
   
A diverse case mix also allows for a broader range of on-the-job training 
opportunities for new Unit investigators.  
STANDARD 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. 
 
Finding  Unit management practices resulted in inconsistent periodic supervisory 
reviews and documentation in Unit case files.  See page 15. 
 
 
STANDARD 8  A Unit cooperates with OIG and other Federal agencies in the 
  investigation and prosecution of Medicaid and other health care 
  fraud. 
 
 
Findings  The Unit did not maintain regular communication and worked few cases 
 
jointly with Federal partners.  See page 13.   
 
 
  The Unit did not report all convictions and adverse actions to Federal 
 
partners within the appropriate timeframes.  See page 16.  
 
 
 
STANDARD  9  A Unit makes statutory or programmatic recommendations, when 
  warranted, to the State government. 
 
 
   
Observation  The Unit made several recommendations to the State Medicaid agency 
 
 
during our review period.  Performance Standard 9(b) states that a Unit, 
 
    when it is warranted and appropriate, should make recommendations 
  regarding program integrity issues to the State Medicaid agency.  During  
 
  FYs 20172019, the New Mexico Unit made 15 recommendations to the 
 
State Medicaid agency.  The Unit recommended, among other items, that 
 
  the State Medicaid agency (1) revise regulations to include additional 
 
  screening and training requirements for caregivers; (2) require that  
out-of-state laboratories be paid only for tests that correspond to codes 
 
 
listed as their specialty/subspecialty in the Certification of Compliance; 
 
 
and (3) require MCOs to refer any fraud detected as a result of member 
audits immediately to the Unit and the New Mexico Department of 
 
Health.  As a result of the third recommendation, the Unit worked with the 
 
State Medicaid agency to clarify the MCO referral process, which led to an 
  update to the managed care contract language specifying a timeframe for 
  reporting fraudulent activities.  The Unit reported that it was in 
discussions with the State Medicaid agency regarding implementation of 
  several other recommendations.40  Unit management also stated that the 
 
 
40 At the time of OIGs review, the State Medicaid agency had not yet implemented any of the Units 
recommendations.   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix A | 27   
outreach and training coordinator, hired in August 2020, will conduct 
further outreach regarding implementation of program 
recommendations. 
STANDARD 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. 
 
Finding  The Units MOU with the State Medicaid agency generally reflected 
current practice, policy, and legal requirements with the exception of a 
 
regulatory requirement regarding procedures for the receipt of 
 
managed care referrals.  See page 17. 
 
STANDARD 11    A Unit exercises proper fiscal control over its resources. 
 
 
 
Finding  Three Unit professional staff temporarily performed non-MFCU duties, 
  and the Unit did not exclude the associated costs from claimed Unit 
 
  expenditures.  See page 17. 
 
S TANDARD 12  A Unit conducts training that aids in the mission of the Unit. 
 
 
 
Observation  During part of our review period, the Units training plan did not 
 
include minimum training hour requirements for each professional 
discipline.  Performance Standard 12(a) states that a Unit should maintain 
 
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.  During FYs 20172018, the Units 
  training plan included minimum training hours for each professional 
discipline.  However, during FY 2019, the Unit submitted a revised training 
 
plan that lacked minimum training hour requirements for each 
  professional discipline.  Specifically, the Units training plan contained a 
required minimum number of Medicaid fraud-related training hours for all 
 
staff, but lacked hourly requirements for investigators, attorneys, and 
 
auditors.  Although the revised training plan lacked minimum training 
hours, most staff continued to meet or exceed the minimum training hour 
requirements contained in the Units previous training plan.  After our 
review, the Unit revised its training plan to include minimum training hour 
requirements that are at least as stringent as those required for 
professional certification.
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix A | 28   
APPENDIX B 
       
 
New Mexico MFCU Referrals Received, by Source, for FYs 20172019 
Exhibit B-1: New Mexico Unit referrals received during FYs 20172019, separated by source 
and FY 
 
FY 2017  FY 2018  FY 2019  3-Year Total 
Abuse &  Abuse &  Abuse &  Abuse & 
Referral Source  Fraud  Fraud  Fraud  Fraud  Total 
Neglect1  Neglect  Neglect  Neglect 
Adult Protective Services  29  147  8  106  8  137  45  390  435 
Anonymous  1  2  2  1  1  0  4  3  7 
Dept. of Health  21  1  13  0  0  0  34  1  35 
HHSOffice of 
2  1  1  0  2  0  5  1  6 
Inspector General (OIG) 
Licensing Board  0  0  0  0  0  0  0  0  0 
Local Prosecutor  1  0  0  0  0  0  1  0  1 
Long-Term Care 
0  0  0  0  1  0  1  0  1 
Ombudsman 
Managed Care 
0  0  0  0  0  0  0  0  0 
Organizations 
Medicaid Agency 
Program Integrity Unit  70  2  121  2  64  11  255  15  270 
(HSD-OIG) 
Medicaid Agency Other  14  3  3  3  9  7  26  13  39 
Other Law Enforcement  5  1  4  1  2  1  11  3  14 
Private Citizens  58  88  57  54  119  63  234  205  439 
Private Health Insurer  0  0  0  0  0  0  0  0  0 
Provider  1  0  1  0  0  0  2  0  2 
Provider Association  0  0  0  0  0  0  0  0  0 
State Agency Other   58  1  13  2  3  0  74  3  77 
Other  20  3  202  2  100  1  322  6  328 
Total  280  249  425  171  309  220  1,014  640  1,654 
Source: OIG analysis of Unit Annual Statistical Reports for FYs 20172019.  
1 The category Abuse & Neglect includes patient fund referrals. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix B | 29   
APPENDIX C  
 
