U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
Utah Medicaid 
Fraud Control 
Unit: 2018 Onsite 
Review 
 
Add
OEI-00-00-00000 
OEI-0M9o-n1t8h- 0200117Y0    Suzanne Murrin 
Augu st 2019  Deputy Inspector General for 
  oig.hhs.gov  Evaluation and Inspections 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
August 2019 
Office  of Inspector General 
OEI-09-18-00170 
 
 
 
Utah Medicaid Fraud Control Unit: 2018 
MFCU Case Outcomes  
Onsite Review  The MFCUs case outcomes for 
FYs 20152017 consisted of:      
What OIG Found   
4 fraud convictions; 
During Federal fiscal years (FYs) 20152017, the number of criminal fraud   
11 convictions of patient 
convictions that the Utah Medicaid Fraud Control Unit (MFCU) obtained
abuse or neglect; 
four convictionsfell below the level that the MFCU had achieved in the 
 
approximately $400,000 
preceding years.  This decrease in fraud convictions came at the same time as 
in criminal recoveries; 
a decrease in fraud referrals to the MFCU from the Utah Inspector General for 
 
Medicaid Services (Utah MIG) and from Medicaid managed care organizations,  44 civil settlements and 
which Utahs Medicaid program refers to as accountable care organizations  judgments; and 
(ACOs).  We note that, subsequent to our period of review, the MFCU obtained    $16.8 million in civil 
seven fraud convictions for FY 2018.  The MFCU increased the number of  recoveries.  
convictions that it obtained for patient abuse or neglect during FYs 20152017,   
compared to previous years. 
Why OIG Did This Review 
Several factors contributed to the MFCUs declining nonglobal civil settlements,  The primary purpose of this onsite 
judgments, and recoveries in FY 2017.  MFCU management reported a decline  review was to identify and address 
in civil cases involving pharmaceutical manufacturers, as well as a change in  factors that contributed to the 
State law that limited the MFCUs ability to follow its historical approach for  MFCUs low number of fraud 
litigating nonglobal civil cases.  convictions during FYs 20152017 
and declining amounts of 
We also found two instances of nonadherence with MFCU performance 
nonglobal* civil settlements, 
standardsone related to the MFCUs practices for storing and maintaining 
judgments, and recoveries in 
case information, and the other regarding a lack of documentation of 
FY 2017. 
supervisory review of case files. 
The Office of Inspector General 
What OIG Recommends and How the Unit Responded  (OIG) administers MFCU grant 
We recommend that the MFCU take steps to address the factors contributing  awards, annually recertifies each 
to its decreased case outcomes.  Specifically, we recommend that the MFCU:  MFCU, and oversees MFCU 
performance in accordance with 
 
develop and implement a plan to increase Medicaid fraud referrals from  the requirements of the grant.  
the Utah MIG and ACOs; and  As part of this oversight, OIG 
  further develop its approach to litigating nonglobal civil cases in-house  conducts periodic onsite reviews of 
or refer them to other appropriate agencies for litigation.  MFCUs and prepares public 
reports.  These onsite reviews 
To address the instances of nonadherence with MFCU performance standards, 
supplement OIGs annual 
we recommend that the MFCU: 
recertifications of the MFCUs.   
 
develop and implement written procedures for storing, maintaining, and   
efficiently accessing case information; and 
* Nonglobal cases involve primarily State 
 
establish a process to ensure that case files contain appropriate  rather than Federal litigation; are pursued 
documentation.  separately by individual MFCUs or with 
other law enforcement partners; and are 
The MFCU concurred with all four recommendations.  not coordinated by the National Association 
of Medicaid Fraud Control Units. 
  
    
TABLE OF CONTENTS                    
BACKGROUND      1 
FINDINGS   
The MFCU obtained fewer fraud convictions during FYs 20152017 than in previous years, but  6 
increased its number of convictions of patient abuse or neglect 
Fraud referrals from the Utah Inspector General for Medicaid Services (Utah MIG) and from  7 
Medicaid accountable care organizations (ACOs) decreased in comparison to previous years 
Several factors contributed to the MFCUs declining nonglobal civil case outcomes  8 
The MFCU did not store and maintain its case information in a manner that allowed for  9 
efficient access to the information 
Many case files were missing documentation of periodic supervisory reviews and/or approval  10 
to open cases 
CONCLUSION AND RECOMMENDATIONS   
Develop and implement a plan to increase Medicaid fraud referrals from the Utah MIG and  11 
ACOs 
Further develop its approach to litigating nonglobal civil cases or refer them to other  11 
appropriate agencies for litigation 
Develop and implement written procedures for storing, maintaining, and efficiently accessing  11 
case information 
Establish a process to ensure that case files contain appropriate documentation, including  12 
records of periodic supervisory reviews and approval to open cases   
MFCU COMMENTS AND OIG RESPONSE  13 
APPENDICES   
A: MFCU Performance Standards  14 
B: Utah MFCU Referrals Received, by Source, Fiscal Years 20152017  20 
C: Detailed Methodology    21 
D: MFCU Comments    25 
29 
ACKNOWLEDGMENTS 
 
    
BACKGROUND 
Objective 
To examine performance and operational issues that the Office of 
Inspector General identified during its recertification and onsite review of 
the Utah Medicaid Fraud Control Unit 
Medicaid Fraud  Medicaid Fraud Control Units (MFCUs or Units) investigate (1) Medicaid 
provider fraud and (2) patient abuse or neglect in facility settings, and 
Control Units 
prosecute those cases under State law or refer them to other prosecuting 
offices.1, 2  Under the Social Security Act (SSA), a MFCU must be a single, 
identifiable entity of State government, separate and distinct from the 
State Medicaid agency, and employ one or more investigators, attorneys, 
and auditors.3  Each State must operate a MFCU or receive a waiver.4  
Currently, 49 States, the District of Columbia, Puerto Rico, and the 
U.S. Virgin Islands operate MFCUs.5  Each MFCU receives a Federal grant 
award, equivalent to 90 percent of total expenditures for new Units and 
75 percent for all other Units.6  In Federal fiscal year (FY) 2018, combined 
Federal and State expenditures for the Units totaled approximately 
$294 million.7   
   
 
1 SSA  1903(q)(3).  Regulations at 42 CFR  1007.11(b)(1) clarify that the Units responsibilities 
include the review of complaints of misappropriation of patients private funds in health care 
facilities. 
2 References to State in this report refer to the States, the District of Columbia, and the 
U.S. Territories. 
3 SSA  1903(q). 
4 SSA  1902(a)(61). 
5 North Dakota and the territories of American Samoa, Guam, and the Northern Mariana 
Islands have not established Units. 
6 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.  (Currently, this 
provision is applicable to the new MFCUs in Puerto Rico and the U.S. Virgin Islands.)  
Thereafter, the Federal government contributes 75 percent and the State contributes 
25 percent. 
7 OIG analysis of MFCU annual statistical reporting data for FY 2018.  The Federal FY 2018 was 
from October 1, 2017, through September 30, 2018. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  1 
    
