St 
 
 
 
 
U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
 
Nevada Medicaid 
Fraud Control 
Unit: 2018 Onsite 
Inspection 
 
OEI-06-18-00190  Suzanne Murrin 
June 2019  Deputy Inspector General 
for Evaluation and Inspections 
 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
June 2019 
Office  of Inspector General 
OEI-06-18-00190 
 
Nevada Medicaid Fraud Control Unit: 2018 Onsite Inspection 
What OIG Found  
We found that during fiscal years (FYs) 20152017, the Nevada Medicaid Fraud  Unit Case Outcomes 
Control Unit (MFCU or Unit) generally operated in accordance with applicable  FYs 20152017 
laws, regulations, policy transmittals, and the MFCU performance standards.  
  43 indictments 
However, from the data we reviewed, we identified three areas in which the Unit 
  42 convictions  
should improve its adherence to performance standards: 
  27 civil settlements and 
1.  The Unit did not maintain approved staffing levels because of air  judgments 
contamination in the workspace, and it declined to fill vacant positions    $11.7 million in recoveries 
until this issue was resolved. 
Unit Snapshot   
2.  The Unit investigated few cases of patient abuse or neglect.  The Unit is part of the Office of 
the Nevada Attorney General. 
3.  The Unit did not maintain an annual training plan.  
The Unit has a total of 
What OIG Recommends  16 employees, with 12 employees 
To address the three findings, we recommend that the Unit:  in its Las Vegas office and 
4 employees in its Carson City 
1.  Fill vacant positions now that the Unit is in a temporary workspace and 
office.  
continue to ensure that the Unit has a safe and adequate work 
environment.  
Why OIG Did This Inspection 
The Office of Inspector General 
2.  Continue to take steps to increase the number of investigations of patient 
(OIG) administers the MFCU grant 
abuse and neglect.  
awards, annually recertifies each 
3.  Establish an annual training plan covering all professional disciplines  Unit, and oversees the Units 
within the Unit.    performance in accordance with 
the requirements of the grant.  As 
  part of this oversight, OIG 
conducts periodic onsite reviews 
of Units and prepares public 
reports. 
Full report can be found at oig.hhs.gov/oei/reports/oei-06-18-00190.asp  TABLE OF CONTENTS 
BACKGROUND  1 
PERFORMANCE ASSESSMENT  6 
Case Outcomes  6 
For FYs 20152017, the Unit reported 43 indictments; 42 convictions; and 27 civil 
settlements and judgments 
Performance Standard 1: Compliance with requirements  7 
From the data we reviewed, the Nevada Unit generally complied with applicable laws, 
regulations, and policy transmittals 
Performance Standard 2: Staffing   7 
The Unit did not maintain approved staffing levels because of air contamination in the 
workspace, and it declined to fill vacant positions until this issue was resolved 
Performance Standard 3: Policies and procedures  8 
The Unit maintained written policies and procedures 
Performance Standard 4: Maintaining adequate referrals  9 
The Unit conducted outreach to encourage referrals    
Performance Standard 5: Maintaining a continuous case flow  9 
Unit case files generally contained supervisory approval of case openings and closings 
Performance Standard 6: Case mix  10 
The Units caseload included a broad mix of provider types 
The Unit investigated few cases of patient abuse or neglect 
Performance Standard 7: Maintaining case information  11 
The Unit maintained case files in an effective manner 
Performance Standard 8: Cooperation with Federal authorities on fraud cases  11 
The Unit maintains a positive working relationship with Federal agencies, including OIG   
and the U.S. Attorneys Office  
 
The Unit reported convictions and adverse actions to Federal partners within the 
 
appropriate timeframes 
Performance Standard 9: Program recommendations   12 
The Unit made recommendations regarding program deficiencies to the State Medicaid 
agency 
 
   
Performance Standard 10: Agreement with State Medicaid agency    12 
The Units MOU with the State Medicaid agency generally reflected current practice,   
policy, and legal requirements 
Performance Standard 11: Fiscal control  12 
The Unit maintained proper fiscal control of its resources during our review period  
Performance Standard 12: Training  12 
The Unit did not maintain an annual training plan  
CONCLUSION AND RECOMMENDATIONS  14 
Fill vacant positions now that the Unit is in a temporary workspace and continue to ensure  14 
that the Unit has a safe and adequate work environment  
Continue to take steps to increase the number of investigations of patient abuse and neglect   14 
Establish an annual training plan covering all professional disciplines within the Unit  14 
UNIT COMMENTS AND OIG RESPONSE     16 
APPENDICES   
A.  MFCU Performance Standards  17 
B.  Unit Referrals by Source for FYs 20152017  22 
C.  Detailed Methodology  23 
D.  Point Estimates and 95-Percent Confidence Intervals of Case File Reviews  26 
E.  Unit Comments  27 
ACKNOWLEDGMENTS  30 
 
   
BACKGROUND 
Objective 
To examine the performance and operations of the Nevada State 
Medicaid Fraud Control Unit (MFCU or Unit) 
Medicaid Fraud  The function of MFCUs is to investigate Medicaid provider fraud and patient 
abuse or neglect in facility settings, and to prosecute those cases under 
Control Units 
State law or refer them to other prosecuting offices.1  Under the Social 
Security Act (SSA), a MFCU is a single, identifiable entity of State 
government and must be separate and distinct from the State Medicaid 
agency and employ one or more investigators, attorneys, and auditors.2  
Each State must operate a MFCU or receive a waiver.3  MFCUs operate in 
49 States, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands.4   
Each Unit receives a Federal grant award equivalent to 75 percent of total 
expenditures.5  In fiscal year (FY) 2018, combined Federal and State 
expenditures for the Units totaled approximately $294 million, with 
a Federal share of $220.5 million.6 
OIG Grant  The Office of Inspector General (OIG) administers the grant award to each 
Unit and provides oversight of Units.7  As part of its oversight, OIG reviews 
Administration 
and recertifies each Unit annually.  The recertification review consists of 
and Oversight of 
examining the following, which are collectively referred to as recertification 
the MFCUs  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 following: its adherence to published performance 
 
