U.S. Department of Health and Human Services 
Office of Inspector General 
 
Iowa Medicaid Fraud Control 
Unit: 2021 Inspection 
 
Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections 
June 2022, OEI-07-21-00340  U.S. Department of Health and Human Services 
 
Office of Inspector General 
Report in Brief 
June 2022, OEI-07-21-00340 
Unit Case Outcomes  Iowa Medicaid Fraud Control Unit: 2021 
Federal fiscal years (FYs) 2019
Inspection  
2021: 
  80 indictments 
What OIG Found 
  79 convictions 
  36 civil settlements and  The Iowa MFCU reported exceptionally strong case outcomes for  
FYs 20192021, as compared to similarly sized MFCUs.  From the data we 
judgments 
  $9.2 million in recoveries  reviewed, we found that the Unit generally operated in accordance with 
applicable laws, regulations, and policy transmittals and the MFCU 
Unit Snapshot  performance standards.  However, we made one finding regarding the 
Units adherence to MFCU performance standards. 
The Iowa Medicaid Fraud Control 
Unit (MFCU or Unit) is housed in 
  Although the Unit operated effectively and achieved high case 
the Iowa Department of 
outcomes, the Unit did not maintain staffing levels in accordance 
Inspections and Appeals.  The 
with its approved budget, maintained low staffing levels in 
Unit does not have prosecutorial 
relation to State Medicaid expenditures, and experienced 
authority and most commonly 
significant turnover of investigators and high caseloads. 
refers cases for prosecution to 
Iowas 99 county attorneys  In addition to the finding, we made observations regarding Unit 
offices.   operations and practices, including the following: 
At the time of our inspection in    The Unit took steps to maintain an adequate volume and quality 
November 2021, the Unit had      of referrals, but referrals from key sources generally decreased 
eight staff located in Des Moines.    during the review period. 
  The Unit took steps to maintain a continuous case flow and to 
complete cases within appropriate timeframes.   
  The Unit maintained a positive working relationship with Federal 
law enforcement partners, including the Office of Inspector 
General (OIG) and U.S. Attorneys Offices.   
What OIG Recommends and How the Unit Responded 
To address the finding, we recommend that the Unit assess the adequacy 
of existing staffing levels, and if warranted, develop a plan to expand the 
size of the Unit.  The Unit concurred with our recommendation. 
 
   
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 1 
Methodology ............................................................................................................................................................................. 5 
PERFORMANCE ASSESSMENT ................................................................................................................... 6 
Case Outcomes ......................................................................................................................................................................... 6 
Observation: The Unit reported 80 indictments, 79 convictions, and 36 civil settlements and 
judgments for FYs 20192021. 
Observation: The Unit reported combined civil and criminal recoveries of over  $9 million for 
FYs 20192021. 
Performance Standard 1: Compliance with Requirements ...................................................................................... 8 
Observation: According to the data we reviewed, the Iowa Unit complied with applicable 
laws, regulations, and policy transmittals. 
Performance Standard 2: Staffing ..................................................................................................................................... 8 
Finding: Although the Unit operated effectively and achieved high case outcomes, the Unit 
did not maintain staffing levels in accordance with its approved budget, maintained low 
staffing levels in relation to State Medicaid expenditures, and experienced significant 
turnover of investigators and high caseloads. 
Performance Standard 3: Policies and Procedures ................................................................................................... 10 
Observation: The Unit maintained policies and procedures. 
Performance Standard 4: Maintaining Adequate Referrals ................................................................................... 10 
Observation: The Unit took steps to maintain an adequate volume and quality of referrals, 
but referrals from key sources generally decreased during the review period. 
Performance Standard 5: Maintaining Continuous Case Flow ............................................................................. 12 
Observation: The Unit took steps to maintain a continuous case flow and to complete cases 
within appropriate timeframes. 
Performance Standard 6: Case Mix ................................................................................................................................. 13 
Observation: The Units caseload included both fraud and patient abuse or neglect cases 
and covered a broad mix of provider types. 
Performance Standard 7: Maintaining Case Information ....................................................................................... 13 
Observation: The Unit maintained case files with appropriate documentation and was able 
to efficiently access performance data and case information. 
Performance Standard 8: Cooperation with Federal Authorities on Fraud Cases ......................................... 14 
   
Observation: The Unit maintained a positive working relationship with Federal law 
enforcement partners, including OIG and U.S. Attorneys Offices. 
Observation: The Unit submitted all convictions and adverse actions to Federal partners 
within the appropriate timeframes. 
Performance Standard 9: Program Recommendations .......................................................................................... 14 
Observation: The Unit made recommendations to the State Medicaid agency during the 
review period. 
Performance Standard 10: Agreement with Medicaid Agency ............................................................................ 15 
Observation: The Units MOU with the State Medicaid agency reflected current practice, 
policy, and legal requirements. 
Performance Standard 11: Fiscal Control ..................................................................................................................... 15 
Observation: From our limited review, we identified no deficiencies in the Units fiscal 
control of its resources. 
Performance Standard 12: Training ................................................................................................................................ 15 
Observation: The Unit provided training to its staff that aided in the mission of the Unit, and 
Unit staff met training requirements. 
CONCLUSION AND RECOMMENDATION ............................................................................................. 16 
Assess the adequacy of existing staffing levels, and if warranted, develop a plan to expand the size of 
the Unit ...................................................................................................................................................................................... 16 
UNIT COMMENTS AND OIG RESPONSE ................................................................................................ 18 
DETAILED METHODOLOGY ....................................................................................................................... 19 
APPENDICES .................................................................................................................................................. 21 
Appendix A: Unit Referrals by Source for Fiscal Years 20192021 ..................................................................... 21 
Appendix B: Unit Comments ............................................................................................................................................. 22 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 24 
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 25 
 
 
   
BACKGROUND 
OBJECTIVE 
To examine the performance and operations of the Iowa Medicaid Fraud Control Unit 
(MFCU or Unit). 
 