Detailed Methodology 
The review team consisted of OIG evaluators, agents, a grant oversight analyst, and a 
director from another State MFCU.  Our pre-review analysis identified low case 
outcomes as an area of concern.  To assist the Unit in identifying ways to improve its 
case outcomes, we focused our data collection and analysis primarily on the factors 
that contributed to low case outcomes during FYs 20172019.  
We analyzed qualitative and quantitative data from a variety of sources, including: 
  case outcome data; 
  referral data; 
  other documentation, such as policies and procedures; 
  structured interviews with key stakeholders and MFCU staff; 
  review of case files; 
  review of Unit submissions to OIG and the NPDB; and 
  documentation related to the MFCUs fiscal controls. 
Data Collection and Analysis 
Review of case outcome data.  Prior to our review, we examined statistical reports 
and other documentation that the MFCU submitted to OIG.  This included Unit case 
outcome data pertaining to the 3-year review period (FYs 20172019).  We examined 
five case outcome measures: (1) the number of indictments of fraud and patient 
abuse or neglect; (2) the number of convictions of fraud and patient abuse or neglect; 
(3) the amount of monetary recoveries associated with criminal convictions; (4) the 
number of civil settlements and judgments; and (5) the amount of monetary 
recoveries associated with civil cases.  We also compared the Units case outcomes to 
those of other MFCUs with similar staff sizes and expenditures during FYs 20172019.   
   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix C | 30   
Exhibit C-1: New Mexico MFCU case outcomes during FYs 20172019 
compared to those of other similarly sized MFCUs 
 Median of 
New Mexico 
Type of Case  Outcome  Similarly Sized 
MFCU 
MFCUs 
Indictments  24  69 
Fraud convictions  11  42 
Criminal 
Patient abuse or neglect convictions  2  16 
Criminal recoveries  $24,874   $5,007,858 
Settlements and judgments   18  15 
Nonglobal Civil 
Recoveries  $1,574,823   $6,059,000 
Settlements and judgments   26  30 
Global Civil 
Recoveries  $5,428,941  $21,626,428 
Source: OIG analysis of Annual Statistical Reports. 
Referrals of fraud and patient abuse or neglect.  We examined data associated with 
the referrals of fraud and patient abuse or neglect that the Unit received from a 
variety of sources.  This included the number of referrals that the Unit reported 
receiving during FYs 20172019 and the number of referrals received by other 
similarly resourced MFCUs during the same 3-year period.  We also examined the 
processes that the Unit used for monitoring the opening of cases, as well as its 
processes for ensuring the receipt of adequate volume and quality of referrals from 
the State Medicaid agency as outlined in the Units MOU with the State Medicaid 
agency.  
Other documentation.  We examined the Units policies and procedures and held 
discussions with Unit management to gain an understanding of those policies and 
procedures.  We also examined data associated with the Units staff, both to identify 
the number of Unit staff and to determine how long each staff member had been 
with the Unit during FYs 20172019.  Finally, we analyzed data on annual training to 
evaluate the Unit staffs adherence to its training plans.   
Interviews with key stakeholders.  In August and September 2020, we interviewed 
five key stakeholders who were familiar with the Units operations, including officials 
in the New Mexico State Medicaid Program Integrity Unit, the New Mexico 
Department of Health, the New Mexico Aging and Long-Term Services Department, 
the U.S. Attorneys Office, and the FBI.  We also interviewed Special Agents from OIGs 
Office of Investigations in Dallas.  We focused these interviews on the Units 
relationship and interaction with the stakeholders as well as opportunities for 
improvement.  We used the information from these interviews to develop subsequent 
interview questions for Unit management and followed up with stakeholders as 
needed.    
Interviews with Unit management and staff.  In September 2020, we conducted 
structured interviews with 16 Unit staff, including the director, attorneys, and 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix C | 31   
investigative supervisors.  We also interviewed staff in the Attorney Generals Office; 
these included the Chief Deputy of the Criminal Affairs Division, who is the supervisor 
of the Unit director, and the Director of the Special Investigations Division.  These 
interviews focused on case outcomesspecifically, why they were low during  
FYs 20172019 and how to improve them.  The interviews were informed by OIGs 
analysis of the Units case outcomes data, other documentation, and stakeholder 
interviews.  We asked Unit staff to provide us with any additional context that could 
help us understand the Units operations.  After our review, we followed up with the 
Unit director to clarify certain data and to gather further information.  
Review of case files.  We asked the Unit to provide us with a list of cases that were 
open at any point during FYs 20172019, and we asked the Unit to include the current 
status of those cases; whether the case was criminal, civil, or global; and the dates on 
which the case was opened and closed, if applicable.  The total number of cases that 
met these parameters was 373.  We excluded a total of 155 global cases because they 
were civil false claims actions that typically involve multiple agencies, such as the U.S. 
Department of Justice and a group of State MFCUs.   
From the 218 remaining case files, we selected a simple random sample of 76 cases.  
This sample allowed us to make estimates of the overall percentage of case files with 
various characteristics with an absolute precision of +/- 10 percent at the 95-percent 
confidence level.  With the assistance of OIG agents and the MFCU director from 
another State, we reviewed the Units processes for monitoring the opening, status, 
and outcomes of these 76 cases.  We also reviewed the Units approach to 
investigating and prosecuting cases that were open at some point during  
FYs 20172019.  Throughout the review of the sampled cases, we consulted Unit staff 
to address any apparent issues with individual case files, such as missing 
documentation.  
Review of Unit submissions to OIG and the NPDB.  We reviewed all convictions 
submitted to OIG for program exclusion and all adverse actions submitted to the 
NPDB during FYs 20172019 and assessed the timeliness of these submissions.   
Review of Unit financial documentation.  We conducted a limited review of the Units 
control over its fiscal resources.  Prior to our review, we analyzed the Units response 
to an internal controls questionnaire and conducted a review of the Units financial 
status reports.  We followed up with Unit officials to clarify issues identified in the 
internal controls questionnaire.   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix C | 32   
 