1 SSA  1903(q)(3).  Regulations at 42 CFR  1007.11(b)(1) add that the Units 
responsibilities may include reviewing complaints of misappropriation of patients 
private funds in residential health care facilities. 
2 SSA  1903(q). 
3 SSA  1902(a)(61). 
4 The State of North Dakota and the territories of American Samoa, Guam, and the 
Northern Mariana Islands have not established Units. 
5 SSA  1903(a)(6).  For a Units first three years of operation, the Federal 
government contributes 90 percent of funding and the State contributes 10 percent 
of Unit funding. 
6 OIG analysis of FY 2018 MFCU annual statistical reporting data. 
7 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. 
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standards;8 its compliance with applicable laws, regulations, and OIG policy 
transmittals;9 and its case outcomes.  See Appendix A for MFCU 
performance standards, including performance indicators for each standard.  
OIG further assesses a Units performance by periodically conducting onsite 
reviews of each Unit that may identify findings and make recommendations 
for improvement.  During the onsite review, OIG may also make 
observations of Unit operations and practices, including identifying 
beneficial practices.  In addition, OIG provides training and technical 
assistance to Units, as appropriate, both during onsite reviews and on 
an ongoing basis. 
Nevada MFCU  The Nevada MFCU is part of the Bureau of Criminal Justice within the 
Nevada Attorney Generals Office.  The Nevada MFCU has one office in 
Las Vegas and another in Carson City, the State capital.  The MFCU has the 
authority to investigate and prosecute Medicaid fraud and patient abuse 
and neglect.  In May 2018, the Unit had 16 employees: 3 attorneys (including 
the Director and the Deputy Director), 8 investigators (including 
3 supervisors), 2 auditors, and 3 support staff.  The Unit Director and 
11 employees were located in the Las Vegas office.  Four additional 
employees were located in Carson City.  During our review period of 
FYs 20152017, the Unit spent approximately $6.1 million (with a State share 
of approximately $1.5 million). 
Referrals.  The Unit receives fraud referrals from private citizens, providers, 
and other sources.  As of October 2018, the State Medicaid program 
requires managed care organizations (MCOs) to make referrals of suspected 
fraud directly to the Unit and send copies of the referrals to the State 
Medicaid program integrity unit, referred to as the Surveillance and 
Utilization Review unit.  The Unit receives most of its referrals of patient 
abuse and neglect from other State agenciessuch as the Bureau of Health 
Care Quality and Compliance and the Nevada Aging and Disability Services 
Divisionand from private citizens.10, 11     
 