Medicaid Fraud Control Units 
MFCUs investigate (1) Medicaid provider fraud and (2) patient abuse or neglect in 
facility settings, and prosecute those cases under State law or refer them to other 
prosecuting offices.1, 2, 3  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.4  
Each State must operate a MFCU or receive a waiver.5  Currently, 50 States, the District 
of Columbia, Puerto Rico, and the U.S. Virgin Islands operate MFCUs.6   
MFCUs are funded jointly by Federal and State Governments.  Each Unit receives a 
Federal grant award equivalent to 90 percent of total expenditures for new Units and 
75 percent for all other Units.7  In Federal fiscal year (FY) 2021, combined Federal and 
State expenditures for the MFCUs totaled approximately $314 million, of which 
approximately $235.9 million represented Federal funds.8   
 
 
_____________________________________________________________________________________________________________________________ 
1 SSA  1903(q).  Regulations at 42 CFR  1007.11(b)(1) clarify that a Units responsibilities may include 
the review of complaints of misappropriation of patients private funds in health care facilities. 
2 As of December 27, 2020, MFCUs may also receive Federal financial participation to investigate and 
prosecute abuse or neglect of Medicaid beneficiaries in a noninstitutional or other setting.  Consolidated 
Appropriations Act, 2021, Public Law 116-260, Division CC,  207. 
3 References to State in this report refer to the States, the District of Columbia, and the U.S. territories. 
4 SSA  1903(q)(2) & (6). 
5 SSA  1902(a)(61). 
6 The territories of American Samoa, Guam, and the Northern Mariana Islands have not established Units. 
7 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.  Thereafter, the Federal Government contributes 
75 percent and the State contributes 25 percent. 
8 OIG analysis of MFCUs FY 2021 reporting of expenditures.  The Federal FY 2021 was from October 1, 
2021, through September 30, 2021. 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
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OIG Grant Administration and Oversight of MFCUs 
The Office of Inspector General (OIG) administers the grant award to each Unit and 
provides oversight of Units.9, 10  As part of its oversight, OIG conducts a desk review of 
each Unit during the annual recertification process.  OIG also conducts periodic 
inspections and reviews.  Finally, OIG provides ongoing training and technical support 
to the Units. 
In its annual recertification review, OIG examines the Units reapplication materials, 
case statistics, and questionnaire responses from Unit stakeholders.  Through the 
recertification review, OIG assesses a Units performance, as measured by the Units 
adherence to published performance standards;11 the Units compliance with 
applicable laws, regulations, and OIG policy transmittals;12 and the Units case 
outcomes. 
OIG further assesses Unit performance by conducting inspections and reviews of 
selected Units.  These inspections and reviews result in public reports of findings and 
recommendations for improvement.  OIG reports may also include observations 
regarding Unit operations and practices, including beneficial practices that may be 
useful to share with other Units.  OIG also provides training and technical assistance 
to Units, as appropriate, during inspections and reviews. 
Iowa MFCU 
The Iowa Unit is located within the Iowa Department of Inspections and Appeals (DIA) 
in Des Moines.13  At the time of our inspection in November 2021, the Unit employed 
a director, four investigators, an attorney, an auditor, and a paralegal.  The Unit 
director supervised all staff and served as the chief investigator.14  During our review 
_____________________________________________________________________________________________________________________________ 
9 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. 
10 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. 
11 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). 
12 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  Policy 
transmittals are located at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.  
13 DIA is a state regulatory agency responsible for inspecting and licensing or certifying health care 
providers and suppliers and other entities within the state.  DIA staff also investigate alleged fraud in 
Iowas public assistance programs. 
14 The Units attorney is an Assistant Attorney General (AAG) assigned solely to the Unit from the Office 
of Attorney General (OAG).  Through a memorandum of understanding between the OAG and DIA, the 
Unit directs the work of the attorney.  The OAG retains certain personnel-related duties such as 
conducting the AAGs performance evaluation and approval of leave, but the Unit and OAG confer and 
coordinate on such duties. 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
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period of FYs 20192021, the Unit spent approximately $3.1 million (with a State share 
of nearly $782,000).  
Referrals  
The Unit receives referrals of Medicaid provider fraud and patient abuse or neglect 
from several sources, including the State Medicaid agencys program integrity unit, 
private citizens, and the State survey and certification agency, known as the Health 
Facilities Division (HFD).  When the Unit receives a referral, the MFCU director reviews 
the referral to determine whether it falls within the MFCUs jurisdiction and decides 
whether the MFCU will open a case for further investigation.  If a referral is within the 
MFCUs jurisdiction, the director evaluates the likelihood of criminal prosecution or 
civil action, and whether the Unit has the investigative resources to conduct an 
investigation.  The director typically makes the determination to open a case within  
2 days of receipt of the referral.  If the director declines the referral, the Unit may refer 
it to other law enforcement or a State agency or may refer it back to the referring 
agency for further evaluation.  
Investigations and Prosecutions 
Once the director decides to open a case, the director assigns the matter to an 
investigator and creates a case plan, which includes a target date for completing the 
investigation.  Investigators typically work on cases alone, but other investigators may 
assist on cases as needed, and the auditor assists with any claims data needs.  The 
Unit attorney serves as a resource to investigators and advises on matters such as 
case strategy, including recommendations on the particular criminal charges to 
pursue.  Investigators participate in quarterly supervisory reviews of their caseloads 
with the director and the attorney.  Upon completion of investigative activities, the 
Unit investigator provides an investigative case report to the director with a 
recommendation for referral to prosecute or close the case.  The director reviews the 
report and determines whether to approve the recommendation.   
The Unit has no prosecutorial authority and must refer cases to the appropriate State 
or Federal prosecuting authorities.15  In Iowa, the local county attorneys offices have 
original jurisdiction to accept and prosecute criminal cases in local court, so the Unit 
may refer cases to the county attorneys office in the county in which the alleged 
crime occurred.16  The assigned Unit investigator coordinates with the appropriate 
county attorneys office regarding the presentation of the investigative case report 
and case files.  Respective county attorneys offices may also authorize the MFCU 
attorney to prosecute in local court on their behalf.  The Unit may refer both criminal 
and civil cases to the appropriate U.S. Attorneys Office in Iowa.   
_____________________________________________________________________________________________________________________________ 
15 In accordance with 42 CFR  1007.7(b), the Unit has formal written procedures ensuring that the Unit 
refers suspected cases of criminal fraud in the Iowa Medicaid program or of patient or resident abuse or 
neglect to the appropriate prosecuting authority. 
16 The State of Iowa has 99 county attorneys offices. 
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Iowa Medicaid Program 
The Iowa Department of Human Services administers the State Medicaid program, 
known as the Iowa Medicaid Enterprise (IME).  As of June 2021, the program served 
703,479 beneficiaries.17  IME transitioned from a fee-for-service model to primarily 
providing services through managed care organizations (MCOs) in 2016.  In FY 2021, 
approximately 95 percent of Medicaid beneficiaries received services through 2 
MCOs.18  In the same year, Iowas Medicaid expenditures were approximately  
$6.1 billion.19  
IMEs Program Integrity Unit (PIU) is responsible for Medicaid program integrity 
efforts.  The PIU receives referrals of suspected provider fraud from MCOs and from a 
contracted audit and investigation team responsible for the fee-for-service 
component of Iowas Medicaid program.  The PIU reviews these referrals to determine 
whether they constitute a credible allegation of fraud, and then refers those cases to 
the MFCU as appropriate. 
Prior OIG report 
OIG conducted a previous onsite review of the Iowa Unit in 2014.20  In that review, 
OIG found that the Unit generally complied with applicable laws, regulations, and 
policy transmittals.  However, OIG made two findings regarding the Units adherence 
to MFCU performance standards.  OIG found that (1) 47 percent of the Units case 
files lacked documentation of periodic supervisory reviews and (2) the Units 
memorandum of understanding (MOU) with the State Medicaid agency did not reflect 
all current requirements.  After the 2014 onsite review, but prior to the publication of 
the report, the Unit revised the MOU. 
OIG recommended that the Iowa Unit implement processes to ensure that supervisors 
conduct and document case reviews periodically, consistent with the Units revised 
practice.  On the basis of the information received from the Unit, OIG considered the 
recommendation implemented as of February 2015. 
_____________________________________________________________________________________________________________________________ 
17 Centers for Medicare & Medicaid Services (CMS), June 2021 Medicaid and CHIP Enrollment Data 
Highlights, accessed at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-
enrollment-data/report-highlights/index.html on January 10, 2022. 
18 Iowa Medicaid Enterprise, Managed Care Organization Report: SFY 2022, Quarter 1, accessed at 
https://dhs.iowa.gov/sites/default/files/Q1_SFY2022-Report_Final.pdf?020120221720 on February 4, 
2022.  Federal FY 2021 corresponds to Iowas State FY 2021 Quarter 2 through State FY 2022 Quarter 1. 
19 OIG, MFCU Statistical Data for FY 2021, accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-
units-mfcu/expenditures_statistics/fy2021-statistical-chart.pdf on March 17, 2022. 
20 OIG, Iowa State Medicaid Fraud Control Unit: 2014 Onsite Review, accessed at 
https://oig.hhs.gov/oei/reports/oei-06-14-00190.pdf on March 4, 2022. 
 
