U. S.  Department of Health and  Human Services  
 
Of fice of Inspector General  
   
 
 
 
 
 
 
 
Illinois Medicaid Fraud Control  
Unit: 2019 Onsite  Review  
 
 
Suzanne Murrin  
Deputy Inspector  General  
for Evaluation  and  Inspections  
March  2021, OEI-06-19-00510   U.S. Department of Health and Human Services  
O  ffice of Inspector General 
 
Report  in Brief 
 
M arch  2021, OEI-06-19-00510  
 
Illinois Medicaid  Fraud Control Unit:  
Unit Case Outcomes  
Federal fiscal  years  (FYs)  20172019  
2019  Onsite Review  
   141  indictments  
   151 convictions   
What OIG Found  
   52  civil settlements  and  
We found that  during FYs  20172019,  the  Illinois  MFCU  generally  operated  in  
judgments  
accordance  with  applicable  laws,  regulations,  and  policy transmittals.  
   $180.5 million  in  recoveries  
However,  we  made  six  findings  regarding  the  Units  adherence  to  MFCU  
performance standards:  
Unit Snapshot 
The  Illinois  Medicaid  Fraud  Control   1.   The  Units  organizational  structure  created  several  staffing challenges,  
Unit  (MFCU  or  Unit)  is  located  
raising  concerns  about  its  operational efficiencies.       
within,  and  follows  the  law  
2.   The  Units  process for  receiving  referrals  of patient  abuse and neglect  led 
enforcement  command  structure  
to  the  Units  screening of thousands of  referrals  that  were unsuitable  for  
of,  the  Illinois  State  Police.   
investigation,  diverting time and resources  from  viable cases.  
At  the  time  of  our  onsite  review  in 
3.   The  Unit  did  not  always  coordinate  on  or  actively  participate  in  cases  
November  2019,  the  Unit  had  a 
with  Federal partners,  missing  opportunities for  sharing  resources 
total of  43  employees across 
and  training.   
multiple  office  locations 
throughout  the  State.   In  addition,   4.   The  Unit  did  not  always  report  convictions  or  adverse  actions  to  Federal  
the  Illinois  Office  of  the  Attorney  partners  within the  appropriate timeframes.  
General  provided 11 attorneys
5.   Newly  hired Unit  investigators  did  not  always complete new  employee 
not  covered under  the MFCU  
trainings, which could  affect  the Units  overall effectiveness.  
grantto  prosecute  the  Units  
cases,  an  arrangement  unique  6.   Although the  Unit  documented its  periodic  supervisory reviews  in  most  
to  Illinois.     of its  case files,  the Unit  had  difficulty adhering  to  its  policy  of  conducting  
the reviews  monthly.   
Why OIG  Did This Review 
What OIG  Recommends and How the Unit Responded 
The  Office of Inspector  General  
(OIG)  administers  the MFCU  grant  To  address  these findings  and further  improve Unit  operations,  we  
awards,  annually  recertifies  each   recommend  that  the  Unit  (1)  develop  and implement  a plan  to  address  
Unit,  and  oversees  the  Units   the  challenges  presented  by  the  Units  organizational structure (i.e.,  its  
performance  in  accordance  with   location within  the  Illinois  State  Police,  rather  than within a  State  Attorney  
the  requirements  of  the  grant.   Generals  office like  most  other  MFCUs);  (2)  establish  minimum  criteria  for  
As  part  of  this oversight,  OIG  referrals  of patient  abuse and neglect  to  be  sent  to  the  MFCU; (3)  establish a  
conducts  periodic  reviews  of Units   process  to coordinate  on  cases and  improve  collaboration  with  Federal 
and  issues public  reports of  partners; (4)  take steps  to  ensure  that  Unit  staff  report  all convictions  and  
its  findings.     adverse  actions  to  Federal  partners  within the  appropriate  timeframes;  
(5)  take  steps  to  ensure  that  newly  hired investigators  complete new  
In  2012,  OIG  found  that  the  Illinois   employee trainings; and (6)  take steps  to  ensure  that  supervisory  reviews  of 
MFCUs  organizational  structure   case files are conducted and documented in  accordance  with  Unit  policy.   
conflicted with  Federal   The  Unit  concurred  with all six  recommendations.   
requirements.   This  onsite  review  
examined this  previously  identified   
area  of  concern and  the  MFCUs  
performance and operations.   
     
   
TABLE OF  CONTENTS  
 
 
 
 
BACKGROUND   1 
CASE  OUTCOMES   9 
FINDINGS   10 
The Units organizational structure created several staffing challenges, raising concerns about   10 
its operational efficiencies      
The Units process for receiving referrals of patient abuse and neglect led to the Units  14 
screening of thousands of referrals that were unsuitable for investigation, diverting time and  
resources from viable  cases  
The Unit did not always coordinate on or actively participate in cases with Federal partners,  15 
missing opportunities for sharing resources and training  
The Unit did not always report convictions or adverse actions to Federal partners within the  16 
appropriate timeframes  
Newly hired  Unit investigators did not always complete new employee trainings, which could   18 
affect the Units overall effectiveness  
Although the Unit documented its periodic supervisory reviews in most  of its case files,  20 
the  Unit had difficulty adhering to its policy of conducting the reviews monthly  
RECOMMENDATIONS    21 
Develop and implement a plan to  address the challenges presented by the Units  21 
organizational structure  
Establish minimum criteria for referrals of patient abuse and neglect to be sent to the MFCU   22 
Establish a process to coordinate on cases and improve collaboration with Federal partners   22 
Take steps to ensure that Unit staff report all convictions and  adverse actions to Federal   22 
partners within the appropriate timeframes  
Take steps to ensure that newly hired investigators complete new employee trainings   23 
Take steps to ensure that supervisory reviews of  case files are conducted and documented in  23 
accordance with Unit  policy  
UNIT COMMENTS AND OIG RESPONSE    24 
APPENDICES   25 
A.   Performance Assessment   25 
B.  Illinois MFCU  Referrals Received, by Source, for FYs 20172019   30 
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510  
    C.   Detailed Methodology   31 
D.  Point Estimates and 95-Percent Confidence Intervals of  Case File Reviews   34 
E.  Unit Comments   35 
ACKNOWLEDGMENTS AND CONTACT   38 
ABOUT THE OFFICE OF INSPECTOR GENERAL   39 
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510  
     