8 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  
The performance standards were developed by OIG, in conjunction with the 
MFCUs, and were originally published at 59 Fed. Reg. 49080 (Sept. 26, 1994). 
9 OIG occasionally issues policy transmittals to provide guidance and instruction to 
MFCUs.  Policy transmittals may be found at https://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/index.asp. 
10 The Division of Public and Behavioral Health, Health Facilities.  This webpage 
describes the Bureau of Health Care Quality and Compliance, which licenses 
medical and other health facilities in Nevada.  Accessed at 
http://dpbh.nv.gov/Reg/HealthFacilities/HealthFacilities_-_Home/ on April 23, 2019.  
11 The Nevada Aging and Disability Services Division, Elder Protective Services.  This 
webpage describes elder protective services, which are for persons over 60 years 
old who may experience abandonment, abuse, neglect, or exploitation.  Accessed at 
http://adsd.nv.gov/Programs/Seniors/EPS/EPS_Prog/ on March 28, 2019.  
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When the Unit receives a referral, Unit staff enter the referral into the Units 
electronic case file system.  On a biweekly basis, a referral team, consisting 
of the Unit Director, the Senior Deputy Attorney General, and the Deputy 
Chief Investigator, reviews the referrals and determines whether to open an 
investigation or refer them to another agency.  See Appendix B for numbers 
of Unit referrals by source for FYs 20152017.   
Investigations.  Once the Unit decides to accept a referral, it conducts 
a preliminary investigation, during which the Unit Director or another 
member of the referral team determines whether to accept the case as 
a field project or a full investigation.  Field projects are designed to serve 
one of two purposes: (1) to obtain additional information about a referral, 
such as supporting documentation or responses from individuals involved in 
the case; or (2) to educate providers regarding relatively minor allegations 
of Medicaid fraud, abuse, or neglect and deter them from any future 
questionable actions.  If the Unit determines that an allegation involves 
a monetary overpayment and not fraud, the Unit will refer the matter to the 
State Medicaid agency for collection.  
If the Unit opens a full investigation, the MFCU Director or another member 
of the referral team assigns an investigative team to the case.  
An investigative team consists of an investigator, an attorney, and (if 
necessary) an analyst.  The investigative team develops an investigative plan 
within 5 days of the case opening and assigns key tasks to the team 
members.  The Unit uses a combination of shared network drives and its 
electronic case file system to manage and store all case recordsincluding 
opening documentation, interviews, summaries, case file reviews, and 
closing requests. 
Prosecutions.  The Nevada MFCU has Statewide authority to criminally 
prosecute Medicaid fraud and patient abuse or neglect.  If a case is not 
within the Units prosecutorial authority, the MFCU typically refers it to 
another division of the State Attorney Generals Office, OIG, or the 
appropriate U.S. Attorneys Office (Northern or Southern Districts of 
Nevada).  The Unit also works with the U.S. Attorneys Offices on criminal 
and civil fraud cases.   
The Nevada Department of Health and Human Services Division of Health 
Nevada Medicaid 
Care Financing and Policy (DHCFP) administers the State Medicaid program.  
Program  
In FY 2017, the Nevada Medicaid program enrolled an average of  
203,334 beneficiaries per month in fee-for-service Medicaid, and an average 
of 466,404 beneficiaries per month in managed care organizations 
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(MCOs).12  In FY 2018, total program expenditures were approximately 
$4.1 billion.13 
OIG conducted a previous onsite review of the Nevada Unit in 2012.  In that 
Prior OIG Report 
review, OIG found that (1) Unit professional staff (including attorneys, 
investigators, auditors, and managers) occasionally performed non-Unit 
duties and that the associated costs were not subtracted from claimed Unit 
expenditures; (2) the Units policies and procedures manual had not been 
updated to reflect Unit operations, and the Units memorandum of 
understanding (MOU) with DHCFP did not reflect current law and practice; 
(3) the Unit did not always comply with the MOU provisions; and 
(4) although the Unit maintained proper fiscal control of its resources, 
it incorrectly claimed indirect costs. 
OIG recommended that the Unit (1) ensure that its professional staff 
perform duties exclusively related to Unit operations; (2) revise its policies 
and procedures manual to reflect current Unit operations; (3) revise its MOU 
with DHCFP to reflect current law and practice; (4) ensure that DHCFP 
consistently receives Unit case information in a timely manner; and  
(5) ensure that indirect costs are claimed correctly. 
In response to the recommendations, the Unit (1) ceased duties unrelated 
to MFCU operations and refunded OIG for unallowable personnel costs;  
(2) initiated periodic reviews of its policies and procedures manual to ensure 
that it reflected current Unit operations; (3) worked with DHCFP to revise the 
MOU; (4) incorporated measures to ensure that DHCFP received Unit case 
information in a timely manner; and (5) worked with OIG to ensure that 
indirect costs were claimed accurately.  On the basis of the information 
received from the Unit, OIG considered these recommendations to be 
implemented. 
Methodology  We conducted our onsite review in May 2018.  Our review covered the       
3-year period of FYs 20152017.  We analyzed data from eight sources:  
(1) Unit documentation; (2) financial documentation; (3) structured 
interviews with key stakeholders; (4) structured interviews with the Units 
managers and selected staff; (5) a survey of Unit staff; (6) a review of 
a random sample of 76 case files for cases that were open at some point 
during the review period; (7) a review of all convictions submitted to OIG for 
program exclusion and all adverse actions submitted to the National 
Practitioner Data Bank (NPDB) during the review period; and 
(8) observations of Unit operations.  See Appendix C for a detailed 
methodology.  In examining the Units operations and performance, we 
 
12 Medicaid MCO enrollment data provided to OIG by DHCFP. 
13 OIG, MFCU Statistical Data for Fiscal Year 2018.  Accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2018-statistical-chart.pdf on March 28, 2018. 
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applied the published performance standards listed in Appendix A, but did 
not consider every performance indicator for every standard. 
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 peer review.   
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PERFORMANCE ASSESSMENT 
We reviewed the Nevada Units compliance with applicable laws, 
regulations, and policy transmittals, as well as its adherence to each of the 
MFCU performance standards.  For this review, we made observations about 
the Units case outcomes, identified opportunities for improvement, and 
made observations regarding the Units adherence to each of the 
performance standards.   
CASE OUTCOMES   
 
Observation  For FYs 20152017, the Unit reported 43 indictments; 42 convictions; 
and 27 civil settlements and judgments.  Of the 42 convictions, 
41 involved provider fraud and 1 involved patient abuse and neglect.    
 
 
Additionally, the Unit reported total recoveries of $11.7 million for  
FYs 20152017.  See Exhibit 1 for the source of the recoveries.  
 
 
Exhibit 1: The Unit reported combined civil and criminal recoveries 
of $11.7 million (FYs 20152017) 
 
Source: OIG analysis of Unit statistical data from FYs 20152017. 
Note: 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. 
   