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Methodology 
OIG conducted an inspection of the Iowa MFCU in November 2021.  Our inspection 
covered the 3-year period of FYs 20192021.  We based the inspection on an analysis 
of data and information from 7 sources: (1) Unit documentation; (2) financial 
documentation; (3) structured interviews with key stakeholders; (4) structured 
interviews with the Unit managers and selected staff; (5) a review of a random sample 
of 84 case files from the 372 nonglobal case files that were open at some point during 
the review period; (6) 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 (7) onsite review of Unit operations.  See the 
Detailed Methodology.   
In examining the Units operations and performance, we applied the published MFCU 
performance standards, but we did not assess adherence to 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 are other OIG evaluations, including internal and external peer 
review. 
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PERFORMANCE ASSESSMENT 
In assessing the performance and operations of the Iowa Unit, OIG identified the 
Units case outcomes, evaluated whether the Unit complied with legal requirements, 
and assessed whether the Unit adhered to each of the 12 performance standards.  
From the data we reviewed, we found that the Unit generally operated in accordance 
with applicable laws, regulations, and policy transmittals and the MFCU performance 
standards.  We identified one finding and made several observations regarding the 
Units performance and operations, and we made one recommendation for 
improvement. 
Case Outcomes 
Observation: The Unit reported 80 indictments, 79 convictions, and 36 civil 
settlements and judgments for FYs 20192021.  
Of the 79 convictions, 43 involved patient abuse or neglect and 36 involved Medicaid 
provider fraud.  Compared to similarly sized MFCUs, the Iowa Unit had a substantially 
higher number of indictments and convictions.21, 22, 23   
 
 
 
 
 
 
 
Several factors may have contributed to the Units high number of indictments and 
convictions.  Because the Unit lacks authority to prosecute its cases, the Unit refers its 
cases to external prosecuting authorities, most commonly Iowas 99 county attorneys 
offices.  In OIGs opinion, the Units ability to refer cases for prosecution to the county 
attorneys is a significant prosecutorial resource for the Unit and allows cases to be 
fully adjudicated with limited delays.  Further, the Unit reported that investigators had 
_____________________________________________________________________________________________________________________________ 
21 In our analysis, we defined similarly sized MFCUs to be those with staff sizes ranging from 4 to 10 
employees.  In FY 2021, 12 MFCUs were in this category, including the Iowa Unit with 8 staff.     
22 Of similarly sized MFCUs during the review period, indictments ranged from 2 to 80 with a mean of   
21 and convictions ranged from 0 to 79 with a mean of 19.  Many factors other than a MFCUs staff size 
can affect case outcomes.   
23 OIG provides information on MFCU operations and outcomes but does not direct or encourage MFCUs 
to investigate or prosecute a specific number of cases.  MFCU investigators and prosecutors should apply 
professional judgment and discretion in determining what criminal and civil cases to pursue. 
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strong relationships with many of the county attorneys, and that cases were rarely 
declined for prosecution.  Additionally, through our review of case files and interviews 
with multiple Unit stakeholders, we observed that the Unit performed thorough 
investigations and provided complete and well-organized investigative reports, which 
likely contributed to swift and positive case resolutions.  Finally, the ability to refer 
cases for external prosecution allowed the Unit to focus its efforts on investigations, 
and we found that the Unit maintained a continuous case flow by implementing a 
number of practices that improved efficiency and timeliness (see Performance 
Standard 5). 
Observation: The Unit reported combined civil and criminal recoveries of over  
$9 million for FYs 20192021. 
 
 
 
 
 
 
 
 
Source: OIG analysis of Unit Annual Statistical Reports, FYs 20192021. 
Note: Global civil recoveries derive from civil settlements or judgments in global cases, which are cases that involve 
the U.S. Department of Justice and a group of State MFCUs and are facilitated by the National Association of Medicaid 
Fraud Control Units. 
 