APPENDIX D 
 
 
Point Estimates and 95-Percent Confidence Intervals of Case 
File Reviews  
Exhibit D-1: Estimates for All Case File Reviews 
95-Percent 
Sample  Point  Confidence Interval 
 Estimate Description 
Size   Estimate 
Lower  Upper 
Percentage of All Cases That Had Supervisory Approval To 
76  100.0%  95.9%  100.0% 
Open  
Percentage of All Cases Closed at the Time of Our Review   76  73.7%  64.2%  81.7% 
Percentage of All Closed Cases That Had Supervisory 
56  100.0%  94.4%  100.0% 
Approval To Close  
Percentage of All Cases Open Longer Than 60 Days   76  97.4%  91.7%  99.1% 
Percentage of All Cases With a Referral Stage Longer Than 
76  65.8%  56.0%  74.8% 
180 Days 
Percentage of All Cases That Had Significant Investigative 
76  51.3%  41.3%  61.0% 
Delays   
Source: OIG analysis of New Mexico Unit case files, 2020. 
Exhibit D-2: Estimates for Case Files Open Longer Than 60 Days 
95-Percent 
Sample  Point  Confidence Interval 
 Estimate Description 
Size   Estimate 
Lower  Upper 
Percentage of All Cases Open Longer Than 60 Days That Had 
Documentation of Supervisory Reviews Consistent With Unit  74  17.6%  10.8%  26.4% 
Policy (i.e., Every 60 Days or More Frequent) 
Percentage of All Cases Open Longer Than 60 Days That Did 
Not Contain Documentation of Supervisory Reviews  74  82.4%  73.6%  89.2% 
Consistent With Unit Policy 
Percentage of All Cases Open Longer Than 60 Days That Had 
Documentation of Supervisory Reviews, But Were  74  75.7%  66.0%  83.5% 
Inconsistent With Unit Policy 
Percentage of All Cases Open Longer Than 60 Days That 
74  6.8%  2.8%  13.7% 
Lacked Documentation of Any Supervisory Review  
Source: OIG analysis of New Mexico Unit case files, 2020.
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix D | 33   
 
APPENDIX E 
 
Unit Comments 
 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix E | 34 
   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix E | 35 
   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix E | 36 
   
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Appendix E | 37 
   
 
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments  
Jordan Clementi served as the team leader for this study, and Anna Brown and Kristen 
Calille served as the lead analysts.  Office of Evaluation and Inspections staff who 
provided support include Kevin Farber, Anthony Soto McGrath, and Sara Swisher.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including special agents from the Office of Investigations. 
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector 
General for Evaluation and Inspections in the Dallas regional office, and Petra Nealy, 
Deputy Regional Inspector General, as well as in consultation with Richard Stern, 
Director of the Medicaid Fraud Control Policy and Oversight Division. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550  Acknowledgments and Contact | 38 
   
 
ABOUT THE OFFICE OF INSPECTOR GENERAL 
 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network 
of audits, investigations, and inspections conducted by the following operating 
components: 
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 audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
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. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
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. 
New Mexico Medicaid Fraud Control Unit: 2020 Review 
OEI-06-20-00550   About the Office of Inspector General | 39