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STANDARD 1  A Unit conforms with all applicable statutes, regulations, and policy 
  directives. 
Observation  From the data we reviewed, the Nevada Unit generally complied with 
applicable laws, regulations, and policy transmittals.  We did not identify 
any legal or compliance concerns related to Unit operations.   
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 did not maintain approved staffing levels because of air 
Finding 
contamination in the workspace, and it declined to fill vacant positions 
until this issue was resolved.  According to Performance Standard 2(e), 
Unit offices should be adequately staffed commensurate with the volume of 
case referrals and workload for each office.  The OIG-approved staffing level 
for the Unit is 19 employees, but the Unit declined to fill 2 vacant positions 
in its Las Vegas office, which at the time of our review was located in the 
Timeline of Air Quality 
Grant Sawyer State building.14  According to Unit management, staff, and 
Testing in the Grant 
the documentation we reviewed, air contamination in this building 
Sawyer State Building 
significantly disrupted Unit operations and had caused health issues for Unit 
January 2016  
staff for more than 3 years.  Because of the impact of this health hazard on 
 The Nevada Public  Unit staff and operations, Unit management decided not to fill the vacant 
Works Division (PWD)  positions in the Units Las Vegas office while it was ongoing.  The air-
conducts internal  contamination issue appeared to have been resolved after the conclusion of 
environmental test,  our onsite review. 
identifying leaks in air 
In 2015, Unit staff reported that they began experiencing symptoms of air 
conditioning system.   
contaminants (e.g., fatigue, headaches, and skin irritation) when working 
September 2017   inside the Grant Sawyer State building.  For one employee, the adverse 
 PWD hires consultants  reactions led to short-term hospitalization.  Over the next 3 years, the 
Public Works Division (PWD)the Nevada agency responsible for State 
to conduct air quality 
buildings and facilitiesconducted three separate air quality tests with 
test, identifying yellow 
varied results, finding yellow dust with isocyanate particles as well as finding 
dust containing 
mold.  Exposure to isocyanate particles can cause asthma, skin irritation, 
isocyanate particles. 
and eye irritation. 
December 2017  
At the time of our review, 6 of the 12 Las Vegas MFCU employees had been 
 PWD hires an external 
teleworking full-time for the preceding 9 months because of the unhealthy 
expert to conduct 
working conditions in the building.  Although half of the employees were 
another air quality test, 
teleworking, the Unit maintained its office space in the Grant Sawyer State 
identifying mold in the 
building to store documents (e.g., evidence for case files); to connect 
air and on surfaces. 
remotely to the Units computer systems and network; and to use shared 
 
 
 
14 The Unit had another vacant position in its Carson City office.   
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office equipment, such as copiers.  Because the Unit was not set up or 
prepared for teleworklacking both telework policies and experience
it initially found the telework arrangement to be challenging.  In particular, 
Unit management and staff noted that they did not have a common 
workspace to discuss investigations, exchange information, and conduct 
supervisory reviews of cases.  They also stated that the lack of a common 
workspace affected team cohesiveness.  However, staff reported 
maintaining a strong morale despite these challenges. 
In September 2018, the Attorney Generals Office granted the MFCUs 
request to relocate to a temporary office in another State building, and the 
lease for this temporary office was set to expire in May 2019.  In December 
2018, the Unit Deputy Director informed OIG that the Attorney Generals 
Office was searching for a permanent space for the Unit.  The Unit Deputy 
Director also reported that since moving out of the Grant Sawyer State 
building, the Unit had hired a new attorney and started the hiring process 
for two investigators.15  These three hires (once the latter two were 
completed) would bring the Unit to its approved staffing levels. 
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 its own policies and procedures manual, which it updated in 
January 2018.  This manual included general guidelines on the Unit roles 
and responsibilities of Unit staff as well as specific procedures related to 
processing referrals; opening and closing cases; outreach and collaboration 
with Federal and State partners; and case management. 
The Unit also reported using policy manuals of the Nevada Attorney 
Generals Office, such as an investigations policy manual for general law 
enforcement matters and supplemental policy manuals for attorneys and 
support staff.  (The latter manuals provide guidance for MFCU staff on 
performing certain tasks and assignments.)  Additionally, the Unit reported 
that for its internal fiscal controls and accounting matters, it used the Office 
of the State Controllers manual on accounting policies and procedures. 
 
 
 
15 After our onsite review, the Unit Director and a support staffer retired.  The Unit 
prioritized filling these two positions before hiring new staff for the two existing 
vacant investigative positions.    
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STANDARD 4  A Unit takes steps to maintain an adequate volume and quality of 
  referrals from the State Medicaid agency and other sources. 
Observation  The Unit conducted outreach to encourage referrals.  The Unit took steps 
to increase the volume and quality of referrals through a number of 
outreach efforts.  The Unit reported that it had regular meetings 
and contact with agencies, prosecutors, and law enforcement across the 
State to encourage referrals.  For example, the Unit reported 
communicating with the Surveillance and Utilization Review unit (the State 
Medicaid program integrity unit); the Nevada Aging and Disability Services 
Division; and MCOs, among others, to encourage referrals. 
During FYs 20152017, the Unit received a total of 926 referrals
290 referrals in FY 2015, 289 referrals in FY 2016, and 347 referrals in 
FY 2017.  Of these referrals, 86 percent were related to fraud, and the 
remaining 14 percent were related to patient abuse or neglect.  See 
Appendix B for numbers of Unit referrals by source for FYs 20152017.  
STANDARD 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. 
Observation 
Unit case files generally contained supervisory approval of case 
openings and closings.  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 an investigation and prosecution is completed in 
an appropriate timeframe.  Our review found that the case files generally 
contained supervisory approval of case openings and closings.   
An estimated 83 percent of cases were closed at the time of our review.  
Of these closed cases, we estimate that 3 percent lacked supervisory 
approval to close the case.  An estimated 66 percent of cases were open 
longer than 90 days and thus subject to periodic supervisory reviews.  All 
Unit case files that we reviewed for cases that were open longer than 
90 days received periodic supervisory reviews.  See Appendix D for 
confidence intervals for the point estimates derived from our review of 
case files. 
 