 
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Performance Standard 1: Compliance with Requirements 
A Unit conforms with all applicable statutes, regulations, and policy directives. 
Observation: According to the data we reviewed, the Iowa Unit complied with 
applicable laws, regulations, and policy transmittals. 
From the information we reviewed, we did not identify any compliance-related 
concerns. 
Performance Standard 2: Staffing 
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: Although the Unit operated effectively and achieved high case 
outcomes, the Unit did not maintain staffing levels in accordance with its 
approved budget, maintained low staffing levels in relation to State Medicaid 
expenditures, and experienced significant turnover of investigators and high 
caseloads. 
Staffing not in accordance with Unit budget.  According to Performance Standard 2(a), 
the Unit should employ the number of staff that is included in the Units budget 
estimate as approved by OIG.  However, we found that the Unit did not maintain 
staffing levels in accordance with its approved budget, particularly with its 
investigative staff.  Although the Unit was approved for 11 staff during the 3-year 
review period, the Unit employed 7 to 8 staff at the end of FYs 2019, 2020, and 2021.  
Nearly all of the Units vacancies consisted of investigator positions; the Unit was 
approved for seven investigators but employed only four at the end of each year of 
the review period. 24  At the time of our inspection, the Unit reported that it was in the 
process of filling one of the investigator vacancies, and had plans to have six Unit 
investigators on board within 18 months. 
Low staffing levels in relation to State Medicaid expenditures.  Additionally, the Units 
staffing levels were low in relation to State Medicaid expenditures.  According to 
Performance Standard 2(b), the Unit should employ 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 or neglect.  In FY 2021, Iowas Medicaid expenditures were 
approximately $6.1 billion, and at the end of FY 2021, the Unit employed eight staff.  
We found that the Units staff size was low compared to that of all other MFCUs 
relative to their respective States Medicaid program expenditures.25  In FY 2021, the 
_____________________________________________________________________________________________________________________________ 
24 At the end of FY 2020, the Unit had one vacancy in an administrative position. 
25 OIG found that both the Units actual staffing level (8) and approved staffing level (11) were low 
relative to State Medicaid expenditures. 
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Unit had approximately $759 million in Medicaid expenditures per MFCU employee, 
which was the third-highest Medicaid expenditure per employee of all MFCUs 
nationally.  This was also more than double the national average of Medicaid 
expenditures per MFCU employee across all MFCUs.   
While the Units staffing levels were low with respect to Medicaid expenditures, the 
Units case outcomes were high compared to those of similarly sized MFCUs for a 
number of reasons (see Case Outcomes).  One small mitigating factor for the Units 
relatively low staffing levels is that, unlike most MFCUs, the Unit does not have the 
authority to prosecute its own cases, and therefore, it does not need the additional 
staff that other MFCUs may require to prosecute cases.26    
Turnover of investigators.  One of the reasons for the Units low staffing levels was 
vacancies created by frequent turnover of investigators.  While the total number of 
investigators employed remained consistent during the review period, with  
four investigators at the end of each FY, there was significant turnover of 
investigators.  During this period, the Unit hired five new investigators and six 
investigators left the Unit.  Of the six investigators who left, four were employed with 
the Unit for short periodsbetween 1 week and 15 months.  Two of the six 
investigators who left the Unit did not complete the Units 6-month probationary 
period and the other four left due to general attrition, such as retiring or taking 
another job.  Three long-time investigators remained employed with the Unit 
throughout the review period. 
Impact of COVID-19 pandemic.  Another reason for the low staffing levels was the 
Units strategic response to the COVID-19 pandemic.  Specifically, the Unit reported 
that it strategically did not fill investigator vacancies during the pandemic because of 
the reduced number of referrals it received and because of pandemic-related 
limitations on the Units ability to investigate patient abuse or neglect.  The Unit 
experienced a general decline in referrals of fraud and patient abuse or neglect during 
the review period, particularly in FY 2020, which was attributable to COVID-19 and 
other factors (see Performance Standard 4).  Additionally, the director reported that 
the pandemic significantly limited the Units ability to conduct field investigative 
activities in nursing facilities.  As a result, the Unit strategically maintained the 
investigator vacancies while focusing on efforts to increase referrals, such as 
stakeholder training and outreach.  The director acknowledged that the Units current 
staffing would not be sufficient once referrals return to prior levels. 
High caseloads.  The low staffing levels led to high caseloads, which may have 
affected the timeliness of investigations.  Unit investigators carried caseloads of 
_____________________________________________________________________________________________________________________________ 
26 In FY 2021, the 8 States with similar Medicaid expenditures to Iowas (as defined by +/- $1.5 billion in 
expenditures) had nonattorney staffing levels ranging from 8 to 28 with a median of 15, while Iowa had a 
nonattorney staff of 7.  Therefore, even after accounting for potential differences in the numbers of 
attorneys required to prosecute cases, we found that the Iowa MFCU was still smaller than MFCUs with 
similar Medicaid expenditures.  
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approximately 20 active cases, which OIG and the Unit observed to be high.27  
Although we did not find evidence of substantial investigative delays in our review of 
the Units case files (see Performance Standard 5), the director and investigative staff 
reported that the caseloads affected how quickly cases could be completed.  The 
director reported that he would like caseloads to be approximately 12 to 15 cases per 
investigator and that lighter caseloads would better ensure that cases are worked in a 
timely manner.  
Performance Standard 3: Policies and Procedures 
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 policies and procedures. 
The Unit maintained a policies and procedures manual specific to the MFCUs 
functions and jurisdiction.  The Unit updated the manual as needed, and staff were 
familiar with Unit policies and procedures.  
Performance Standard 4: Maintaining Adequate Referrals 
A Unit takes steps to maintain an adequate volume and quality of referrals from the 
State Medicaid agency and other sources. 
Observation: The Unit took steps to maintain an adequate volume and quality of 
referrals, but referrals from key sources generally decreased during the review 
period. 
Consistent with Performance Standard 4, the Unit took steps to encourage high-
quality fraud and patient abuse or neglect referrals from key referral sources during 
the review period.  IMEs PIU is responsible for Medicaid program integrity and was an 
important source of fraud referrals, providing the Unit with referrals from both the 
fee-for-service and managed care components of IME.  To encourage quality fraud 
referrals from the PIU, the Unit provided education and training to the PIU and MCOs.  
Additionally, the Unit maintained strong relationships and regular communication 
with the PIU, including a monthly meeting of the MFCU and PIU, as well as a separate 
monthly meeting with the PIU and MCOs.  To encourage patient abuse or neglect 
referrals, the Unit maintained a strong relationship and communication with Iowas 
State survey and certification agency, HFD, which was the Units primary source of 
patient abuse or neglect complaints.  To encourage higher-quality referrals, the Unit 
provided training to HFD on the types of complaints that could potentially constitute 
abuse or neglect according to State laws.   
In addition to the Units efforts to encourage quality referrals from the PIU and HFD, 
the director conducted outreach to various professional groups and law enforcement 
_____________________________________________________________________________________________________________________________ 
27 Investigators caseloads did not include cases referred for prosecution, which were monitored by the 
paralegal (see Performance Standard 5). 
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agencies to provide education on Medicaid provider fraud and patient abuse and 
neglect and to develop these groups as referral sources. 
Although the Unit took steps to encourage referrals from the PIU and HFD, referrals 
from these key referral sources generally declined during the review period, with 
sharp declines in FY 2020 and modest increases in FY 2021 (see Exhibit 1).  During the 
review period, the Unit received 227 fraud referrals from the PIU; 60 of these were 
from the fee-for-service component of the Medicaid program and 167 originated with 
MCOs.  During this period, fee-for-service referrals from the PIU declined dramatically, 
and referrals from the PIU that originated with MCOs decreased in FY 2020 and 
increased modestly in FY 2021 (see Exhibit 1).  Similarly, referrals of patient abuse or 
neglect from HFD declined in FY 2020 and increased slightly during FY 2021.  See 
Appendix A for all sources of referrals involving fraud and patient abuse or neglect 
during FYs 20192021. 
Exhibit 1: Referrals received from the PIU and HFD decreased sharply in  
FY 2020 and increased slightly in FY 2021 
 