The Office of Inspector General (OIG) administers the grant award to each 
OIG Grant 
Unit and provides oversight of Units.8, 9  As part of its oversight, OIG reviews 
Administration and 
and recertifies each MFCU annually and conducts periodic onsite reviews, 
Oversight of the  such as this review.   
MFCUs  
In a recertification review, OIG examines the following (collectively referred 
to as recertification data): the Units annual report; questionnaire 
responses from the Units director and stakeholders; and annual case 
statistics.  Through the recertification review, OIG assesses a Units 
performance, as measured by the Units adherence to published 
performance standards;10 the Units compliance with applicable laws, 
regulations, and OIG policy transmittals;11 and the Units case outcomes.  
(See Appendix A for MFCU performance standards, including performance 
indicators for each standard.)   
OIG further assesses Unit performance by conducting onsite Unit reviews 
that may identify findings and make recommendations for improvement.  
During an onsite review, OIG also makes observations regarding Unit 
operations and practices, and may identify beneficial practices that may be 
useful to share with other Units.  Finally, OIG provides training and technical 
assistance to Units while onsite, as appropriate, and on an ongoing basis.  
The Utah MFCUs office is located in Murraya suburb of Salt Lake City, the 
Utah MFCU  
State capital.  The MFCU is an entity within the State Attorney Generals 
Office.  At the time of our April 2018 onsite review, the MFCU had 13 staff 
positions: a director (who was also an attorney), 2 other attorneys (one of 
whom served as the deputy director), 6 investigators (one of whom served 
as the chief investigator), 2 auditors, a paralegal, and an office administrator.  
The chief investigator supervised the MFCUs investigators, and the director 
served as the immediate supervisor for the chief investigator and other 
 
8 As part of grant administration, OIG receives and examines financial information from Units, 
such as budgets and quarterly and final Federal Financial Reports that detail MFCU income 
and expenditures. 
9 The SSA 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. 
10 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  The 
performance standards were developed by OIG in collaboration with the MFCUs and were 
originally published at 59 Fed. Reg. 49080 (Sept. 26, 1994). 
11 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  
These policy transmittals may be found at https://oig.hhs.gov/fraud/medicaid-fraud-control-
units-mfcu/index.asp.  
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  2 
    
staff members.  During our review period of FYs 20152017, the MFCU spent 
approximately $6 million, with a State share of about $1.5 million.12 
Referrals.  The MFCU receives fraud referrals from the Utah Medicaid 
Inspector General (Utah MIG), the State Medicaid agency, and Medicaid 
managed care organizations (which Utah refers to as accountable care 
organizations (ACOs)13), as well as from other sources, such as OIG and 
other law enforcement agencies.  The Utah MFCU receives referrals of 
patient abuse or neglect from Adult Protective Services and the State 
Medicaid agency, as well as other sources.  Appendix B identifies the 
MFCUs referrals, by source, during FYs 20152017. 
When the MFCU receives a referral, the chief investigator reviews it 
to determine whether it has potential to be a full investigation.  If the chief 
investigator determines that the referral has this potential, he sends the 
referral to the director, who decides whether to open a case.  If the chief 
investigator declines a referral or the director decides not to open a case, 
the MFCU can send the referral to another agency for investigation or 
administrative action. 
Investigations and Prosecutions.  After the MFCU opens a case, the director 
and chief investigator assign the case to an investigator and attorney 
to conduct a full investigation.  After the investigation concludes, the 
director determines whether the case warrants prosecution.14      
Utah Medicaid  In FY 2017, Utahs Medicaid expenditures were approximately $2.6 billion.15  
In 13 of Utahs 29 counties, all Medicaid beneficiaries receive their services 
Program 
through ACOs.  In Utahs other 16 counties, Medicaid beneficiaries have 
the option to receive their services through either ACOs or fee-for-service 
 
12 OIG, Expenditures and Statistics, MFCU Statistical Data, accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp on September 28, 
2018.  
13 Utahs ACOs arenotwithstanding the phrase accountable caresimilar to managed 
care organizations in other States in that their contracts with the State are full risk capitated 
contracts and therefore assume the risk for all health care costs for their members.  Utah 
Department of Health, 2017 Utah Medicaid & CHIP Annual Report, p. 39, accessed at 
https://medicaid.utah.gov/Documents/pdfs/annual%20reports/medicaid%20annual% 
20reports/MedicaidAnnualReport_2017.pdf on October 16, 2018.   
14 Utah enacted a False Claims Act in 2007.  Among other provisions, the Act (Utah Code 
 26-20-1 through 26-20-15) imposes civil monetary and criminal penalties on persons or 
entities that submit false claims; make false statements; or receive or pay kickbacks or bribes.  
The civil provisions of Utahs False Claims Actunlike the Federal civil false claims act (31 U.S.C. 
 37293733) and civil fraud statutes in many other Statesdo not contain a qui tam, or 
whistleblower, provision that would provide a monetary incentive to whistleblowers who identify 
fraud.       
15 OIG, Medicaid Fraud Control Unit 2017 Statistical Chart, accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2017-
statistical-chart.pdf on October 10, 2018. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  3 
    
providers.16  As of FY 2015, nearly 90 percent of Utahs roughly 
291,000 Medicaid beneficiaries received their services through managed 
care entities.17  All of the ACOs operate Special Investigation Units that 
engage in a variety of program integrity activities, such as conducting audits 
of claims data to identify and address fraud, waste, and abuse.  State 
contracts with the ACOs, as well as the ACOs policies and procedures, 
require ACOs to refer any suspected provider fraud to either the Utah MIG 
or MFCU.  However, these contracts do not require the ACOs to refer 
suspected fraud to both agencies.18 
The Utah MIG is responsible for Medicaid program integrity efforts in Utah. 
Among other duties, Utah MIG staff analyze the States Medicaid claims 
data to identify fraud, waste, and abuse.19, 20  The Utah MIG also conducts 
preliminary investigations of referrals that it receives from other sources.  
The Utah MIG is required to refer all cases of suspected fraud to the 
MFCU.21  
 