 
BACKGROUND  
 
 
Objectives  
1.   To examine a  previously identified  area of concern related to  the 
organizational  structure of the Illinois Medicaid  Fraud Control Unit  
(MFCU  or  Unit).  
2.   To examine the performance and operations of the Unit.   
Medicaid  Fraud  Control  Units  
The function of  MFCUs is to investigate Medicaid  provider fraud and patient abuse or 
neglect and to prosecute those cases under State law or refer them to other 
prosecuting offices.1   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  
50 States, the District  of  Columbia, Puerto Rico, and  the U.S. Virgin  Islands.4     
Each Unit receives a Federal grant award equivalent to 90 percent of total 
expenditures for new Units and 75 percent for all other Units.5   In Federal  fiscal 
year  (FY) 2020, combined Federal and State expenditures for the  Units totaled  
$306  million, with a  Federal share of  $229  million.6   
 
 
 
_____________________________________________________________________________________________________________________________  
1  SSA  1903(q)(3).  Regulations at 42 CFR 1007.11(b) add that the Units responsibilities may include  
reviewing complaints of  misappropriation of patients or residents private funds in facilities.  As of  
December 27,  2020, MFCUs  may also investigate  and prosecute patient abuse or neglect of Medicaid  
beneficiaries in a noninstitutional or other setting.  Consolidated Appropriations Act, 2021, P.L.  
No.  116-260, Division CC, Section 207.  
2  SSA  1903(q).  
3  SSA  1902(a)(61).  
4  The territories of American Samoa, Guam, and the Northern Mariana Islands  have not established Units.  
5  SSA  1903(a)(6).  For a Units first 3 years of operation, the  Federal  government contributes 90 percent 
of funding and  the State contributes 10 percent of Unit funding.  
6  OIG analysis of MFCUs FY 2020 reporting of expenditures.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  1 
     
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.7, 8   As part of  its oversight, OIG recertifies each Unit  
annually and conducts periodic reviews or inspections.   
In its annual  recertification review, OIG examines the Units reapplication, the Units 
case statistics, and questionnaire responses from Unit stakeholders.  Through the 
recertification review, OIG assesses a Units performance, as measured by the  
following: its adherence to published performance standards;9   its compliance with 
applicable laws, regulations, and OIG policy transmittals;10  and its case outcomes.  
See  Appendix A  for the 12 performance standards and our assessment of the Illinois 
MFCUs adherence to those standards.   
OIG further assesses Units performance through periodic  reviews of selected Units.  
OIG selects Units for these reviews based on an annual risk assessment of all Units.  
Each of  OIGs reviews  may identify findings and result in recommendations for 
improvement.  OIG may also make observations on Unit operations and practices, 
including identifying beneficial practices that may be useful to share with other Units.  
In addition, OIG provides training and technical assistance to Units, as appropriate,  
both during the review and on an ongoing basis.  
Illinois MFCU  
The Illinois MFCU, also  known as the Medicaid  Fraud Control Bureau, operates under 
the Division of  Criminal Investigations within  the  Illinois State Police  (ISP).  Under the 
ISP, the MFCU  conforms to a  law enforcement command structure  and  has six offices 
across the Northern, Central, and Southern regions.11   At the time of our review in 
November 2019, the Unit had 43 staff members across its 3  regions1 director; 
_____________________________________________________________________________________________________________________________  
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.          
8  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.  
9  MFCU performance standards are published  at 77 Fed. Reg.  32645 (June 1,  2012) and can  be viewed at 
https://www.oig.hhs.gov/authorities/docs/2012/PerformanceStandardsFinal060112.pdf.  OIG developed  
the performance standards in conjunction with the MFCUs, and the standards were originally published 
at 59  Fed. Reg.  49080 (Sept. 26, 1994).  
10  OIG occasionally issues policy transmittals to provide  guidance and instruction to MFCUs.  Policy  
transmittals may be found at https://www.oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/index.asp.  
11  The Northern region includes  a regional office in the Chicago suburb of Tinley Park and two satellite  
offices in  Sterling and Des Plaines.  The Central region includes an office  in  Springfield, the States capital.   
The Southern region  includes  a regional office in Collinsville  and a satellite  office in Du Quoin.    
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  2 
     
24  sworn law enforcement investigators;12  8 civilian investigators, referred to as 
internal security investigators; 1 nurse investigator; 2  auditors;  2 in-house attorneys,  
including the assistant director or bureau chief; 4  analysts; and 1  administrative  
staffer.13   The  Unit director is located in the Central  region.  Command supervisors  
report to the Unit  director,  and  first-line supervisors report to a  command  supervisor.  
All other Unit  investigators  report to a  first-line supervisor.   The  supervising auditor, 
supervising analyst,  administrative  staffer, and in-house attorneys  report to  the  Unit  
director, regardless of  their  office  location.14   See  Exhibit  1  for an organizational chart  
of the Units reporting structure.  
Exhibit 1: Organization and reporting structure of the Illinois MFCU 
(November 2019)  
 
NOTE: The dotted line represents a working relationship, but not direct supervision. 
Source: OIG analysis of Illinois MFCU  and State  Attorney  General  Offices  organizational charts,  position 
descriptions, and Unit  responses,  November  2019.  
 