 
 
 
 
 
 
 
 
Source: OIG analysis of Unit Annual Statistical Reports, FYs 20192021. 
Note: The PIU total includes referrals originating with MCOs and fee-for-service referrals. 
 
Two factors contributed to the general decline in numbers of fraud referrals from the 
PIU.  In FY 2020, the PIU modified its long-standing practice of referring all cases of 
potential fraud to the Unit and began to only refer cases for which documentation 
supported a credible allegation of fraud. 28  A second factor that affected fraud 
_____________________________________________________________________________________________________________________________ 
28 CMS regulations define credible allegation of fraud at 42 CFR  455.2 as an allegation that has been 
verified by the State from any source, including but not limited to fraud hotline tips verified by further 
evidence; claims data mining; and patterns identified through provider audits, civil false claims cases, and 
law enforcement investigations.  Allegations are considered credible when they have indicia of 
reliability and the Medicaid agency has reviewed all allegations, facts, and evidence carefully and acts 
judiciously on a case-by-case basis. 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Performance Assessment | 11    
referrals was MCOs leaving and joining the Iowa Medicaid program.29  These 
transitions disrupted MCO program integrity operations, limiting the number and 
quality of referrals to the Unit for a period of time following the changes.   
The primary factor that contributed to the decrease in referrals of patient abuse or 
neglect from HFD in FY 2020 was the COVID-19 pandemic.  Long-term care 
complaints to HFD decreased in FY 2020 because of limits on HFDs survey activity 
and restricted visitation in long-term care facilities, which in turn limited the number 
of complaints referred to the MFCU.  In FY 2021, the survey activity increased and 
visitation restrictions were eased, which provided more opportunities for identification 
and reporting of patient abuse and neglect concerns.   
Performance Standard 5: Maintaining Continuous Case 
Flow 
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: The Unit took steps to maintain a continuous case flow and to 
complete cases within appropriate timeframes. 
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 is completed within an appropriate 
timeframe.  Our review of the Units case files found no significant delays in the 
completion of the investigations or in the subsequent prosecutions or settlements.  
Further, nearly all case files contained appropriate documentation of supervisory 
approval for case openings and applicable case closings, as well as applicable 
quarterly reviews of case files. 
We identified several practices that may have contributed to the Units continuous 
case flow.  First, case assignments were made to investigators on the basis of their 
preferences and expertise.30  Unit staff and management identified this practice as 
highly beneficial to productivity and timeliness of cases.  One staff member stated 
that, because of the investigators areas of expertise, when the investigators go out 
to investigate, theyre well-versed and know what to look for and what to ask.  They 
know how to interpret the evidence they get back.  Another practice that contributed 
to continuous case flow was that the director developed a case plan, which he shared 
with the investigator when assigning the case.  The case plan established the scope of 
the investigation and the primary allegations to be investigated; determined any 
necessary coordination with law enforcement partners; and addressed any additional 
administrative, procedural, or investigative issues.  In addition, the case plan 
_____________________________________________________________________________________________________________________________ 
29 One of three MCOs left the Iowa Medicaid program in FY 2018, which disrupted MCO program 
integrity operations into the review period.  Additionally, one MCO left the program during the review 
period and one new MCO joined. 
30 The cases were assigned to investigators depending upon whether the case involved provider fraud, 
patient abuse or neglect, or drug diversion. 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Performance Assessment | 12    
established a date by which the investigator was expected to submit a case to be 
closed or to be reviewed for referral for prosecution.  The investigation completion 
date was flexible and could be modified as needed as the investigation progressed.  
The timelines for investigations were also incorporated into the investigators 
performance evaluations, which the director believed provided incentive to complete 
cases in a timely manner.   
Finally, to improve investigators efficiency, the Unit transferred responsibility for 
administrative duties from the investigators to the Units paralegal.  The directors 
goal in doing so was to have investigators focusing solely on investigative activities.  
For example, investigators did not have to track their cases after they were referred 
and accepted for prosecution.  Those cases were transferred to the Units paralegal for 
monitoring.31   
Performance Standard 6: Case Mix 
A Units case mix, as practicable, covers all significant provider types and includes a 
balance of fraud and, where appropriate, patient abuse and neglect cases.  
Observation: The Units caseload included both fraud and patient abuse or 
neglect cases and covered a broad mix of provider types. 
Of the 764 cases that were open during FYs 20192021, 83 percent (631 cases) 
involved provider fraud and 17 percent (133 cases) involved patient abuse or neglect.  
During this period, the Units cases covered 48 different provider types, including 
various types of physicians, licensed practitioners, health care facilities, and medical 
service providers.  
Performance Standard 7: Maintaining Case Information 
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 with appropriate documentation 
and was able to efficiently access performance data and case information. 
The Unit maintained case files electronically within two platforms for case 
management purposes.  Unit investigators documented case milestones, supervisory 
reviews, and summaries of investigative activities within a proprietary case 
management system.  Additionally, the Unit stored copies of all electronic case 
materials on a shared drive.  OIG examined the Units case files by reviewing a random 
sample of 84 cases open during our review period.  In addition to assessing whether 
the case management system was efficient, we determined whether the case files 
contained the appropriate documentation, such as opening and closing documents, 
_____________________________________________________________________________________________________________________________ 
31 Upon case reassignment, the MFCU paralegal monitored cases throughout the adjudication process, 
entering case updates into the case monitoring system.  The paralegal notified investigators if follow-up 
work was necessary.  Additionally, the paralegal submitted, as appropriate, documentation on convictions 
to OIG and the NPDB (see also Performance Standard 8). 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Performance Assessment | 13    
interview summaries, investigative activity summaries, and quarterly supervisory 
reviews.  In OIGs professional judgment, the Units case files were maintained in an 
effective manner, and the case management system allowed efficient access to case 
information and performance data.  We also judged the case files to be complete and 
organized in such a way that an investigator unfamiliar with the case could 
understand the case history and continue the investigation with little to no difficulty.  