16 Utah Department of Health, 2017 Utah Medicaid & CHIP Annual Report, p. 38, accessed at 
https://medicaid.utah.gov/Documents/pdfs/annual%20reports/medicaid%20annual% 
20reports/MedicaidAnnualReport_2017.pdf on October 16, 2018.   
17 CMS, Center for Program Integrity, Utah Focused Program Integrity Review (June 2017), p. 1, 
accessed at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/UTfy16.pdf on October 16, 2018.  In addition to 
receiving services from the ACOs, some Utah Medicaid beneficiaries receive certain services, 
such as behavioral health and substance abuse treatment, through other managed care 
entities.  Utah Department of Health, 2017 Utah Medicaid & CHIP Annual Report, p. 42, 
accessed at https://medicaid.utah.gov/Documents/pdfs/annual%20reports/ 
medicaid%20annual% 20reports/MedicaidAnnualReport_2017.pdf on October 16, 2018.   
18 Federal regulation requires managed care entities (effective July 1, 2017) to refer any 
potential fraud, waste, or abuse to the State Medicaid program integrity unit, and to refer 
any potential fraud directly to the MFCU(s) in the State(s) where the potential fraud occurred.  
42 CFR  438.608(a)(7). 
19 The Utah State Legislature established the Utah MIG during its 2011 General Session as an 
independent office within the Utah Department of Administrative Services.  The mission of 
the Utah MIG is to maximize the recovery of improper Medicaid payments and the 
identification of fraud, waste, and abuse within the Medicaid program.  These Medicaid 
program integrity functions were previously performed by the States Department of Health, 
which serves as the State Medicaid agency.  Utah Inspector General for Medicaid Services, 
2017 Annual Report, p. 5, accessed at https://le.utah.gov/interim/2017/pdf/00004914.pdf on 
October 16, 2018.  
20 If the Utah MIG receives a complaint of Medicaid fraud or identifies questionable practices, 
it is required to conduct a preliminary investigation to determine whether sufficient evidence 
exists to warrant a full investigation.  See 42 CFR  455.14. 
21 42 CFR  455.21(a)(1) and Utah Code  63A-13-202(1)(j).  Consistent with these 
requirements, a memorandum of understanding among the Utah MIG, the State Medicaid 
agency, and the MFCU states that the Utah MIG must notify the MFCU whenever the Utah 
MIG has a suspicion of fraud, patient abuse, patient neglect, or patient exploitation.  
Memorandum of Understanding between the Utah MFCU, Utah OMIG, and Utah Department 
of Health, February 22, 2012, p. 5, Term 5(B) (Article V(2) of the 2018 version).      
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  4 
    
Previous OIG Onsite  In 2014, OIG issued a report on its previous onsite review of the MFCU.  The 
report contained four recommendations to improve the MFCUs adherence 
Review 
to certain performance standards.  OIG recommended that the MFCU 
(1) ensure that case files contain documented evidence of supervisory 
approval to open and close cases and periodic supervisory reviews; 
(2) ensure that letters referring convicted providers for exclusion from 
Federal health care programs are submitted to OIG within an appropriate 
timeframe; (3) revise its policies and procedures manual to include the 
MFCUs periodic supervisory review process; and (4) ensure that adverse 
actions are reported to the National Practitioner Data Bank, as specified in 
Federal regulations.  From the MFCUs reporting of subsequent actions that 
it took, OIG considers each of these recommendations as implemented. 
We conducted the onsite review in April 2018.  The review team consisted of 
Methodology 
OIG evaluators, law enforcement agents, and a director from another State 
MFCU.  The primary purpose of the review was to follow up on issues that 
OIG had identified through its ongoing administration and oversight 
activities.  Our analysis identified three specific areas of concern: (1) a low 
number of fraud convictions compared to those in previous FYs and 
compared to those of similarly sized MFCUs; (2) a low number of fraud 
referrals from the MFCUs key State partners; and (3) declining nonglobal 
civil settlements and judgments in FY 2017.22  We focused our data 
collection and analysis primarily on identifying factors that contributed to 
these conditions.  We also reviewed the MFCUs operations and fiscal 
controls.   
Our review covered the 3-year period of FYs 20152017.  We based our 
inspection on an analysis of data from six sources: (1) general MFCU 
documentation; (2) financial documentation; (3) structured interviews with 
key stakeholders; (4) structured interviews with the MFCUs managers and 
staff; (5) a review of case files that were open at some point during the 
review period; and (6) observation of MFCU operations.  (See Appendix C 
for a detailed methodology.)       
Standards  We 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 they are subject to the same internal quality controls as other OIG 
evaluations, including internal and external peer review.    
 
22 Global civil cases are False Claims Act cases that are litigated in Federal court by the U.S. 
Department of Justice and typically involve a group of MFCUs.  The National Association of 
Medicaid Fraud Control Units facilitates the settlement of global cases on behalf of the 
States.  Nonglobal cases involve primarily State rather than Federal litigation; are pursued 
separately by Units or with other law enforcement partners; and are not coordinated by the 
National Association of Medicaid Fraud Control Units. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  5 
    
FINDINGS  
The MFCU obtained  During the 3-year period of FYs 2015 through 2017the period of our 
reviewthe Utah MFCU reported four convictions of provider fraud.  This 
fewer fraud 
number represented a decrease from the nine fraud convictions that the 
convictions during 
Utah MFCU had reported during the previous 3-year period.  It was also the 
FYs 20152017 than  lowest total among other similarly sized MFCUs for FYs 20152017.23, 24  
During this period, the number of fraud convictions among other similarly 
in previous years, 
sized MFCUs ranged from 10 to 95.  However, subsequent to our period of 
but increased its 
review, the MFCU reported seven fraud convictions for FY 2018
number of 
a significant increase compared to any of the fiscal years during the period 
convictions of  of our review.25 
patient abuse or  Exhibit 1 displays the Utah MFCUs convictions during FYs 20152017 and 
neglect  FYs 20122014, and the range of convictions among other similarly sized 
MFCUs during FYs 20152017. 
 
Exhibit 1: Utah MFCU convictions in FYs 20152017 as compared to 
those from the previous 3-year period and those for similarly sized 
MFCUs.   
Utah   Range Among Other 
MFCU  Similarly Sized MFCUs 
Type of  FYs  FYs   FYs 
Case  Outcome  20122014  20152017  20152017 
Fraud convictions  9  4  10 to 95 
Criminal  Convictions of 
patient abuse or  4  11  0 to 19 
neglect 
Source: OIG, Expenditures and Statistics, MFCU Statistical Data, accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp on September 28, 2018. 
During FYs 2015 through 2017, the Utah MFCU reported 11 convictions 
related to allegations of patient abuse or neglect, almost tripling its number 
 
23 MFCU management reported that circumstances outside the MFCUs control involving 
a single case significantly reduced the total number of fraud convictions that it reported 
during FYs 20152017. 
24 Although comparing a MFCUs case outcomes with those of similarly sized MFCUs 
provides some context, many factors other than a MFCUs number of staff can affect case 
outcomes.  See Appendix C for a detailed description of our analysis, including the selection 
of similarly sized MFCUs and limitations associated with the comparative analysis. 
25 MFCUs were not required to report their FY 2018 recertification data (for example, the total 
number of convictions and referrals) to OIG until after we completed our onsite review.  
Therefore, we did not conduct analysis to determine why FY 2018 totals may have increased 
or decreased from our period of review. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  6 
    