_____________________________________________________________________________________________________________________________  
12  The sworn law enforcement investigators include two command supervisors (one who supervises the  
Northern region and one who supervises the  Central and Southern regions) and four first-line 
supervisors.  One of the command supervisors and one of  the first-line supervisors were  in an acting 
capacity at the  time of our review.  
13  During our review period of FYs 20172019,  the Unit spent $23.6  million (with a State share of 
approximately $5.9  million).   
14  The remaining analysts and auditors report to their respective supervisors, except for one  analyst,  
who  reports to an investigator  who is a first-line supervisor.   
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  3 
     
The Unit is one of  four  MFCUs that  is not part of a  State Attorney Generals  office.15   
Through a memorandum of understanding (MOU) with the Attorney Generals Office,  
the  Unit  relies  on  11 attorneys from the  Illinois  Attorney Generals Office  to prosecute 
the  Units  cases of  Medicaid fraud and patient abuse and neglect.   These attorneys 
work  exclusively on MFCU cases but report to the Attorney Generals Office, are  paid  
for by the ISP, and are not  covered by the MFCU  grant.  The MFCUs two  in-house 
attorneys do not prosecute cases; instead, they provide legal advice  on cases and,  
among other duties, handle global civil fraud cases, which  are False Claims Act cases 
that involve the U.S. Department of Justice and a  group of MFCUs.16,  17    
Referrals.   During FYs 20172019, the Unit reported receiving fraud referrals from 
several sources, including  the  Illinois  Department of Healthcare and Family Services  
Office of Inspector General  (HFS-OIG),  which serves as the program integrity unit for 
the State Medicaid agency;  and  the  Department of Human Services/Department of  
Rehabilitation Services (DHS/DORS), which administers the States home and 
community-based services (HCBS)  waiver program.18   The Unit  received a significant  
number of referrals related to  personal care services from DHS/DORS.   The Unit  also  
reported receiving referrals of patient abuse and neglect  from the Illinois Department  
of Public Health,  which serves as the State survey and certification agency.   
The  Department of Public Health  conducts  inspections  to certify health  care facilities  
for Medicaid compliance  and  investigates  and validates  referrals.19   Appendix  B  lists 
Unit referrals by source for FYs 20172019.  
The Unit  has  different procedures for receiving  referrals  based on the referral  source.  
Fraud  referrals from  the HFS-OIG  and DHS/DORS are sent to the Unit  via a secure 
email.   A Unit  analyst reviews the fraud  referrals to determine to  which MFCU  region  
to  send the referral  and may conduct  additional analyses to  assist the command  
_____________________________________________________________________________________________________________________________  
15  The other three MFCUs that do not reside in an Attorney Generals Office, or another office with State-
wide authority to prosecute criminal  cases, are those of the District of Columbia, Iowa, and  Tennessee.   
While  each of the four MFCUs have arrangements with other State, county, and Federal  prosecutors to 
prosecute  their cases, Illinois is the only MFCU that has a dedicated team of attorneys from the Attorney  
Generals Office assigned to MFCU prosecutions.    
16  The MFCU complies  with staffing requirements, as the MFCU employs [o]ne or more  attorneys  
capable of prosecuting the Units health care fraud or criminal cases and capable of  giving informed 
advice on applicable law and procedures and providing effective prosecution or liaison with other  
prosecutors.  42  CFR 1007.13(b)(1).    
17  The National Association of Medicaid Fraud Control Units (NAMFCU) facilitates the settlement of 
global cases on behalf of the States.  
18  Under the HCBS waiver program,  States can provide  care and services to  Medicaid-eligible  
beneficiaries in their homes and other community-based settings, such as assisted living facilities.  
Examples of care and services  include case  management services, homemaker services, and personal  care 
services, such as activities of daily living (e.g., bathing, light housework, and meal preparation).  For HCBS  
waiver requirements, see  42 CFR pt. 441,  subpt. G.  
19  Illinois Department of Public Health,  Who Regulates Nursing Homes?   Accessed at  
https://dph.illinois.gov/topics-services/health-care-regulation/nursing-homes/regulation                         
on August 12,  2020.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  4 
     
supervisor, who has the responsibility on behalf  of the MFCU to  determine  whether to  
accept  the referral.  Referrals of patient abuse and neglect  from  the Department of  
Public Health  are sent directly to the respective MFCU  region,  and  an  analyst enters  
the  referrals  into the Units case management system.  A Unit  supervisor  determines 
whether to accept the referral and may involve the nurse investigator  for issues 
pertaining to quality of  care or standards of medical practice.   Referrals of  fraud and  
patient abuse and neglect  from  any other sources are  entered into  the  Units case 
management system by an analyst in the receiving  region  and are reviewed by  a 
command  supervisor.   
Investigations.   Once  the Unit accepts a referral, the command  supervisor assigns  
an investigative team  to  the case.  The investigative team consists of  an investigator  
(sworn or  civilian),  an analyst,  an  attorney  from the Attorney Generals Office,  and  Unit  
support staff  (e.g.,  auditor, in-house attorney), as appropriate.  The investigative team 
completes an  investigative plan,  which  outlines  and assigns key investigative tasks to 
the team members  and includes dates for  regularly scheduled  meetings  to discuss 
progress and  adjustments  to the initial investigative plan.   The Unit stores all case 
recordsincluding  opening documentation,  interviews, summaries, case  file reviews, 
and closing  requestsin  its  electronic case  management  system.   If the investigative 
team decides to prosecute  a case  following  a  full  investigation, the  team  consults  and  
obtains  approval  from the Unit director.  
Prosecutions.   After  the Unit director  approves a case for prosecution, the  Unit  
must formally refer the case to the Attorney Generals Office for a prosecutorial  
decision.   If  the Attorney Generals Office accepts the case,  it  may prosecute the case 
in State  court but  must first  obtain  approval  from the local  district  attorney  because  
the Attorney Generals Office does not have Statewide authority to prosecute cases.     
The Attorney Generals Office may also  pursue civil cases on the Units behalf in State 
court under the States False  Claims  Act.20   The Unit may also  prosecute criminal cases 
and litigate civil cases in Federal court.  The Unit may pursue those cases in 
collaboration with, or referral by, the U.S. Attorneys Offices or OIG.  If  the Attorney 
Generals Office declines a  case, the Unit may refer the case to  another agency with 
prosecutorial authority, such as local  law enforcement  or Federal  partners.   There are 
three  U.S. Attorneys Offices  that operate in the State of Illinois, located  in the 
Northern, Central, and  Southern  Districts.   The MFCU has regions  that correspond  
with  these  three U.S. Attorneys  Offices.  
 