Performance Standard 8: Cooperation with Federal 
Authorities on Fraud Cases 
A Unit cooperates with OIG and other Federal agencies in the investigation and 
prosecution of Medicaid and other health care fraud. 
Observation: The Unit maintained a positive working relationship with Federal 
law enforcement partners, including OIG and U.S. Attorneys Offices. 
During the review period, the Unit reported working 38 joint cases with OIGs Office of 
Investigations (OI).  The Unit director communicated regularly with OI management, 
and Unit investigators maintained strong working relationships with OI agents.  The 
Unit also maintained positive working relationships with both U.S. Attorneys Offices 
in Iowa.  
Observation: The Unit submitted all convictions and adverse actions to Federal 
partners within the appropriate timeframes. 
During the review period, the Unit submitted all of its 84 convictions to OIG within  
30 days of sentencing, as required by Performance Standard 8(f).32  The Unit also 
submitted all of its 84 adverse actions to the NPDB within 30 days of the final adverse 
action, as required by Federal regulations.33, 34  
Performance Standard 9: Program Recommendations 
A Unit makes statutory or programmatic recommendations, when warranted, to the 
State government. 
Observation: The Unit made recommendations to the State Medicaid agency 
during the review period.  
_____________________________________________________________________________________________________________________________ 
32 Effective May 21, 2019, 42 CFR  1007.11(g) required the Unit to transmit information on convictions 
within 30 days of sentencing, or as soon as practicable if the Unit encountered delays in receiving the 
necessary information from the court. 
33 45 CFR  60.5.  Examples of adverse actions include, but are not limited to, health care-related criminal 
convictions and civil judgments (but not civil settlements), and program exclusions.  See SSA  1128E(a) 
and (g)(1). 
34 The NPDB is intended to restrict the ability of physicians, dentists, and other health care practitioners 
to move from State to State without disclosure or discovery of previous medical malpractice and adverse 
actions.  
 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Performance Assessment | 14    
Performance Standard 9(b) states that the Unit, when warranted and appropriate, 
should make recommendations regarding program integrity issues to the State 
Medicaid agency.  During the review period, the Unit recommended that IME 
eliminate existing rules requiring some beneficiaries to hire independent support 
brokers, after the Unit identified a lack of oversight and program integrity controls.  
The Unit reported that IME had not implemented this recommendation.  The Unit also 
recommended that IME extend rules prohibiting spousal and parental relationships 
between personal care service providers and beneficiaries to include any individual 
with whom the beneficiary resides.  As of April 2022, the Unit reported that IME had 
not provided an update regarding this recommendation. 
Performance Standard 10: Agreement with Medicaid 
Agency 
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. 
Observation: The Units MOU with the State Medicaid agency reflected current 
practice, policy, and legal requirements. 
The MFCU and the State Medicaid agency had a current MOU, amended in February 
2021.  
Performance Standard 11: Fiscal Control 
A Unit exercises proper fiscal control over its resources.  
Observation: From our limited review, we identified no deficiencies in the Units 
fiscal control of its resources. 
From the responses to a detailed fiscal controls questionnaire, we identified no issues 
related to the Units budget process, accounting system, cash management, 
procurement, electronic data security, property, or personnel.  In our inventory review, 
we located 30 of the 30 sampled inventory items.  
Performance Standard 12: Training 
A Unit conducts training that aids in the mission of the Unit.  
Observation: The Unit provided training to its staff that aided in the mission of 
the Unit, and Unit staff met training requirements. 
The Unit had a training plan that included minimum training hours for professional 
staff, and staff exceeded the training hour requirements.  Professional staff attended a 
range of classes that aided in the mission of the Unit, and new employees completed 
a series of in-house training sessions provided by the Unit director and other staff.  
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Performance Assessment | 15    
CONCLUSION AND RECOMMENDATION 
The Iowa Unit reported exceptionally strong case outcomes for FYs 20192021, as 
compared to those of similarly sized MFCUs.  OIG observed a number of factors 
contributing to the Units success in combatting Medicaid provider fraud and patient 
abuse or neglect, including the Units ability to refer cases for prosecution to county 
attorneys and the thorough investigations conducted by Unit staff.  We also observed 
several practices that contributed to an efficient case flow and positive relationships 
with State and Federal stakeholders. 
From the information we reviewed, we determined that the Iowa Unit complied with 
applicable legal requirements and generally adhered to the performance standards.  
However, we found one opportunity for the Unit to enhance its success.  We found 
that although the Unit generally operated effectively and achieved high case 
outcomes despite significant turnover of investigators and high caseloads, the Units 
staffing levels were low in relation to State Medicaid expenditures, and the Unit did 
not maintain staffing levels in accordance with its approved budget during the review 
period, particularly with its investigator positions.   
We also observed that the Unit took steps to maintain an adequate volume and 
quality of referrals, but referrals from key sources, such as the PIU and HFD, generally 
decreased during the review period.  If the circumstances that led to decreased 
referrals resolve and the Unit begins to receive an increased volume of referrals, 
employing a full staff of investigators will be important for the Units future success.  
Further, in OIGs judgment, a full staff of investigators would result in reduced 
caseloads, which may improve the timeliness of investigations and improve upon the 
Units already strong case outcomes.  Increasing the Units staff size to be more 
proportionate with the size of Iowas Medicaid program would ultimately enhance the 
Units ability to protect the Medicaid program and its beneficiaries.  
To address the finding identified in this report, we made the following 
recommendation to the Iowa Unit. 
We recommend that the Iowa Unit: 
Assess the adequacy of existing staffing levels, and if warranted, 
develop a plan to expand the size of the Unit  
At the time of our review, the Unit reported that it was in the process of hiring  
one additional investigator, with plans to have six of the seven approved investigator 
positions filled by mid-2023.  In addition to those hiring plans, the Unit should assess 
whether its planned staffing levels are sufficient, and if warranted, develop a plan to 
further increase its staff.  In assessing staffing levels, the Unit should consider the 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Conclusion and Recommendation | 16    
number of referrals received by the Unit, the timeliness of investigations, the relatively 
high caseloads of investigators, and the States total Medicaid program expenditures.  
As a part of the assessment, the Unit should also consider the causes of turnover of 
investigators and whether any steps can be taken to reduce turnover.  The Unit should 
share its assessment with OIG, and if warranted, the Unit should propose an 
expansion plan to satisfy current and/or future needs.    
 