 
 
 
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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. 
Finding  The Units caseload included a broad mix of provider types.  At the end 
of FY 2017, the Units cases were distributed among more than 40 provider 
types, including hospitals, nursing homes, hospices, pharmacies, physicians, 
dentists, and mental health providers. 
Observation  The Unit investigated few cases of patient abuse or neglect.  According 
to Performance Standard 6, the Units case mix should include a balance of 
fraud and patient abuse or neglect cases, where appropriate.  During 
FYs 20152017, the Unit investigated a total of only 12 cases of patient abuse 
or neglect (4 cases in each year), representing approximately 1 percent of the 
919 cases that the Unit opened during the review period.  This was a decrease 
from the previous 3-year period (FYs 20122014), during which the Unit 
investigated a total of 39 cases of patient abuse or neglect, representing 
13 percent of the 294 cases it opened during that period.  Moreover, only 
2 percent of the Units criminal convictions during our review period1 of 
42 convictionsinvolved patient abuse or neglect, compared to 14 percent 
(6 of 42 convictions) during the previous 3-year period (FYs 20122014). 
Unit staff attributed the low number of investigations involving patient abuse 
or neglect to the challenges the Unit experienced in obtaining quality referrals 
from State partners.  For example, staff explained that many of the referrals 
that the Unit receivessuch as those involving exploitation of funds in 
a private settingwere not within the Units grant authority.  The Unit 
reported taking steps to increase its visibility and generate more referrals of 
patient abuse and neglect.  For example, the Unit reported that it had 
begun providing trainings to skilled nursing facilities, the Senior Medicare 
Patrol, and Elder Protective Services about when and how to refer 
allegations of patient abuse or neglect to the Unit.16  The Unit also provided 
trainings to the Bureau of Health Care Quality and Compliance and to the 
Division of Health Care Financing and Policy (which administers the State 
Medicaid program) to explain its role as a law enforcement agency that 
investigates and prosecutes cases of patient abuse and neglect. 
 
 
 
16 The Senior Medicare Patrol program is part of the Nevada Department of Health 
and Human Services, Aging and Disability Services Division, and assists Medicare 
beneficiaries, their families, and caregivers to prevent, detect, and report healthcare 
fraud, errors, and abuse through outreach, counseling, and education. 
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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. 
Observation  The Unit maintained case files in an effective manner.  According to 
Performance Standard 7(e), the Unit should have an information 
management system that manages and tracks case information from 
initiation to resolution.  The Unit used an electronic case file system to 
record and track information for both civil and criminal cases; however, 
it did not store all case information in this system.  For example, for civil 
cases, the Unit recorded opening and closing dates and monetary amounts 
from settlements in the electronic case file tracking system, but it 
maintained case documents on a separate secured shared folder on the 
Attorney Generals network.  Although we determined that the Unit 
maintained case information appropriately using both systems, we provided 
the Unit with technical assistance to further enhance its electronic case file 
system. 
STANDARD 8  A Unit cooperates with OIG and other Federal agencies in the 
investigation and prosecution of Medicaid and other health care fraud. 
 
Observation  The Unit maintains a positive working relationship with Federal 
agencies, including OIG and U.S. Attorneys Offices.  OIG agents have 
regular communication with Unit investigators and reported a positive 
working relationship with Unit staff.  The U.S. Attorneys Offices also 
reported regular communication with the Unitboth informally and as part 
of a Health Care Fraud Task Forceand described the relationship as 
effective.  Recent areas of collaboration included opioid and behavioral 
health cases. 
Observation 
The Unit reported convictions and adverse actions to Federal partners 
within the appropriate timeframes.  Standard 8(f) states that the Unit 
should transmit to OIG all pertinent information on convictions within  
30 days of sentencing, including charging documents, plea agreements, and 
sentencing orders, for purposes of exclusion from Federal health care 
programs.  The Unit transmitted all 42 convictions to OIG either within  
30 days of sentencing or within 1 day of receiving pertinent information 
from the court.  Late reporting of convictions to OIG delays the initiation of 
the program exclusion process, which may result in improper payments to 
providers by Medicaid or other Federal health care programs or possible 
harm to beneficiaries. 
Similarly, the Unit reported 38 adverse actions to NPDB within 30 days after 
the final action occurred.  Federal regulations require Units to report any 
adverse actions resulting from investigations or prosecution of healthcare 
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providers to the NPDB within 30 calendar days of the date of the final 
adverse action.17  Examples of final adverse actions include convictions, civil 
judgments (but not civil settlements), and program exclusions. 
STANDARD 9  A Unit makes statutory or programmatic recommendations, when 
  warranted, to the State government. 
Observation  The Unit made recommendations regarding program deficiencies to the 
State Medicaid agency.  The Unit informed the DHCFP of Medicaid 
program deficiencies that MFCU investigations had identified.  The Unit 
made recommendations and conducted followup through regular phone 
and email communication with the Surveillance and Utilization Review unit 
(DHCFPs program integrity unit).  For example, the Unit proposed 
amendments to the Medicaid Services Manual to stop improper billing 
practices for rehabilitative mental health providers and to close a loophole 
in policy where certain case management services were not covered under 
the Medicaid Services Manual.  The Unit also recommended revisions to 
billing edits for certain types of case management services that were 
consistently billed for the maximum allowable amount.   
STANDARD 10  A Unit periodically reviews its MOU with the State Medicaid agency to 
ensure that it reflects current practice, policy, and legal requirements. 
Observation 
Observation  The Units MOU with the State Medicaid agency reflected current 
practice, policy, and legal requirements.  The Unit and DHCFP had 
a current MOU, most recently amended in February 2017. 
 
STANDARD 11  A Unit exercises proper fiscal control over its resources. 
 