 
 
_____________________________________________________________________________________________________________________________  
20  Illinois State Statutes 740 ILCS 175.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  5 
     
Illinois Medicaid  Program  
The Illinois Medicaid program is administered by  the Department of Healthcare and  
Family Services  (HFS).  In FY 2020, Illinois  Medicaid expenditures were $23.3  billion.21   
The  HFS administers the States Medicaid fee-for-service and managed care 
programs.22   There are seven  Medicaid  managed care organizations (MCOs) in the 
State of Illinois.23   In February  2021, 77 percent of  Illinois  approximately 3.5 million 
Medicaid beneficiaries received their services through these 7  MCOs.24  
Medicaid Program Integrity.  The HFS-OIG  and  the States  seven MCOs are  
primarily  responsible for Medicaid program integrity efforts in Illinois.  Under 
managed  care, the HFS  contracts with MCOs to  process, pay,  and  monitor claims of  
providers in the MCOs networks.   Each MCO deploys Special  Investigative Units that  
identify and  investigate potential  fraud and abuse in its networks  and refer suspected  
cases of provider fraud or patient  abuse to  the HFS-OIG.25   The  HFS-OIG  conducts 
administrative investigations on referrals received,  including those from  MCOs  and  
from  its  hotline,  and  refers suspected  fraudulent activity  to the  MFCU,  as specified in 
an  intergovernmental agreement between the HFS-OIG and the MFCU.   The  MFCU  
reviews all referrals  from  the HFS-OIG  to determine whether  credible allegations  of  
fraud  exist  and  notifies HFS-OIG  in writing  of its  determination.    
Previous  OIG  Reports and  Oversight  
In 2012, OIG  conducted  an onsite review of the Unit.26   OIG found  that the Units 
organizational  structure  for its attorneys, who did not report to the Unit director,  
conflicted with the Federal requirements implementing the principle that the Unit be 
a single, identifiable entity, and found that  the  attorneys assigned to the Unit were 
ineligible for  Federal Financial Participation.27   The  attorneys were housed in a  
_____________________________________________________________________________________________________________________________  
21  OIG,  MFCU Statistical Data for FY 2020,  March 2020 (not yet available  online).    
22  HFS, Managed Care in Illinois.  Accessed at  
https://www.illinois.gov/hfs/MedicalClients/ManagedCare/Pages/default.aspx  on April 23, 2020.  
23  DHS, Managed Care Organizations.  Accessed at  
https://www.illinois.gov/hfs/SiteCollectionDocuments/StatewideHealthChoiceIllinoisPlans.pdf  on 
March  10, 2021.  
24  On March 1, 2021,  the State Medicaid agency reported that approximately 2,667,101 of its  
3,479,292  beneficiaries were  enrolled in MCOs in February 2021.  The total number of beneficiaries  
enrolled in Medicaid for February 2021 may increase from 3,479,292 over the next few  months as the  
agency  processes retroactive enrollments.   
25  42 CFR  438.608.  
26  OIG,  Illinois State Medicaid Fraud Control Unit: 2012 Onsite  Review, OEI-07-12-00510, June 2013.   
Accessed at  https://oig.hhs.gov/oei/reports/oei-07-12-00510.asp  on March 29, 2020.  
27  The portion of funds reimbursed to States by the Federal  government for  its share of expenditures for  
the Federal Medicaid program, including MFCUs, is called the Federal Financial Participation.  Federal 
Financial Participation is not available for the compensation of persons other than full-time professional 
employees of the Unit.  42 CFR    1007.13 and 1007.19(e)(4).  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  6 
     