 
 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Conclusion and Recommendation | 17    
UNIT COMMENTS AND OIG RESPONSE 
 
The Iowa Unit concurred with our recommendation to assess the adequacy of existing 
staffing levels, and if warranted, develop a plan to expand the size of the Unit.  In its 
response, the Unit indicated that it had hired an additional investigator in the period 
following our onsite inspection.  The Unit stated, on the basis of its most recent 
staffing assessments, that its current staffing level is sufficient to respond to its 
current volume of referrals and to ensure reasonable investigative caseloads.  The Unit 
noted that as it continues to develop and enhance referral sources in order to 
increase the number of investigations, it will continue to assess existing staffing levels 
and fill vacant investigator positions when appropriate to do so. 
Although the Unit concurred with our recommendation, it noted that it disagrees with 
aspects of our finding.  The Unit stated that the finding implies that if the Unit is 
below the staffing levels allowed by its budget, regardless of the Units workload, the 
Unit will be out of compliance in a future inspection conducted by OIG.  Although OIG 
examines approved budget projections when evaluating MFCU staffing levels, we 
consider this alongside many other factors, including State Medicaid expenditures, 
investigative caseloads, and overall Unit effectiveness. 
For the full text of the Units comments, see Appendix B.
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Unit Comments and OIG Response | 18    
DETAILED METHODOLOGY 
Data Collection and Analysis 
We collected and analyzed data from the seven sources described 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 applicable laws, 
regulations, or policy transmittals.  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 inspection, we reviewed the recertification information for  
FYs 20192021, which involved examining the Units recertification materials, 
including (1) the annual reports; (2) the Unit directors recertification questionnaires; 
(3) the Units MOU with the State Medicaid agency (IME); (4) the IME program 
integrity directors questionnaires; and (5) the OIG Special Agent in Charge 
questionnaires.  We also reviewed the Units policies and procedures manual and the 
Units self-reported case outcomes and referrals included in its annual statistical 
reports for FYs 20192021.  Additionally, we examined the recommendation from the 
2014 OIG onsite review report and the Units implementation of the recommendation.   
Review of Unit Financial Documentation 
We conducted a limited review of the Units control over its fiscal resources.  Before 
the onsite inspection, we analyzed the Units responses to a questionnaire about 
internal controls and conducted a desk review of the Units financial status reports.  
We also selected a purposive sample of 30 items from the current inventory list of  
290 items maintained in the Units office and verified those items onsite.  
Interviews with Key Stakeholders 
In September and October 2021, we interviewed key stakeholders, including officials 
in the IME Program Integrity Unit, the State survey and certification agency (HFD 
Abuse Coordinating Unit), the two U.S. Attorneys Offices located in Iowa, and a 
county attorneys office.  We also interviewed a manager from OIGs Office of 
Investigations who works with the Unit.  We focused these interviews on the Units 
relationship and interaction with the stakeholders, as well as opportunities for 
improvement.  We used the information collected from these interviews to develop 
subsequent interview questions for Unit management and staff.   
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Detailed Methodology | 19    
Onsite Interviews with Unit Management and Selected Staff 
We conducted structured interviews with the Units management and selected staff in 
November 2021.  We interviewed the director, the attorney, three investigators, and 
the auditor.  In addition, we interviewed the supervisor of the Unitthe DIA 
Investigations Division Administrator.  We asked these individuals questions related to 
(1) Unit operations; (2) Unit practices that contributed to the effectiveness and 
efficiency of Unit operations and/or performance; (3) opportunities for the Unit to 
improve its operations and/or performance; (4) clarification regarding information 
obtained from other data sources; and (5) the Units training and technical assistance 
needs.   
Onsite Review of Case Files 
We requested that the Unit provide us with a list of cases that were open at any time 
during FYs 20192021 and include the status of each case; whether the case was 
criminal, civil, or global; and the dates on which the case was opened and closed, if 
applicable.  The total number of cases was 764.  We excluded all global cases from 
our review of the Units case files because global cases are civil false claims actions 
that typically involve multiple agencies, such as the Department of Justice and a 
group of State MFCUs.  We excluded 392 global cases, leaving 372 case files.  We 
then selected a simple random sample of 84 cases from the population of 372 cases.  
This sample allowed us to make estimates of the overall percentage of case files with 
various characteristics with absolute precision of no more than +/- 10 percent at the 
95-percent confidence level.  We reviewed the 84 case files for adherence to the 
relevant performance standards and compliance with statute, regulation, and policy 
transmittals.  During the review of the sampled case files, we consulted MFCU staff to 
address any apparent issues with individual case files, such as missing documentation. 
Review of Unit Submissions to OIG and the National Practitioner 
Data Bank 
We also reviewed all convictions submitted to OIG for program exclusion during the 
review period (84) and all adverse actions submitted to the NPDB during the review 
period (84).  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 20192021.  We also assessed the timeliness of the submissions to OIG 
and the NPDB.   
Onsite Review of Unit Operations 
During the onsite inspection, we observed the Units workspace and operations of the 
Units office in Des Moines.  We observed the Units office and meeting spaces; 
security of data and case files; location of select equipment; and the general 
functioning of the Unit. 
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   Detailed Methodology | 20   APPENDICES 
Appendix A: Unit Referrals by Source for Fiscal Years 20192021 