of such convictions (4 convictions) from the previous 3-year period.  During 
FYs 20152017, the number of patient abuse or neglect convictions among 
other similarly sized MFCUs ranged from 0 to 19.  For FY 2018, the MFCU 
reported 7 patient abuse or neglect convictions. 
Fraud referrals  During FYs 2015 through 2017, the Utah MFCU received a total of six fraud 
referrals from the Utah MIG.  This number represented a decrease from the 
from the Utah MIG 
14 fraud referrals that the MFCU received from the MIG during the previous 
and ACOs  3-year period.26  It was also the second-lowest total among other similarly 
decreased in  sized MFCUs for the number of fraud referrals that the MFCUs received 
from their respective State Medicaid program integrity units during 
comparison to 
FYs 2015 through 2017.27  Performance Standard 4 states that a MFCU 
previous years 
should take steps to ensure that it receives an adequate volume and quality 
of referrals.  For FY 2018, the MFCU received 3 fraud referrals from the Utah 
MIG, a number that was consistent with the previous 3 fiscal years. 
The low number of fraud referrals from the Utah MIG to the MFCU is 
concerning because the Utah MIG has the primary responsibility of 
monitoring the States Medicaid program for cases of suspected fraud.  It 
employs staff who are trained to analyze Medicaid data for potential fraud 
and to conduct preliminary investigations of fraud allegations.  Therefore, it 
should be a significant source of quality referrals for the MFCU.  Appendix B 
identifies the MFCUs referrals, by source, during FYs 20152017. 
In addition, the MFCU reported that during the review period, it received 
only one fraud referral from Utahs four ACOs.  The low volume of 
ACO-generated referrals over a 3-year period is concerning in a State where 
nearly 90 percent of the Medicaid population is served by ACOs.28  
Performance Standard 6(B) states that for those States that rely substantially 
on managed care entities for the provision of Medicaid services, the MFCUs 
case mix should consist of a commensurate number" of managed care 
cases.  In a 2017 report on program integrity oversight in managed care in 
Utahs Medicaid program, CMS noted that the number of fraud referrals 
 
26 MFCU management explained that when the MFCU reports to OIG the number of referrals 
that the MFCU received in a prior fiscal year, the MFCU reports only those referrals that it 
opened as full investigations.  Therefore, it is possible that the MFCU received additional 
referrals from its key State partners that it did not open or pursue as full investigations 
because the MFCU judged that there was not sufficient preliminary evidence of fraud or 
because the allegation was outside of the MFCUs grant authority. 
27 By comparison, the number of fraud referrals that similarly sized MFCUs received from 
their respective MIG equivalents (i.e., from the agencies that primarily were responsible for 
Medicaid program integrity functions in their respective States) during FYs 20152017 ranged 
from 2 to 138.   
28 CMS, Center for Program Integrity, Utah Focused Program Integrity Review (June 2017), p. 1, 
accessed at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/UTfy16.pdf on October 16, 2018.  
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  7 
    
that the ACOs sent to either the Utah MFCU or the Utah MIG was low 
compared to the size of the ACOs.29  A low number of fraud referrals from 
ACOs in a State that is served primarily by managed care entities could 
make it difficult for the MFCU to carry out its mission effectively.30  The 
MFCU reported that it received no fraud referrals from the ACOs in FY 2018.   
Although the MFCU reported receiving few fraud referrals, MFCU 
management and staff stated that the MFCU regularly conducts outreach to 
other State agencies and associations of health care providers to encourage 
both referrals of fraud and referrals of patient abuse or neglect.  MFCU and 
Utah MIG management and ACO program integrity staff stated that the 
MFCU meets with the Utah MIG, the State Medicaid agency, and ACOs 
collectivelyon a quarterly basisto discuss potential referrals and other 
program integrity issues.  In addition, the MFCU and the Utah MIG meet 
quarterly with each of the four ACOs. 
Several factors  One area of concern for the Utah MFCU involved declining outcomes from 
nonglobal civil cases in FY 2017.  The MFCU had no nonglobal civil 
contributed to the 
settlements or judgments in FY 2017, compared to 10 settlements and 
MFCUs declining 
judgments in FY 2016 and 6 in FY 2015.  (See Exhibit 2.)  Additionally, the 
nonglobal civil case  MFCUs nonglobal civil recoveries substantially declined in FY 2017
to $3,318, down from $7.9 million in FY 2016 and $5.6 million in FY 2015.  
outcomes  
Exhibit 2 shows the MFCUs nonglobal civil case outcomes during  
FYs 20152017. 
Exhibit 2: The Utah MFCUs nonglobal civil case outcomes declined in 
FY 2017. 
Type of Case  Outcome  FY 2015  FY 2016  FY 2017 
Settlements and  
6  10  0 
Nonglobal civil  judgments  
Recoveries  $5.6 million  $7.9 million  $3,318 
Source: MFCU response to OIG data request, 2018. 
 
29 CMS, Center for Program Integrity, Utah Focused Program Integrity Review (June 2017), p. 7, 
accessed at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/UTfy16.pdf on October 16, 2018. CMSs analysis 
of referrals used data from three of the ACOs for FYs 20132015. 
30 The total number of fraud referrals that the MFCU received from all sources declined 
during the review period, from 46 in FY 2015 to 36 in FY 2016 to 20 in FY 2017.  The MFCU 
said that the reason for this decline was the drop in referrals of global fraud cases from the 
National Association of Medicaid Fraud Control Units.  (Such referrals constituted the 
majority of fraud referrals that the MFCU received in FYs 2015 through 2017, as shown in 
Appendix B.)  MFCU management reported that the MFCU does not control the number of 
global case referrals that it receives.   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  8 
    
At the time of our review in April 2018, MFCU management stated that the 
MFCU had only a limited footprint with regard to civil cases and identified 
key factors that contributed to its declining nonglobal civil case outcomes.  
The MFCU director reported that historically, the MFCUs nonglobal civil 
cases had involved pharmaceutical manufacturers,31 but fewer of these cases 
were available now than in the past.  The director further explained that the 
MFCU could no longer use its historical approach for litigating these types 
of civil cases because a 2015 State law restricts the use of outside counsel 
under contingent fee contracts, which the MFCU previously used.32  
Subsequent to our onsite review, the MFCU reported two nonglobal 
settlements in FY 2018, neither of which was litigated by outside counsel 
under contingent fee contracts.  Performance Standard 6(E) indicates that 
the MFCU should seek to maintain a balance of criminal and civil fraud 
cases.33  
The MFCU did not have standard practices to ensure that its staff 
The MFCU did not 
consistently stored and maintained case information; this limited the 
store and maintain 
MFCUs ability to efficiently access the information.  Performance 
its case information 
Standard 7 states that a MFCU should maintain its case files in an effective 
in a manner that  manner and have a case management system that, among other things, 
allows efficient access to case information for both monitoring and 
allowed for efficient 
reporting restitution and recoveries. 
access to the 
information   We found that the MFCU stored information in four different places: 
(1) a case management and tracking system; (2) a networked drive shared 
by the MFCU office; (3) paper case files; and (4) staffs personal computers.  
Because the MFCU lacked standard practices for case information storage, 
case file information was not always complete, accurate, or consistently 
maintained in these four locations.  In some cases, we could not locate 
certain information in any of the four locations.  We found that the MFCU 
 