different location in State government, the Attorney Generals Office, and reported to  
a  Bureau Chief  (see Exhibit 1 on page 3).  Given this organizational structure, OIG  
determined that the MFCU  should not have used  the MFCU grant  to pay for these 
attorneys,  as they were not MFCU employees.  OIG recommended that the Unit  
develop and implement a corrective action plan to address noncompliance with the 
certification  requirements, including  the full-time employment rule for attorneys.   
Based on other findings in the report, OIG  also recommended that the Unit  (1)  refer 
convicted providers to OIG  for program exclusion  within appropriate timeframes;  
(2) update the Units MOU with the State Medicaid agency to comply with Federal  
grant  requirements; (3) ensure that  all case files  contain  opening and closing  
documents, investigative  memoranda,  documented  supervisory approvals,  and  
documented periodic supervisory  case file reviews; (4) ensure referrals for prosecution 
follow established protocols; (5)  ensure investigations are related to Medicaid and  
repay grant funds for ineligible cases; (6)  upgrade the Units case management  
system; (7)  improve  communication and cooperation with key stakeholders; and  
(8)  establish  training  hour  requirements for professional disciplines.   
OIG assisted  the Unit with developing the corrective action plan, which was approved  
by OIG in  July  2013  but took effect in  June  2015.  As  a  result of the corrective action 
plan, the MFCU removed  from the Federal grant the 10  attorneys who  were  employed 
and supervised by the Attorney Generals Office.28   Under its amended MOU with the 
Attorney Generals Office, the MFCU agreed to designate ISP  funds to pay for 
11 attorneys from the Attorney Generals Office to work exclusively on MFCU 
matters.29   The MFCU also  hired its own in-house attorneys,  who  report to the Unit  
director.  By  June  2015, OIG considered  all  of the  recommendations to have been 
implemented by the  Unit.  
In addition to these recommendations, OIG,  in its 2012 review,  made an observation 
concerning  turnover with the Unit director position.  External stakeholders and Unit  
staff  reported  that the frequent turnover of the Unit  director was problematic and 
impeded  Unit  productivity.  The Unit employed six directors (some of  whom  were in 
acting capacity)  during  our  3-year review period  (FYs  20092011).  OIG  noted  the 
same observation  in  an  earlier  onsite report,  issued  in 2011.  We found that the Unit  
had  three directors  during  a 12-month  period, which staff reported  was affecting  the  
Units continuity and ability to effectively carry out  its mission.30  
_____________________________________________________________________________________________________________________________  
28  Subsequent to our 2012 onsite review, the Attorney Generals Office added  an additional  attorney to 
work exclusively on MFCU matters, bringing the total to 11 attorneys.   
29  Although the attorneys in the State Attorney Generals Office work solely on MFCU matters, they are  
not eligible for  Federal Financial Participation under the Federal grant because they are not MFCU  
employees.  In FY 2019, the ISP paid  an estimated $975,000 for the salaries  of the attorneys in the State  
Attorney Generals Office.  OIG would have paid 75 percent of these salaries  if these positions were a part 
of the MFCU.   
30  OIG,  Onsite Review of the State of Illinois Medicaid Fraud Control Bureau, May 2011 (not 
available  online).  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  7 
     
Methodology  
We conducted  an  onsite review of the Illinois Unit  in November 2019.  The review  
team consisted of OIG evaluators, OIG agents, and an  OIG  grant  oversight analyst.  
Our review covered the 3-year period of  FYs 20172019.  The primary purpose of this 
review  was to examine an area of  concern related to the Units  organizational  
structure within the ISP and its relationship with the  Attorney Generals Office and to  
examine  the Units operations and adherence to the 12 performance standards and  
applicable Federal laws, regulations, and policy transmittals.  In  examining the Units 
operations and performance, we applied the published  MFCU  performance standards 
listed in Appendix A, but we did not assess every performance indicator for each of 
the 12 standards.   See  Appendix  C  for a detailed methodology.  
We based our review on an analysis of data from  eight  sources: (1) Unit 
documentation, such as policies and  procedures; (2) financial documentation;  
(3)structured interviews with key stakeholders; (4) structured interviews with Unit  
management; (5)  survey of Unit  staff; (6)  review  of a random sample of case files that  
were open at some point during the review period; (7)  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)  observation 
of Unit  operations.   
Standards  
We conducted this study in accordance with the Quality Standards for Inspection  and  
Evaluation  issued by the Council  of the Inspectors General  on Integrity and Efficiency.  
These inspections differ from other OIG  evaluations in that they support  OIGs direct 
administration of  the MFCU  grant program, but  they are subject to the same internal  
quality controls as  other OIG evaluations, including internal and external peer review. 
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Background  |  8 
     
CASE  OUTCOMES 
The Illinois Unit  reported 141 indictments;  151  convictions;  and 52  civil 
 
settlements  and judgments for FYs 20172019.31    
Of the 151  convictions, 120 involved  provider fraud and  31 involved patient  
abuse or neglect.   Our analysis  showed that  these statistical  outcomes by 
the  Illinois Unit  were comparable to  those of  other similarly sized  
MFCUs.32    
 
The Unit reported $180.5 million in  total recoveries for  FYs  20172019.  
The Unit reported total recoveries of  $180.5 million for  FYs 20172019, with 
nonglobal civil recoveries representing  nearly $140  million.   See Exhibit  2  
for the source of the  recoveries.  
Exhibit 2: The Unit reported  combined civil and  criminal recoveries  of 
$180.5 million during FYs 20172019.  
 
Source: OIG analysis of Unit statistical data  FYs  20172019.  
_____________________________________________________________________________________________________________________________  
31  OIG provides information on MFCU operations and outcomes, but it does not direct or  encourage  
MFCUs to investigate or prosecute a specific number of cases.   MFCU investigators and prosecutors 
should apply professional judgment and discretion in determining which criminal and civil cases  
to  pursue.  
32  In FY 2019, 9 other similarly sized MFCUs had staffs that ranged in size from 40 to 97 employees; the  
Illinois MFCU had a staff of 43 employees.  Although comparison across similarly sized MFCUs provides  
context for the case outcomes  of a particular  MFCU, many factors other than the size of a  MFCUs staff  
can affect case  outcomes.  
Illinois Medicaid Fraud Control Unit:  2019 Onsite Review  
OEI-06-19-00510   Case Outcomes  | 9    
 