Observation  The Unit maintained proper fiscal control of its resources during our 
review period.  Our review of the Units financial documentation indicated 
that the Units requests for reimbursement for FYs 20152017 represented 
allowable, allocable, and reasonable costs.  Further, we identified no internal 
control issues related to the Units accounting, budgeting, personnel, 
property, or equipment. 
STANDARD 12  A Unit conducts training that aids in the mission of the Unit. 
Finding  The Unit did not maintain an annual training plan.  According to 
Performance Standard 12, the Unit should maintain a training plan covering 
all professional disciplines that includes an annual minimum number of 
training hours.  Although the Unit reported that all staff regularly attended 
 
17 45 CFR  60.5.  See also SSA  1128E(g)(1) and 45 CFR  60.3. 
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training paid for by the Unitsuch as the National Association of Medicaid 
Fraud Control Units annual trainingthe Unit did not require a minimum 
number of training hours for each professional discipline.  In August 2018, 
the Unit Director informed OIG that the Unit had begun working on 
an annual training plan for its employees.    
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CONCLUSION AND RECOMMENDATIONS 
For FYs 20152017, the Nevada Unit reported 43 indictments; 
42 convictions; 27 civil settlements and judgments; and combined criminal 
and civil recoveries of $11.7 million.   
From the data we reviewed, we found that the Unit generally adhered to 
applicable legal requirements and performance standards, but we identified 
three areas in which the Unit should improve its adherence to program 
requirements: (1) the Unit did not maintain OIG-approved staffing levels 
because of air contamination in the workspace; (2) the Unit investigated few 
cases of patient abuse or neglect; and (3) the Unit did not maintain 
an annual training plan for its professional staff.  We recommend that to 
address these findings, the Nevada Unit: 
Fill vacant positions now that the Unit is in a temporary 
workspace and continue to ensure that the Unit has a safe and 
adequate work environment  
Now that the Unit has relocated to a temporary workspace, it should 
continue to fill its vacant positions.  The Unit should also continue to work 
with the Nevada Attorney Generals Office to identify and maintain a 
permanent workspace free of air contaminants and other health hazards.  A 
safe working environment is a basic necessity that will help the Unit recruit 
and retain staff and ensure that it has appropriate staffing levels.  OIG will 
continue to monitor this situation to ensure that Unit staff can perform their 
activities in a safe and adequate workspace.  
Continue to take steps to increase the number of investigations 
of patient abuse and neglect  
The Unit should increase the number of investigations of patient abuse and 
neglect.  This could include (as appropriate) opening more investigations 
from referrals that the Unit receives through trainings and outreach efforts.  
The Unit conducts trainingsintended to help boost referralsfor 
the Bureau of Health Care Quality and Compliance and for the Division of 
Health Care Financing and Policy.  The Unit could also assess and 
(as needed) revise its referral process using information it obtains during 
these trainings.  Additionally, the Unit could coordinate with other 
stakeholders, such as the Long-Term Care Ombudsman, to increase the 
quality and number of referrals. 
Establish an annual training plan covering all professional 
disciplines within the Unit  
The Unit should establish formal training plans for each professional 
discipline that include the type and duration of training (e.g., number of 
hours) that employees are expected to complete each year.  The Unit could 
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work with the National Association of Medicaid Fraud Control Units or OIG 
to identify additional relevant training opportunities for staff.     
 
 
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UNIT COMMENTS AND OIG RESPONSE  
The Nevada Unit concurred with all three of our recommendations. 
The Unit concurred with our first recommendation (for it to fill vacant 
positions).  The Unit reported that it is in the process of obtaining 
a permanent workspace, and that it will fill the vacant positions once it 
moves into the new workspace.  The Unit expects to do this in the summer 
of 2019.    
The Unit concurred with our second recommendation (for it to continue to 
take steps to increase its number of investigations of patient abuse and 
neglect).  The Unit reported that it is using its outreach program
Project SNFto increase the number of patient abuse and neglect referrals 
it receives.  The Unit also reported using other means to increase referrals, 
including meeting with the State licensing agency and local law 
enforcement and providing trainings to the Bureau of Health Care Quality 
and Compliance.  The Unit stated that it will continue to work with local law 
enforcement, the local District Attorneys Office, and OIG to identify ways to 
increase referrals of patient abuse or neglect. 
The Unit concurred with our third recommendation (for it to establish 
an annual training plan covering all professional disciplines within the Unit).  
The Unit reported that it has obtained samples of training plans that 
another MFCU uses.  The Unit will update its current training plan to reflect 
the minimum number of training hours for each professional discipline in 
the Unit.  The Unit also reported that it will ensure that staff are provided 
with opportunities to attend trainings provided by the National Association 
of Medicaid Fraud Control Units.  
For the full text of the Units comments, see Appendix E. 
   
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APPENDIX A: MFCU Performance Standards18 
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;19 
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 Unite employs an appropriate mix and number of attorneys, auditors, 
investigators, and other professional staff that is both commensurate with 
the States total Medicaid program expenditures and that allows the Unit to 
effectively investigate and prosecute (or refer for prosecution) an 
appropriate volume of case referrals and workload for both Medicaid fraud 
and patient abuse and neglect. 
D)  The Unit employs a number of support staff in relation to its overall size 
that allows the Unit to operate effectively. 
E)  To the extent that a Unit maintains multiple office locations, such locations 
are distributed throughout the State, and are adequately staffed, 
commensurate with the volume of case referrals and workload for each 
location. 
3)  A Unit establishes written policies and procedures for its operations and 
ensures that staff are familiar with, and adhere to, policies and 
procedures. 
A)  The Unit has written guidelines or manuals that contain current policies and 
procedures, consistent with these performance standards, for the 
investigation and (for those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect. 
B)  The Unit adheres to current policies and procedures in its operations. 
C)  Procedures include a process for referring cases, when appropriate, to 
Federal and State agencies.  Referrals to State agencies, including the State 
Medicaid agency, should identify whether further investigation or other 
 