31 MFCU management explained that in these cases, pharmaceutical manufacturers had 
substantially inflated the average wholesale prices that they reported to CMS.  This inflated 
the prices that retailers ultimately paid for prescription drugs, thereby increasing costs to 
Medicaid. 
32 Utah Code  67-5-33(5)(c), enacted in May 2015.  The law prohibits the Office of Attorney 
General from using outside counsel under contingent fee contracts that are based on the 
imposition or amount of a penalty or civil fine.  The law does not apply to any contingent 
fee contracts that were in existence before May 12, 2015.  Therefore, the effects of the law on 
the MFCUs nonglobal outcomes were not apparent until FY 2017. 
33 Additionally, Performance Standard 8(E) specifies that for cases that have civil fraud 
potential, the Unit should investigate and prosecute such cases under State authority or refer 
them to OIG or the U.S. Department of Justice.  Also, OIG State Fraud Policy Transmittal 
99-01 states that all provider fraud cases that are declined criminally [should] be investigated 
and/or analyzed fully for their civil potential.  The policy transmittal further states that 
MFCUs should either try meritorious civil cases under State law or refer them to another 
agency if no State civil fraud statute exists.   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  9 
    
designated eight cases as open strictly for the purpose of collecting 
restitution, even though the cases had been resolved.  However, for some of 
these cases, the MFCU could not determine whether restitution had been 
received and, if so, how much.  For one case, the MFCU did not know 
whether restitution had ever been received.  Our review also found 11 cases 
that were listed as open in the system but were actually closed.  In 
addition, three cases listed as nonglobal in the system were actually 
global cases.   
Many case files  Of the 101 total case files that we reviewed, 68 lacked documentation of 
periodic supervisory reviews that complied with the MFCUs policy for 
were missing 
periodic supervisory review.34  Of the 87 fraud case files we reviewed, 
documentation of 
62 lacked this documentation. Of the 14 files for cases of patient abuse or 
periodic  neglect we reviewed, 6 lacked this documentation.  Performance 
supervisory reviews  Standard 7(A) states thatconsistent with the MFCUs policies and 
proceduressupervisors should review case files periodically and these 
and/or approval to 
reviews should be noted in the case files.  According to the MFCUs policy 
open cases 
for periodic supervisory review, these reviews should occur every 45 days.  
However, 30 case files that we reviewed lacked documentation that 
supervisors had conducted any periodic reviews of the cases.  An additional 
38 case files contained documentation of some periodic supervisory review; 
however, the frequency of these documented reviews did not comply with 
the MFCUs policy for supervisory review.  OIGs prior (2014) Utah MFCU 
onsite review report included a similar finding.  According to MFCU 
management, the MFCU does not document periodic supervisory reviews 
during the prosecution phase of cases.35   
In addition, documentation of supervisory approval to open cases was 
missing in 27 of the 87 fraud case files that we reviewed.36  Performance 
Standard 5(B) states that supervisors should approve the opening and 
closing of all investigations, and Performance Standard 7(B) states that case 
files should contain all relevant information and justify the opening of cases.  
OIGs prior (2014) Utah MFCU onsite review report included a similar finding. 
   
 
34 Of the 105 case files in our sample, 3 cases were global fraud cases and 1 case was a fraud 
case that the MFCU had closed after a preliminary investigation.  Therefore, we reviewed only 
101 cases87 cases of provider fraud and 14 cases of patient abuse or neglectfor 
documentation of supervisory approval to open the case and for documentation of periodic 
supervisory reviews. 
35 For those cases that did not comply with the MFCUs policy for periodic supervisory review, 
we determined that this noncompliance with regard to reviews and recordkeeping had not 
affected case outcomes. 
36 We did not find a lack of documentation of supervisory approval to open cases in any of 
the files we reviewed for the 14 cases of patient abuse or neglect. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  10 
    
CONCLUSION AND RECOMMENDATIONS 
The number of fraud convictions during FYs 2015 through 2017 fell below 
the level that the Utah MFCU had achieved in previous years.  We note 
that, subsequent to our period of review, the MFCU reported 7 fraud 
convictions for FY 2018.  The MFCU achieved more convictions of patient 
abuse or neglect during FYs 2015 through 2017 than it had during the 
previous 3-year period. 
The MFCUs FY 20152017 decrease in fraud convictions came at the 
same time as a decrease in fraud referrals from the Utah MIG and ACOs.  
Additionally, several factors contributed to the MFCUs declining 
nonglobal civil cases and its civil settlements, judgments, and recoveries in 
FY 2017. 
Our review identified two instances of nonadherence with MFCU 
performance standardsspecifically, issues with the MFCUs practices for 
storing and maintaining case information and a lack of documentation of 
periodic supervisory review of case files. 
To address these issues related to case outcomes and nonadherence to 
performance standards, we recommend that the MFCU: 
Develop and implement a plan to increase Medicaid fraud 
referrals from the Utah MIG and ACOs  
The MFCU should further engage with the Utah MIG and the ACOs 
to develop and implement a plan to increase the number of fraud referrals 
to the MFCU.  As part of this plan, the MFCU could assess its outreach 
efforts and identify ways to improve the volume of fraud referrals from 
other potential sources.   
Further develop its approach to litigating nonglobal civil cases 
or refer them to other appropriate agencies for litigation  
The MFCU should develop and implement a plan to ensure that it can either 
effectively litigate nonglobal civil cases in-house or refer cases with the 
potential to be litigated under Utahs False Claims Act or other State laws to 
another agency with the authority to litigate these cases. 
Develop and implement written procedures for storing, 
maintaining, and efficiently accessing case information 
The MFCU should develop written procedures to standardize how it stores 
and maintains case file information.  At a minimum, the procedures should 
specify where particular categories of case information will be stored.  For 
example, case file information could be consolidated from the current four 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  11 
    
types of locations into a single location.  This could improve the MFCUs 
ability to maintain, locate, and retrieve case information and more efficiently 
determine the status of cases, including any associated restitution owed or 
received.   
Establish a process to ensure that case files contain appropriate 
documentation, including records of periodic supervisory 
reviews and approval to open cases   
Both this 2018 onsite review and OIGs prior (2014) review found that case 
files in the samples we reviewed lacked documented periodic supervisory 
reviews and/or supervisory approval to open cases.  Although the MFCU 
took actions that appeared to have addressed OIGs 2014 recommendation, 
our 2018 onsite review again found that many of the MFCUs case files had 
no documentation that periodic supervisory reviews and/or supervisory 
approval to open cases had occurred.  As part of a process to ensure 
documentation of periodic supervisory reviews, the MFCU could develop 
and use a systemelectronic or otherwisethat reminds supervisors 
to both perform and document the reviews. 
   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  12 
    
MFCU COMMENTS AND OIG RESPONSE  
The MFCU concurred with all four of our recommendations. 
Regarding our recommendation for it to develop and implement a plan to 
increase Medicaid fraud referrals from the Utah MIG and ACOs, the MFCU 
stated that it will continue to evaluate the results of its outreach activities 
and implement additional strategies to increase referrals, as necessary. The 
MFCU said that it will continue to work closely with its State and Federal 
partners and further develop its relationship with the Utah Department of 
Health.  The MFCU further noted that its numbers of fraud referrals and 
convictions had increased since the period of our review, and the MFCU 
stated that it anticipates these trends will continue.    
Regarding our recommendation for it to further develop an approach for 
litigating nonglobal civil cases or refer them to other appropriate agencies 
for litigation, the MFCU stated that it is attempting to identify the most 
effective plan to handle these cases.  The MFCU further explained that it is 
pursuing multiple joint civil cases with the U.S. Attorneys Office and that the 
Utah State Legislature recently approved funding for the MFCU to hire a 
civil attorney, should the MFCU determine that is the most effective way to 
pursue nonglobal civil cases. 
Regarding our recommendation for it to develop and implement written 
procedures for storing, maintaining, and efficiently accessing case 
information, the MFCU reported that it has created procedures, checklists, 
and standardized forms to improve its case documentation.  The MFCU 
further indicated that it will create a case documentation subcommittee to 
determine what additional policies, processes, and forms are necessary. 
Regarding our recommendation for it to establish a process to ensure that 
case files contain appropriate documentation, the MFCU reported that it has 
worked to analyze and improve the case-tracking and documenting 
processes and said that it will continue to refine processes, as needed.  
Finally, the MFCU stated that it has improved the documentation of its case 
reviews and has implemented a new case review process.    
The full text of the MFCUs comments is provided in Appendix D.    
 