 FINDINGS  
 
 
We  reviewed  a  previously identified  area of concern related to the  Illinois  Units  
\
organizational structure,  and we assessed the Units adherence to the MFCU  
performance standards.   From  this  review, we identified six  areas in which the Unit 
should improve its adherence to the MFCU performance standardstwo  of which  
also involved compliance with Federal regulationsand  for which  we  are issuing  
recommendations.  See Appendix A  for our full assessment of the Units adherence 
with all 12 MFCU performance standards, including observations of Unit operations 
and  practices.   
The Units  organizational structure created  several staffing 
challenges, raising  concerns about  its  operational efficiencies       
The Units organizational structure within the ISP created  staffing  challenges  and  
instability for the Unit.  Under the ISP  command structure, the  Unit directors position  
was  often used  as a temporary means  for law  enforcement officials to advance  
through the ranks, resulting  in frequent turnover of Unit directors.   This turnover, 
which is a  longstanding  issue for the Unit, affected the Units ability to make long-
term improvements to  its operations.  Further, the Units placement within the ISP, 
coupled with State-wide hiring restrictions, affected the Units ability to maintain 
approved staffing  levels.  
The Unit experienced significant turnover of  directors,  largely 
as a  result of  the ISP command structure, hampering  the 
Units  long-term improvements and  straining relationships 
with  stakeholders  
Historically, the Unit  has had  frequent  turnover  in the directors position.  From  
FYs  20092019, the Unit employed a  total of  11  directors, some of whom were in an  
acting capacity.  Of these 11  directors, 3 were employed during our review period  of 
FYs 20172019, 1  of whom  was serving  in an acting capacity.  The Unit hired the 
current director in January  2019.  Following OIGs 2012 onsite review, the Unit  
reported that it had created a deputy director position to  increase stability for the 
Unit and mitigate the impact of the frequent turnover of directors.33   However, we 
found that despite this effort, the director turnover continued to  negatively impact 
the Unit.    
_____________________________________________________________________________________________________________________________  
33  As of January 2021, the current deputy director had been in that position for 7 years and  had been 
employed  with the MFCU for approximately 8  years beyond that.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 10    
In interviews, Unit staff and stakeholders attributed the director turnover to the ISP  
command structure  and  described  the directors position as a revolving  door.    
According to Unit staff  and stakeholders, the Unit  director  position was often used to 
provide senior law enforcement officials with  an opportunity  to maximize  their pay 
and benefits before retirement or as  a stepping stone  to assist  officials in  rising  
through the  ranks  within the command structure.   As  a result, although all of the 
Units past directors had previous supervisory experience within the ISP, interview  
respondents reported  that some of these  directors were not equipped to fulfill the 
role of the Unit director, largely because they lacked  knowledge and experience as to 
how to investigate and prosecute Medicaid fraud.  Further, most  Unit directors did not  
stay long enough with the Unit to invest in long-term improvements, thereby 
potentially impeding  the Units  success.  
Some  stakeholders reported that  the turnover of directors had strained  the Units 
relationships with some key stakeholders, including Federal partners,  because the 
stakeholders had  to rebuild their relationships with the  director each time a new  
director came on board.  Because  Medicaid fraud  cases often depend  on  the 
involvement of  other  State and Federal  agenciesboth  to  obtain strong referrals and  
to collaborate with other agencies in investigating and prosecuting  casesthe 
frequent change in Unit leadership  undermined the long-term relationships necessary 
to the success of the Unit.   Stakeholders stated  that over  time,  collaboration efforts  
with the Unit director decreased  as a result of the director turnover.  Stakeholders 
reported that on the other hand, this  disruption to relationships was mitigated by 
regular contact with Unit  supervisors and frontline  staff,  some  of  whom  had been 
employed  with  the Unit for more than a decade.  
During our onsite review, the current director acknowledged the Units history of  
leadership instability  and  expressed  his intent to  remain with the Unit until he 
becomes eligible for retirement in 2024.  The director  also  stated his belief  that a 
recent reorganization within the ISP should reduce future turnover of directors.  
In  FY  2019, the Unit  moved from the Operations Division  within the ISP  to  the 
Criminal Investigations Division, which has only one colonel  position.   The Unit  
director believed that  with  limited promotional  opportunities within the Criminal  
Investigations Division,  there will be less  director turnover  in the  future.  
 
 
 
 
 
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 11    
State-controlled hiring  restrictions  and the Units placement in 
the ISP  affected  the Units ability  to  maintain  approved staffing 
levels, contributing to large caseloads   
According to Performance Standard 2, a Unit should 
Performance Standard 2(e): 
employ the number of staff  included in its OIG-
To  the  extent  that  a  Unit  
approved budget and commensurate with the  maintains  multiple  office  
States Medicaid program expenditures.   At the time   locations,  such  locations  are  
of our review, the Unit employed 43  staff members,  distributed  throughout  the 
which was less than its OIG-approved staffing  level   State,  and  are  adequately 
of 60  employees.34   For a  MFCU with the level of   staffed,  commensurate  with  
the volume of  case referrals  
State Medicaid expenditures that Illinois had in 
and  workload  for  location.  
FY  2019, the average staff size would be between  
65  and  82 staff  members.35   
We  found that  the Units number of employees decreased  over  the last decade,  at the 
same time as the  State  Medicaid  expenditures increased.   From  FYs  20102019, the  
State  Medicaid  expenditures increased from $15.9  billion to  $19.4 billion.   During the 
same period, the Units number of staff decreased from 69  employees to  
43 employees  (see Exhibit  3  on the  next page).    
According to the Unit, the shift of  10  attorneys  from the MFCU to  the Attorney 
Generals Office in 2013 contributed to  this  decrease in the Units staff size.   These 
attorneys continued to  work exclusively on the Units cases  but were  no longer 
considered  to be Unit employees.  However, even if one were to count the  
11  non-Unit attorneys36  in FY 2019, the resulting number (54) would still be below  
the  average staffing  levels (65 to 82 employees) for a State with a Medicaid program 
the size of Illinois.  
_____________________________________________________________________________________________________________________________  
34  Following our  2012 onsite review, the Attorney Generals Office assigned an additional attorney to 
work on MFCU cases, bringing the total to 11 attorneys.  The  Units 43 employees did not include these  
11 attorneys.    
35  OIG  does not prescribe MFCUs staffing levels.  We assessed the Units staffing levels using a linear  
regression model to compare Medicaid expenditures to actual staff.    
36  The 11  non-Unit attorneys consisted of the 10 who were  moved in 2013 and 1  additional attorney.   
(See also footnote 34.)   
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 12    
Exhibit 3:  The  Units number of  staff decreased  while the  State Medicaid  
expenditures increased during  FYs 20102019.  
$25
69  70  $23.1 
$20 65 
58  $20.2  $19.4 
$17.7  $18.0 
$15 $16.5 
$15.9  45  41  41  45  42  43 
$13.5  $14.0  $16.1 
$10
$5
$0
2010  2011  2012  2013*  2014  2015  2016  2017  2018  2019 
 