18 77 Fed. Reg. 32645, June 1, 2012. 
19 For FYs 2016 and later, grant administration requirements and cost principles are 
found at 45 CFR part 75. 
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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. 
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. 
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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. 
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, 
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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. 
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. 
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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. 
11)  A Unit exercises proper fiscal control over Unit resources. 
A)  The Unit promptly submits to OIG its preliminary budget estimates, 
proposed budget, and Federal financial expenditure reports. 
B)  The Unit maintains an equipment inventory that is updated regularly to 
reflect all property under the Units control. 
C)  The Unit maintains an effective time and attendance system and personnel 
activity records. 
D)  The Unit applies generally accepted accounting principles in its control of 
Unit funding. 
E)  The Unit employs a financial system in compliance with the standards for 
financial management systems contained in 45 CFR 92.20. 
12)  A Unit conducts training that aids in the mission of the Unit. 
A)  The Unit maintains a training plan for each professional discipline that 
includes an annual minimum number of training hours and that is at least 
as stringent as required for professional certification. 
B)  The Unit ensures that professional staff comply with their training plans and 
maintain records of their staffs compliance. 
C)  Professional certifications are maintained for all staff, including those that 
fulfill continuing education requirements. 
D)  The Unit participates in MFCU-related training, including training offered by 
OIG and other MFCUs, as such training is available and as funding permits. 
E)  The Unit participates in cross-training with the fraud detection staff of the 
State Medicaid agency.  As part of such training, Unit staff provide training 
on the elements of successful fraud referrals and receive training on the 
role and responsibilities of the State Medicaid agency. 
 
 
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APPENDIX B: Unit Referrals by Source for Fiscal 
Years (FYs) 20152017 
  FY 2015  FY 2016  FY 2017 
Abuse or  Abuse &  Abuse & 
Referral Source  Fraud  Fraud  Fraud 
Neglect  Neglect  Neglect 
Nevada Aging and Disability Services 
1  2  0  2  0  3 
Division 
Anonymous  5  0  3  0  4  0 
HHS-Office of Inspector General (OIG)  6  2  3  2  2  0 
Licensing Board  1  0  3  0  1  1 
Local Prosecutor  2  0  0  0  0  0 
Long-Term Care Ombudsman  0  1  1  0  0  0 
Managed Care Organizations  0  0  0  0  9  0 
Medicaid AgencyPI/SURS1  7  1  5  1  15  0 
Medicaid AgencyOther  1  0  2  0  1  1 
Other Law Enforcement  13  7  12  4  19  4 
Private Citizen  115  10  87  17  99  14 
Provider and Provider Association  29  1  43  4  45  1 
State AgencyOther  19  1  14  7  13  42 
State Survey and Certification  0  0  0  1  0  0 
Other  66  0  76  2  73  0 
     Total (By Type of Case)  265  25  249  40  281  66 
     Totals (For Each Fiscal Year)  290  289  347 
Source: OIG analysis of Unit Quarterly and Annual Statistical Reports, FYs 20152017. 
1 The abbreviation PI stands for program integrity; the abbreviation SURS stands for Surveillance and Utilization Review Subsystem. 
   
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APPENDIX C: Detailed Methodology 
Data Collection and Analysis 
We collected and analyzed data from the eight sources below to identify 
any opportunities for improvement and instances in which the Unit did not 
adhere to the performance standards or was not operating in accordance 
with laws, regulations, or policy transmittals.20  We also used the data 
sources to make observations about the Units case outcomes as well as the 
Units operations and practices concerning the performance standards. 
Review of Unit Documentation.  Prior to the onsite review, we analyzed the 
Units recertification data for FYs 20152017, including (1) the annual reports, 
(2) the Unit Directors recertification questionnaires, (3) the Units MOU with 
the State Medicaid agency, (4) the Program Integrity Directors 
questionnaires, and (5) the OIG Special Agent-in-Charge questionnaires.  
We also reviewed the Units self-reported annual statistical reports about 
case outcomes for FYs 20152017.  We reviewed the 2012 OIG onsite review 
recommendations and the Units implementation of those 
recommendations.  Finally, we reviewed the Units policies and procedures. 
Review of Unit Financial Documentation.  To evaluate internal control of 
fiscal resources, we reviewed policies and procedures related to the Units 
budgeting, accounting systems, cash management, procurement, property, 
and staffing.  We reviewed records in the Payment Management System 
(PMS)21 and revenue accounts to determine the accuracy of the Federal 
Financial Reports (FFRs) for FYs 20152017.  We also obtained the Units 
claimed grant expenditures from its FFRs and the supporting schedules.   
We selected three purposive samples to assess the Units internal control of 
fiscal resources.  The three samples included the following:  
1.  To assess the Units expenditures, we selected 31 transactions totaling 
$64,64222 within the direct cost categories across the 3-year review 
period.  We reviewed supporting documentation to determine whether 
 