 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  13 
    
APPENDIX A: MFCU Performance Standards  
37
1)  A Unit conforms with all applicable statutes, regulations, 
and policy directives, including: 
A)  Section 1903(q) of the Social Security Act, containing the basic 
requirements for operation of a MFCU; 
B)  Regulations for operation of a MFCU contained in 42 CFR part 1007; 
C)  Grant administration requirements at 45 CFR part 92 and Federal 
cost principles at 2 CFR part 225; 
D)  OIG policy transmittals as maintained on the OIG website; and 
E)  Terms and conditions of the notice of the grant award. 
2)  A Unit maintains reasonable staff levels and office locations 
in relation to the States Medicaid program expenditures 
and in accordance with staffing allocations approved in its 
budget. 
A)  The Unit employs the number of staff that is included in the Units 
budget estimate as approved by OIG. 
B)  The Unit employs a total number of professional staff that is 
commensurate with the States total Medicaid program expenditures 
and that enables the Unit to effectively investigate and prosecute (or 
refer for prosecution) an appropriate volume of case referrals and 
workload for both Medicaid fraud and patient abuse and neglect. 
C)  The Unit employs an appropriate mix and number of attorneys, 
auditors, investigators, and other professional staff that is both 
commensurate with the States total Medicaid program expenditures 
and that allows the Unit to effectively investigate and prosecute (or 
refer for prosecution) an appropriate volume of case referrals and 
workload for both Medicaid fraud and patient abuse and neglect. 
D)  The Unit employs a number of support staff in relation to its overall 
size that allows the Unit to operate effectively. 
E)  To the extent that a Unit maintains multiple office locations, such 
locations are distributed throughout the State, and are adequately 
staffed, commensurate with the volume of case referrals and 
workload for each location. 
3)  A Unit establishes written policies and procedures for its 
operations and ensures that staff are familiar with, and 
adhere to, policies and procedures. 
A)  The Unit has written guidelines or manuals that contain current 
policies and procedures, consistent with these performance 
 
37 77 Fed. Reg. 32645 (June 1, 2012). 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  14 
    
standards, for the investigation and (for those Units with 
prosecutorial authority) prosecution of Medicaid fraud and patient 
abuse and neglect. 
B)  The Unit adheres to current policies and procedures in its 
operations. 
C)  Procedures include a process for referring cases, when appropriate, 
to Federal and State agencies.  Referrals to State agencies, including 
the State Medicaid agency, should identify whether further 
investigation or other administrative action is warranted, such as the 
collection of overpayments or suspension of payments. 
D)  Written guidelines and manuals are readily available to all Unit staff, 
either online or in hard copy. 
E)  Policies and procedures address training standards for Unit 
employees. 
4)  A Unit takes steps to maintain an adequate volume and 
quality of referrals from the State Medicaid agency and 
other sources. 
A)  The Unit takes steps, such as the development of operational 
protocols, to ensure that the State Medicaid agency, managed care 
organizations, and other agencies refer to the Unit all suspected 
provider fraud cases.  Consistent with 42 CFR 1007.9(g), the Unit 
provides timely written notice to the State Medicaid agency when 
referred cases are accepted or declined for investigation. 
B)  The Unit provides periodic feedback to the State Medicaid agency 
and other referral sources on the adequacy of both the volume and 
quality of its referrals. 
C)  The Unit provides timely information to the State Medicaid or other 
agency when the Medicaid or other agency requests information on 
the status of MFCU investigations, including when the Medicaid 
agency requests quarterly certification pursuant to 42 CFR 
455.23(d)(3)(ii). 
D)  For those States in which the Unit has original jurisdiction to 
investigate or prosecute patient abuse and neglect cases, the Unit 
takes steps, such as the development of operational protocols, to 
ensure that pertinent agencies refer such cases to the Unit, 
consistent with patient confidentiality and consent.  Pertinent 
agencies vary by State but may include licensing and certification 
agencies, the State Long Term Care Ombudsman, and adult 
protective services offices. 
E)  The Unit provides timely information, when requested, to those 
agencies identified in (D) above regarding the status of referrals. 
F)  The Unit takes steps, through public outreach or other means, to 
encourage the public to refer cases to the Unit. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  15 
    
5)  A Unit takes steps to maintain a continuous case flow and to 
complete cases in an appropriate timeframe based on the 
complexity of the cases. 
A)  Each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
B)  Supervisors approve the opening and closing of all investigations 
and review the progress of cases and take action as necessary to 
ensure that each stage of an investigation and prosecution is 
completed in an appropriate timeframe. 
C)  Delays to investigations and prosecutions are limited to situations 
imposed by resource constraints or other exigencies. 
6)  A Units case mix, as practicable, covers all significant 
providers types and includes a balance of fraud and, where 
appropriate, patient abuse and neglect cases. 
A)  The Unit seeks to have a mix of cases from all significant provider 
types in the State. 
B)  For those States that rely substantially on managed care entities for 
the provision of Medicaid services, the Unit includes a 
commensurate number of managed care cases in its mix of cases. 
C)  The Unit seeks to allocate resources among provider types based on 
levels of Medicaid expenditures or other risk factors.  Special Unit 
initiatives may focus on specific provider types. 
D)  As part of its case mix, the Unit maintains a balance of fraud and 
patient abuse and neglect cases for those States in which the Unit 
has original jurisdiction to investigate or prosecute patient abuse 
and neglect cases. 
E)  As part of its case mix, the Unit seeks to maintain, consistent with its 
legal authorities, a balance of criminal and civil fraud cases. 
7)  A Unit maintains case files in an effective manner and 
develops a case management system that allows efficient 
access to case information and other performance data. 
A)  Reviews by supervisors are conducted periodically, consistent with 
MFCU policies and procedures, and are noted in the case file. 
B)  Case files include all relevant facts and information and justify the 
opening and closing of the cases. 
C)  Significant documents, such as charging documents and settlement 
agreements, are included in the file. 
D)  Interview summaries are written promptly, as defined by the Units 
policies and procedures. 
E)  The Unit has an information management system that manages and 
tracks case information from initiation to resolution. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  16 
    