*The Unit  shifted 10 attorneys  from the  MFCU grant to the  Attorney Generals Office  in 2013.  
Source:  OIG analysis of  Unit Annual Statistical  Reports  and  Unit-provided  documentation, FYs  2010-2019.   
State  Medicaid expenditures are  reported  in  the  billions  of dollars.  
Unit management expressed the need for additional staff across all professional  
disciplines but  reported that  State-controlled hiring freezes and budget deficits  
made  it difficult to reach full staffing  levels across all  departments  in  the ISP.   Unit  
management reported that the Units limited staff size impeded the Units capacity  
to  investigate cases of fraud and patient abuse and neglect.   We found that to  keep 
up with the workload, many investigators across the Unit  worked  overtime and  
covered other  roles  in addition to their  own  positions.   For example,  a  Unit  supervisor  
in the Units Northern  region  stated  that because of staffing  shortages, he had   
10 investigators doing the job of 22 investigators.   Similarly, an investigator  in the 
Units Central region  described how  one of  the  supervisors  in the region  had  
performed the duties of  two supervisors for the past  2 years.  An  investigator  in  
the  Units  Southern region also explained that these staffing  limitations sometimes 
affected  the timeliness of  cases.  In OIGs professional judgment, the  Units staffing  
shortages  could  limit the type and complexity of cases that the Unit  is able  
to  investigate.   
Unit staff also reported that the MFCU faced recruiting challenges, which further 
affected the Units ability to reach full staffing levels.  For example, Unit staff reported  
difficulties  in  attracting qualified candidates because the MFCUs  mission is not well-
known among ISP personnel.  Further, the ISP does not offer courses on health care  
fraud, so sworn officers are less likely to gain relevant training in the  police academy 
prior to applying to the Unit.37   Staff explained that the lack  of knowledge of  the  
MFCUs work would make candidates less likely to apply for a position with the MFCU,  
as they would be unaware whether the job would be  a good  match.   We found that  
_____________________________________________________________________________________________________________________________  
37  The MFCU must hire sworn investigators from within the ISP.  However, the Unit can hire  its other staff  
(e.g., auditors and civilian investigators) from  outside the ISP.    
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 13    
despite these recruiting challenges, the  Unit  did  not have any ongoing  efforts to 
educate the ISP on the MFCUs mission and role in investigating Medicaid fraud and  
patient abuse and  neglect.    
The Units  process  for receiving  referrals  of  patient  abuse and 
neglect  led  to  the Units  screening  of  thousands  of  referrals  that 
were unsuitable for investigation,  diverting  time  and  resources 
from  viable cases   
Unlike in most other States where the referring agency screens potential  cases 
of  patient abuse and  neglect before referring them to the MFCU, the Illinois Unit  
requested that  the Department of Public Healththe Units largest source for 
such  referralsforward  all  referrals  to the Unit  without first  
screening them for credibility or need for investigation.  
4,352  
During FYs  20172019, the Unit reported receiving 
4,563  referrals of patient  abuse or neglect, 95  percent of  unscreened referrals  
of patient  abuse and 
which  (4,352)  were from  the Department of Public Health.  
neglect  were sent  to 
We  found that only  4  percent of  the referrals of patient  
the  Unit  during              
abuse or neglect from the Department of Public Health  
FYs  20172019;  
(190  of  4,352)  resulted in the Units  opening  of  
about  4  percent  
an  investigation.    
resulted in  
investigations.   
Because  the Department of Public Health  did not  screen 
the referrals  prior to sending them to the Unit,  many of the 
referrals were missing key information (e.g.,  names  or  dates of incidents) or  were not  
within the Units jurisdiction (e.g.,  complaints  about cold  food  or  cleanliness of  
facilities).  Consequently, the Unit reported that  reviewing these referrals was time-
consumingsupervisors  were spending several hours per week screening referrals 
that were unsuitable for investigation, which diverted time and resources from viable 
cases.  In  interviews, one supervisor  reported working overtime on the weekends to  
keep up with the large quantity of referrals that  needed  screening.   
During OIGs previous onsite review  in 2012, we found that the Unit received  
4,879  referrals of patient  abuse and neglect  from  the Department of Public Health  
during FYs 20092011.  The  Unit reported that following the 2012 onsite review,  
the  MFCUs efforts to educate the Department of Public Health  on referrals 
temporarily improved  the quantity and quality of referrals, but over time, the Unit  
started receiving unscreened referrals  again.   
Shortly after our onsite visit in November 2019, the Unit reported working with the  
Department of Public Health to establish a standard for screening referrals of patient  
abuse or  neglect  before forwarding  them to the MFCU.  The  Unit reported that the 
standard, which will be included in an MOU with  the Department of Public Heath,  
will  outline minimum criteria that  referrals must meet in order  to be sent to the  Unit.   
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 14    
The Unit  did  not  always  coordinate on  or  actively participate  in 
cases with  Federal partners,  missing  opportunities  for  sharing 
resources  and  training   
Performance Standard  8(b) states that  Units should 
Performance Standard 8:  
cooperate and, as appropriate, coordinate with OIG 
The  Unit  cooperates  with 
and other Federal agencies on cases being pursued  
OIG  and other  Federal  
jointly;  cases involving the same suspects or 
agencies  in  the  investigation 