20 All relevant regulations, statutes, and policy transmittals are available online at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp. 
21 The PMS is a grant payment system operated and maintained by the Department 
of Health and Human Services, Program Support Center, Division of Payment 
Management.  The PMS provides disbursement, grant monitoring, reporting, and 
case management services to awarding agencies and grant recipients, such as 
MFCUs. 
22 The transaction detail included multiple lines relating to accounting entries that 
comprised the reported expenditures.  We selected 31 transactions from Federal 
cost categories, which contained 7,000 transactions.   
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the costs claimed were allowable, allocable, and reasonable, in 
accordance with Federal regulations.   
2.  To assess inventory, we selected and verified 10 items from the current 
inventory list of 69 fixed assets.   
3.  To assess employee time and effort, we reconciled Unit payroll registers 
to payroll expenditures.  We then reviewed timecard records from 
five pay periods across the 3-year review period for eight Unit 
employees on staff.23   
Interviews with Key Stakeholders.  In March and April 2018, we interviewed 
key stakeholders, including officials in the Nevada Department of Health 
and Human Services Aging and Disability Services Division; the Division of 
Health Care Financing and Policy, the Surveillance and Utilization Review 
Unit; and the U.S. Attorneys Offices.  We also interviewed the supervisor 
from OIGs Office of Investigations Region IX who interacts regularly with 
the Unit.  We focused these interviews on the Units relationship and 
interaction with OIG and other Federal and State authorities, as well as 
opportunities for improvement.  We used the information collected from 
these interviews to develop subsequent interview questions for Unit 
management. 
Onsite Interviews with Unit Management.  We conducted structured onsite 
interviews with the Units management in May 2018.  We interviewed the 
Unit Director, Chief Attorneys, and the Deputy Chief Investigator.  We asked 
about Unit operations; Unit practices that contributed to the effectiveness 
and efficiency of Unit operations and/or performance; opportunities for the 
Unit to improve its operations and/or performance; and clarification 
regarding information obtained from other data sources.   
Survey of Unit Staff.  In April 2018, we conducted an online survey of 13 Unit 
staff members within the professional disciplines (i.e., investigators, auditors, 
and attorneys) and support staff.  Our questions focused on operations of 
the Unit; opportunities for improvement; and practices that contributed to 
the effectiveness and efficiency of Unit operations and/or performance.  The 
survey also sought information about the Units compliance with applicable 
laws and regulations.  
Onsite Review of Case Files.  We requested from the Unit a list of cases that 
were open at any time during FYs 20152017, and we asked the Unit to 
include the current status of the case; whether the case was criminal, civil, or 
global; and the date(s) on which the case was opened and (if applicable) 
closed.  The total number of cases was 832.  We then excluded a total of 
577 cases from our review.  We excluded 536 global cases because global 
cases are civil false claims actions that typically involve multiple agencies, 
such as the U.S. Department of Justice and a group of State MFCUs.  We 
 
23 We randomly selected eight Unit employees for review from the payroll registers. 
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also excluded 30 agency assist cases because the Unit does not lead these 
investigations; instead, the Unit provides assistance to another law 
enforcement agency in charge of the case.  Finally, we excluded 
an additional 11 referral cases because they were not under full 
investigation.  These cases were under preliminary investigation by the Unit.  
From the 255 remaining case files, we selected a simple random sample of 
76 cases.  With the assistance of OIG Special Agents, we reviewed the Units 
processes for monitoring the opening, status, and outcomes of these cases.  
We also reviewed the Units approach to investigating and prosecuting 
these cases and reviewed them for adherence to the relevant performance 
standards and compliance with statute, regulation, and policy transmittals.   
Review of Unit Submissions to OIG and NPDB.  We also reviewed all 
convictions submitted to OIG for program exclusion during the review 
period (45 convictions), and all adverse actions submitted to the National 
Practitioner Data Bank (NPDB) during the review period (38 adverse 
actions).  We reviewed whether the Unit submitted information on all 
sentenced individuals and entities to OIG for program exclusion and all 
adverse actions to the NPDB for FYs  20152017.  We also assessed the 
timeliness of the submissions to OIG and the NPDB.  
Onsite Review of Unit Operations.  During our onsite review, we observed 
the Units workspace and the operations of the Units Las Vegas office.  
Specifically, we observed the Units offices and meeting spaces; security of 
data and case files; location of select equipment; and the general 
functioning of the Unit. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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APPENDIX D: Point Estimates and 95-Percent 
Confidence Intervals of Case File Reviews 
 
95-Percent Confidence 
Point 
 Estimate Description  Sample Size   Interval 
Estimate 
Lower  Upper 
Percentage of All Cases Closed at the Time of 
76  82.9%  74.1%  89.8% 
Our Review 
Percentage of All Cases That Lacked Supervisory 
63  3.2%  0.9%  10.0% 
Approval To Close  
Percentage of All Cases Opened Longer Than 90 
76  65.8%  55.7%  74.9% 
Days 
Percentage of All Cases That Had Been Open 
Longer Than 90 Days and For Which the Case 
50  0.0%  0.0%  6.5% 
Files Lacked Documentation of a Periodic 
Supervisory Review 
Source: OIG analysis of Nevada MFCU case files, 2018. 
   
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APPENDIX E: UNIT COMMENTS 
 
 
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ACKNOWLEDGMENTS 
Anthony Soto McGrath served as the team leader for this study.  Others in 
the Office of Evaluation and Inspections who conducted the inspection 
include Cory Carr and Richard Stern, the Director of the Medicaid Fraud 
Policy and Oversight Division.  Office of Evaluation and Inspections staff 
who provided support include Kevin Farber and Christine Moritz.   
We would like to acknowledge the contributions of Ben Gaddis in the Office 
of Evaluation and Inspections; Jordan Clementi in the Medicaid Fraud Policy 
and Oversight Division; Lorrali Herrera, Shelton Jensen, Richard Temcho, 
and Iman Zbinden in the Office of Audit Services; and staff 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.  
 
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