F)  The Unit has an information management system that allows for the 
monitoring and reporting of case information, including the 
following: 
1)  The number of cases opened and closed and the reason 
that cases are closed. 
2)  The length of time taken to determine whether to open a 
case referred by the State Medicaid agency or other 
referring source. 
3)  The number, age, and types of cases in the Units 
inventory/docket. 
4)  The number of referrals received by the Unit and the 
number of referrals by the Unit to other agencies. 
5)  The dollar amount of overpayments identified. 
6)  The number of cases criminally prosecuted by the Unit or 
referred to others for prosecution, the number of 
individuals or entities charged, and the number of 
pending prosecutions. 
7)  The number of criminal convictions and the number of 
civil judgments. 
8)  The dollar amount of fines, penalties, and restitution 
ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil 
judgments or prefiling settlements. 
8)  A Unit cooperates with OIG and other Federal agencies in 
the investigation and prosecution of Medicaid and other 
health care fraud. 
A)  The Unit communicates on a regular basis with OIG and other 
Federal agencies investigating or prosecuting health care fraud in 
the State. 
B)  The Unit cooperates and, as appropriate, coordinates with OIGs 
Office of Investigations and other Federal agencies on cases being 
pursued jointly, case involving the same suspects or allegations, and 
cases that have been referred to the Unit by OIG or another Federal 
agency. 
C)  The Unit makes available, to the extent authorized by law and upon 
request by Federal investigators and prosecutors, all information in 
its possession concerning provider fraud or fraud in the 
administration of the Medicaid program. 
D)  For cases that require the granting of extended jurisdiction to 
investigate Medicare or other Federal health care fraud, the Unit 
seeks permission from OIG or other relevant agencies under 
procedures as set by those agencies. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  17 
    
E)  For cases that have civil fraud potential, the Unit investigates and 
prosecutes such cases under State authority or refers such cases to 
OIG or the U.S. Department of Justice. 
F)  The Unit transmits to OIG, for purposes of program exclusions under 
section 1128 of the Social Security Act, all pertinent information on 
MFCU convictions within 30 days of sentencing, including charging 
documents, plea agreements, and sentencing orders. 
G)  The Unit reports qualifying cases to the Healthcare Integrity & 
Protection Databank, the National Practitioner Data Bank, or 
successor data bases. 
9)  A Unit makes statutory or programmatic recommendations, 
when warranted, to the State government. 
A)  The Unit, when warranted and appropriate, makes statutory 
recommendations to the State legislature to improve the operation 
of the Unit, including amendments to the enforcement provisions of 
the State code. 
B)  The Unit, when warranted and appropriate, makes other regulatory 
or administrative recommendations regarding program integrity 
issues to the State Medicaid agency and to other agencies 
responsible for Medicaid operations or funding.  The Unit monitors 
actions taken by the State legislature and the State Medicaid or 
other agencies in response to recommendations. 
10) A Unit periodically reviews its Memorandum of 
Understanding (MOU) with the State Medicaid agency to 
ensure that it reflects current practice, policy, and legal 
requirements. 
A)  The MFCU documents that it has reviewed the MOU at least every 5 
years, and has renegotiated the MOU as necessary, to ensure that it 
reflects current practice, policy, and legal requirements. 
B)  The MOU meets current Federal legal requirements as contained in 
law or regulation, including 42 CFR 455.21, Cooperation with State 
Medicaid fraud control units, and 42 CFR 455.23, Suspension of 
payments in cases of fraud. 
C)  The MOU is consistent with current Federal and State policy, 
including any policies issued by OIG or the Centers for Medicare & 
Medicaid Services (CMS). 
D)  Consistent with Performance Standard 4, the MOU establishes a 
process to ensure the receipt of an adequate volume and quality of 
referrals to the Unit from the State Medicaid agency. 
E)  The MOU incorporates by reference the CMS Performance Standard 
for Referrals of Suspected Fraud From a State Agency to a Medicaid 
Fraud Control Unit. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  18 
    
11) A Unit exercise proper fiscal control over Unit resources. 
A)  The Unit promptly submits to OIG its preliminary budget estimates, 
proposed budget, and Federal financial expenditure reports. 
B)  The Unit maintains an equipment inventory that is updated regularly 
to reflect all property under the Units control. 
C)  The Unit maintains an effective time and attendance system and 
personnel activity records. 
D)  The Unit applies generally accepted accounting principles in its 
control of Unit funding. 
E)  The Unit employs a financial system in compliance with the 
standards for financial management systems contained in 45 CFR 
92.20. 
12) A Unit conducts training that aids in the mission of the 
Unit. 
A)  The Unit maintains a training plan for each professional discipline 
that includes an annual minimum number of training hours and that 
is at least as stringent as required for professional certification. 
B)  The Unit ensures that professional staff comply with their training 
plans and maintain records of their staffs compliance. 
C)  Professional certifications are maintained for all staff, including those 
that fulfill continuing education requirements. 
D)  The Unit participates in MFCU-related training, including training 
offered by OIG and other MFCUs, as such training is available and as 
funding permits. 
E)  The Unit participates in cross-training with the fraud detection staff 
of the State Medicaid agency.  As part of such training, Unit staff 
provide training on the elements of successful fraud referrals and 
receive training on the role and responsibilities of the State 
Medicaid agency.   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  19 
    
APPENDIX B: Utah MFCU Referrals Received, by 
Source, Fiscal Years 20152017 
 
FY 2015  FY 2016  FY 2017  3-Year Total 
Patient  Patient  Patient  Patient 
Abuse/  Abuse/  Abuse/  Abuse/ 
Source  Fraud  Neglect  Fraud  Neglect  Fraud  Neglect  Fraud  Neglect  Total 
Adult Protective 
0  6  0  17  1  14  1  37  38 
Services 
Medicaid 
3  2  4  2  0  4  7  8  15 
Agency 
HHS OIG  2  0  6  1  3  0  11  1  12 
Utah MIG  1  0  3  0  2  0  6  0  6 
Licensing Board  1  0  0  1  1  1  2  2  4 
Other Law 
0  0  0  1  0  0  0  1  1 
Enforcement 
Providers  1  0  0  0  0  0  1  0  1 
Prosecutors  0  0  1  0  0  0  1  0  1 
Private Health 
1  0  0  0  0  0  1  0  1 
Insurers 
ACOs  0  0  0  0  1  0  1  0  1 
Other  37  0  22  0  12  1  71*  1  72 
     Total  46  8  36  22  20  20  102  50  152 
* Allegations related to global cases accounted for 66 of the 71 other fraud referrals that the MFCU reported in FYs 20152017.   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  20 
    