FY 2019  FY 2020  FY 2021  3-Year Total
Abuse or  Abuse or  Abuse or  Abuse or 
Referral Source  Fraud  Fraud  Fraud  Fraud  Total 
Neglect  Neglect  Neglect  Neglect 
Adult Protective 
0  2  0  0  0  0  0  2  2 
Services 
Anonymous  1  0  1  0  1  0  3  0  3 
HHS-OIG  4  0  9  0  7  1  20  1  21 
Law enforcement 
18  6  9  4  10  2  37  12  49 
(other) 
Licensing board  1  0  1  0  2  0  4  0  4 
Local prosecutor  0  2  1  1  2  0  3  3  6 
Long-Term Care 
0  0  0  0  0  1  0  1  1 
Ombudsman 
Medicaid agency 
(IME-PIU), fee-for- 43  0  13  0  4  0  60  0  60 
service* 
Medicaid agency 
80  0  32  0  55  0  167  0  167 
(IME-PIU), MCO*
Medicaid agency 
0  0  0  0  0  1  0  1  1 
(other) 
Private citizen  72  1  55  1  44  0  171  2  173 
Provider  0  2  0  2  4  1  4  5  9 
State survey and 
2  171  2  124  4  145  8  440  448 
certification agency 
State agency (other)  3  1  0  0  5  1  8  2  10 
Other  6  0  0  0  1  0  7  0  7 
Sub-Total  230  185  123  132  139  152  492  469  961 
Total  415  255  291  961 
Source: OIG analysis of Unit Annual Statistical Reports, FYs 20192021. 
*The IME Program Integrity Unit (IME-PIU) provided both fee-for-service referrals and referrals that originated from MCOs.
Iowa Medicaid Fraud Control Unit: 2021 Inspection 
OEI-07-21-00340   Appendix A | 21  Appendix B: Unit Comments
KIM REYNOLDS, GOVERNOR  LARRY JOHNSON, JR., DIRECTOR 
ADAM GREGG, LT. GOVERNOR 
June 7, 2022 
Suzanne Murrin 
Deputy Inspector General, Evaluations and Inspections 
Office of Inspector General 
Department of Health and Human Services 
Cohen Building, Room 5660 
330 Independence Ave SW 
Washington, DC 20201 
RE:  Iowa Medicaid Fraud Control Unit:  2021 Inspection, OEI-07-21-00340 
Deputy Inspector General Murrin: 
The Iowa Department of Inspections and Appeals reviewed the Iowa Medicaid Fraud Control Unit:  2021 
Inspection report.   
OIG reported one finding pertaining to Unit staffing pursuant to Performance Standard 2: 
Although the Unit operated effectively and achieved high case outcomes, the Unit 
did  not  maintain  staffing  levels  in  accordance  with  its  approved  budget, 
maintained low staffing levels in relation to State Medicaid expenditures, and 
experienced significant turnover of investigators and high caseloads.   
OIG also provided the following recommendation:  
Assess the adequacy of existing staffing levels, and if warranted, develop a plan 
to expand the size of the Unit.   
The Department appreciates the OIGs comments that the Unit operated effectively and achieved high 
case outcomes.  The Unit achieved these results due to the hard work and dedication of the Units staff, 
the policies and procedures developed and implemented by the Units leadership, and the working 
relationships among the Units stakeholders, including the Iowa Medicaid Enterprise.   
The Department disagrees with aspects of the OIGs finding but agrees with the overall recommendation.  
The OIGs finding implies if the Unit is below the staffing levels allowed by its budget, regardless of the 
Units workload, the Unit would be out of compliance in a future audit conducted by the OIG.   
The Department agrees with the recommendation to continue its practice of assessing the adequacy of 
its staffing levels based on its workload.  As of today, the Unit maintains nine full-time employees 
consisting of the Unit director, attorney, auditor, paralegal, and five investigators.  The Unit currently 
maintains two vacant investigator positions.  Based on most recent staffing assessments, the Unit 
determined  that  nine  full-time  employees  are  adequate  at  this  time  to  operate  effectively  and 
321 East 12th Street | Des Moines, Iowa 50319-0083 | 515-281-7102 | FAX 515-242-6863 | TTY 515-242-6515 
Iowa Medicaid Fraud Control Unit: 2021 Inspection 
OEI-07-21-00340                      Appendix B | 22 KIM REYNOLDS, GOVERNOR  LARRY JOHNSON, JR., DIRECTOR 
ADAM GREGG, LT. GOVERNOR 
efficiently.  Specifically, five investigators are sufficient to respond to current referral intakes.  This has 
resulted in reasonable caseloads to keep investigators working diligently on Unit investigations without 
overwhelming investigators with unmanageable caseloads or using taxpayer funds to employ unnecessary 
personnel based on current investigative needs.  Current staffing has also allowed the Unit to accept all 
quality referrals that fall within the scope and authority of the Unit's investigative activities without 
declining quality referrals solely due to insufficient investigative resources.  As the Unit continues to 
develop and enhance referral sources in order to generate more investigations, the Unit will continue to 
assess existing staffing levels and fill vacant investigator positions when appropriate to do so. 
Thank you for the opportunity to respond to the 2021 audit report. 
Sincerely, 
Larry Johnson, Jr. 
Director 
Iowa Department of Inspections & Appeals 
321 East 12th Street | Des Moines, Iowa 50319-0083 | 515-281-7102 | FAX 515-242-6863 | TTY 515-242-6515 
Iowa Medicaid Fraud Control Unit: 2021 Inspection 
OEI-07-21-00340                      Appendix B | 23 ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Susan Burbach of the Medicaid Fraud Policy and Oversight Division served as the 
team leader for this inspection.  Sarah Smith and Jordan Swoyer served as analysts.  
Medicaid Fraud Policy and Oversight Division staff who consulted on the inspection 
include Jordan Clementi Gerken.  Office of Evaluation and Inspections headquarters 
staff who provided support include Robert Gibbons and Sara Swisher.   
Two agents from the Office of Investigations also participated in the inspection and 
provided technical assistance to the Unit.  
This report was prepared under the direction of Brian Whitley, Regional Inspector 
General for Evaluation and Inspections in the Kansas City regional office, and Dana 
Squires and Abbi Warmker, Deputy Regional Inspectors General, as well as in 
consultation with Richard Stern, Director of the Medicaid Fraud Policy and Oversight 
Division. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Iowa Medicaid Fraud Control Unit: 2021 Inspection 
OEI-07-21-00340   Acknowledgments and Contact | 24   
ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable 
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs.  To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries.  With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
 
   
Iowa Medicaid Fraud Control Unit: 2021 Inspection   
OEI-07-21-00340   About the Office of Inspector General | 25