APPENDIX C: Detailed Methodology 
The onsite review team consisted of OIG evaluators and agents, as well as 
a director from another State MFCU.  The primary purpose of the review 
was to follow up on issues that OIG had identified through its ongoing 
oversight activities.  We focused the review on four general areas: (1) case 
outcomes; (2) referrals; (3) MFCU operations; and (4) fiscal controls. 
We analyzed qualitative and quantitative data from a variety of sources.  
These included:  
  case outcome data;  
  referral data associated with the MFCU;  
  other documentation that the MFCU had submitted; 
  structured interviews with MFCU staff and key stakeholders; 
  onsite review of case files; 
  onsite observations; and 
  documentation related to the MFCUs fiscal controls.  
Data Collection    Case outcomes  
Prior to the onsite visit, we examined statistical reports and other 
and Analysis  
documentation that the MFCU had submitted to OIG.  This included MFCU 
case outcome data pertaining to FYs 20152017 and the previous 3-year 
period (FYs 20122014).  We examined five case outcome measures: (1) the 
number of fraud convictions; (2) the number of convictions of 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.   
For each measure, we performed two types of comparative analysis.  We 
compared outcomes for the Utah MFCU during each period of 3 fiscal years 
to determine whether outcomes changed during FYs 20152017.  We also 
compared Utahs outcomes for FYs 20152017 to those of other similarly 
sized MFCUs.38  The nine similarly sized MFCUs have staffs ranging in size 
from 11 to 15 employees; the Utah MFCU has an approved staffing level of 
13 employees.39 
Referrals of fraud and patient abuse or neglect 
We examined data associated with referrals sent to and that the MFCU 
received from a variety of sources.  This included the number of referrals 
 
38 Although comparison across similarly sized MFCUs provides context for the case outcomes 
of a particular MFCU, many factors other than a MFCUs staff size can affect case outcomes. 
39 The figures of 1115 employees come from the numbers of employees that MFCUs 
reporting having at the end of FY 2017.  
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  21 
    
that the MFCU reported receiving during FYs 20152017; the number of 
referrals from the previous period of 3 fiscal years; and the number of 
referrals received by similarly sized MFCUs during FYs 20152017.  These 
referral-related data included referrals relating to both general types of 
cases that the MFCU handles: those regarding fraud and those regarding 
patient abuse or neglect.  We also examined the processes that the MFCU 
used for monitoring the opening of cases, and we examined the outcomes 
of cases.  We also reviewed the MFCUs memorandum of understanding 
with the Utah MIG and State Medicaid agency.   
Other documentation 
We examined the MFCUs policies and procedures and held discussions with 
MFCU management to gain an understanding of those policies and 
procedures.  We confirmed with the MFCU director that the information we 
had was current, and we requested any additional data and clarification that 
we needed.  We also examined data associated with the MFCUs staff, both 
to identify the number of MFCU staff and to determine how long each staff 
member had been at the MFCU during the period of FYs 20152017. 
Interviews with MFCU staff and director 
We conducted interviews with nine MFCU staff, including the MFCU 
director.40  These interviews focused on case outcomesspecifically, why 
they were low during FYs 20152017 and how to improve them.  The 
interviews were informed by our analysis of the MFCUs case-outcomes 
data, other documentation, and stakeholder interviews.  We asked MFCU 
staff to provide us with any additional context that could help us understand 
the MFCUs operations.  Subsequent to the onsite review, we followed up 
with the MFCU director to clarify certain data we collected onsite and 
to gain further information. 
Key stakeholder interviews 
In March and April 2018, we interviewed individual stakeholders from 
12 entities who were familiar with the MFCUs operations.  Staff conducting 
the structured interviews included OIG evaluators and OIG agents, and 
a director from another State MFCU.  Stakeholders whom we interviewed 
included the following: program integrity staff from the States four ACOs; 
a manager from the Department of Aging and Adult Services (Adult 
Protective Services); an Assistant U.S. Attorney; a manager from the Bureau 
of Internal Review and Audit; the Deputy Director and another manager 
from the State Medicaid agency; the Utah Medicaid Inspector General; two 
managers from the Medicaid agencys Survey and Certification bureau; 
 
40 We did not interview the office administrator, one auditor, and two investigators. 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  22 
    
a Deputy Attorney General;41 and another OIG agent who worked closely 
with the MFCU.   
We focused these interviews on (1) the MFCUs relationship and interactions 
with these entities; (2) any areas in which stakeholders believed the MFCU 
had opportunities for improvement; and (3) practices that may be beneficial 
to the MFCUs operations or to other MFCUs.  As needed, we followed up 
with some of the interviewees after the onsite review. 
Case file reviews 
We asked the MFCU to provide us with a list of cases that were open at any 
point during FYs 20152017.  The MFCU provided us with a list of 274 cases 
that met these parameters.  The MFCU categorized 122 of these cases as 
global cases, which we excluded from consideration for our onsite review 
of case files.  We formed two strata from the remaining 152 cases on the list.  
Stratum 1 consisted of 91 fraud cases, and stratum 2 consisted of 61 cases of 
patient abuse or neglect.42    
We selected our sample of 105 cases by including all 91 fraud cases from 
stratum 1 and selecting a simple random sample of 14 of the 61 cases of 
patient abuse or neglect from stratum 2.  We allocated our sample this way 
because of our concerns about the MFCUs low fraud outcomes for 
FYs 20152017.  
With the assistance of OIG agents and the director from another State 
MFCU, we reviewed referrals that the MFCU received and the MFCUs 
processes for monitoring the opening, status, and outcomes of cases.43  We 
also reviewed the MFCUs approach to investigating and prosecuting cases 
that were open at some point during FYs 20152017. 
Onsite observations 
While onsite, we examined the MFCUs workspace and operations 
to identify any instances of nonadherence to performance standards and/or 
instances of noncompliance with applicable Federal laws, regulations, and 
OIG policy transmittals.  Among other things, we evaluated the security of 
the MFCUs case files and the functionality of the MFCUs electronic system 
for tracking case files.   
   
 
41 The Deputy Attorney General supervises the MFCU director. 
42 While onsite, we determined that three additional cases marked by the MFCU as 
nonglobal fraud were in fact global cases.  We removed these three cases from our sample 
of case files for onsite review. 
43 To verifyin the absence of documentationwhether the periodic reviews for these files 
had ever been conducted, we followed up with the MFCU staff.   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  23 
    
Review of MFCU financial documentation 
We conducted a limited review of the MFCUs control over its fiscal 
resources.  Prior to the onsite review, we analyzed the MFCUs response to 
an internal-controls questionnaire and conducted a desk review of the 
MFCUs financial status reports.  While onsite, we followed up with MFCU 
officials to clarify issues identified in the internal-controls questionnaire.  We 
also selected a purposive sample of 30 items from the current inventory list 
of 369 items maintained in the MFCUs office and verified those items 
onsite.  This limited review did not produce any findings related to the 
MFCUs control over its fiscal resources. 
   
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  24 
    
APPENDIX D: MFCU Comments 
 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  25 
    
 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  26 
    
 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  27 
    
 
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  28 
    
ACKNOWLEDGMENTS 
Matthew DeFraga served as the team leader for this study.  Others in the 
Office of Evaluation and Inspections who conducted the study include 
Michael Henry and Christina Lester.  Medicaid Fraud Policy and Oversight 
Division staff who participated in the review include Susan Burbach.  Office 
of Evaluation and Inspections staff who provided support include 
Kevin Farber and Christine Moritz.  
Office of Investigations staff and a peer reviewer from another State MFCU 
also participated in this review. 
This report was prepared under the direction of Blaine Collins, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Abigail Amoroso and Michael Henry, Deputy Regional 
Inspectors General; and in consultation with Richard Stern, Director of the 
Medicaid Fraud Policy and Oversight Division.     
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
Utah Medicaid Fraud Control Unit: 2018 Onsite Review (OEI-09-18-00170)  29 
    
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: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
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.