allegations;  and cases that are  referred  to the Unit  and prosecution  of Medicaid 
by OIG or another Federal agency.38   Although most   and other  healthcare  fraud.  
Federal partners reported positive interactions with 
the Unit, we  found that  the Unit did  not  always  coordinate with Federal partners 
on  cases involving the same suspects and allegations.39   In law enforcement, such 
coordination is known as deconfliction.  
During our review period, the Unit investigated 35  cases jointly with OIG17 cases  
in  the Units Southern region, 9 cases in its  Northern region, and  9 cases in its  Central  
region.  However, in cases in which  the MFCU was conducting investigations without  
Federal involvement, the MFCU did not  always  take the necessary steps to  deconflict  
those cases with Federal partners.   Although the Unit  reported  deconflicting  on  
certain  cases, OIG agents  who  work  with the MFCU expressed to us the need to  
deconflict all MFCU  cases with  OIG  to avoid  duplicative and  overlapping actions.  
OIG agents working  with the MFCUs Northern region reported  that  they  had  
minimal interaction with Unit  staff  outside of the  nine  cases worked jointly.  
The  agents believed  that the Units constrained resources (e.g.,  staffing shortages)  
contributed to a  lack of regular dialogue  between the agencies and  resulted in OIGs  
investigating few  cases jointly  with the MFCU.  Further,  the OIG  agents  in that region  
reported challenges arising from the MFCUs placement within the ISP.  Unlike  the  
Illinois  MFCU,  MFCUs  are  typically  located within  a  State Attorney Generals office.   
Specifically, the OIG  agents believed  that the Units placement in the ISP  constrained  
the  MFCUs  ability to  investigate complex Medicaid fraud cases,  thereby reducing  
opportunities  for  collaboration.  In  contrast to  the situation in the Northern region, 
OIG  agents  working  with the Units Central and  Southern regions reported  that they  
had a close working relationship with Unit  staff in  those  regions.  
Similarly, we found that the Units Northern region  did not actively participate on 
cases with the U.S. Attorneys Office  for the Northern District  of Illinois, but the Units 
Central and  Southern regions had strong collaboration with the U.S. Attorneys 
_____________________________________________________________________________________________________________________________  
38  Effective May  2019, Federal regulations require that MFCUs make available all information in their  
possession about an investigation or prosecution to OIG  or other Federal investigators and prosecutors  
upon request.  The  Unit should also establish regular meetings or communication with OIG investigators  
and other Federal prosecutors.  42 CFR  1007.11(e).  
39  OIGs previous onsite review in 2012 found that the Units  Northern region did not consistently  
communicate  or collaborate  with the U.S. Attorneys Office  or OIG.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 15    
Offices for the Central and Southern Districts.  Officials in the U.S. Attorneys Office 
for the Northern District reported that they had not had any regular contact with the 
Units Northern region in over 3 years.  In contrast, we found that the Units Central  
and Southern regions communicated and shared information regularly with the U.S. 
Attorneys Offices  for the Central and Southern Districts.  However, officials in the 
Central District reported that the Unit declined to  participate in civil fraud  cases 
because of the perception that the Illinois  Attorney Generals Office would not  
prosecute such cases.   
The lack of  collaboration  with Federal partners in the Units Northern region  limited  
the Units possibility  of  receiving  fraud  referrals from  OIG and the U.S.  Attorneys 
Office  in that region, and  potentially  affected  the  Units ability to achieve criminal  
convictions and civil settlements and judgments.   Further, not  working  joint  cases 
with Federal partners in all the regions  created  missed opportunities  for the Unit  to 
access and  share  resources (e.g., equipment and personnel) more effectively  with  
other law enforcement  agencies.  The Unit  also  missed  valuable opportunities for  
training  with and  receiving  guidance from  other agencies  on  investigating Medicaid  
fraud, particularly complex  cases.    
The Unit  did  not  always  report  convictions  or adverse actions  to 
Federal partners  within the appropriate timeframes  
Performance 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, so that convicted individuals can 
be excluded from Federal health  care programs.40   The Unit  must also report any 
adverse actions against  health  care practitioners, providers,  or suppliers to the 
National Practitioner Data Bank (NPDB) within 30 calendar days of the date of  the 
adverse action.41, 42   We found that the Unit did not  always  report convictions to OIG 
or  adverse actions to  the  NPDB within the appropriate timeframes,  and some were 
not reported at all until  after  we  identified  them  during our onsite review.  
_____________________________________________________________________________________________________________________________  
40  Effective May  21, 2019, 42 CFR  1007.11(g) requires the Unit to transmit information on convictions  
within 30 days of sentencing, or as soon as practicable if the Unit encounters delays in receiving the  
necessary information from the court.  Convictions include those obtained  either by Unit prosecutors or  
non-Unit prosecutors in any case investigated by the Unit.    
41  45 CFR  60.5.  Examples of final adverse actions include, but are not limited to, convictions, civil  
judgments (but not civil settlements), and program exclusions.  See SSA   1128E(g)(1).      
42  Performance Standard 8(g) states that the Unit should report qualifying cases to the Healthcare  
Integrity & Protection Databank [HIPDB], the National Practitioner Data Bank, or successor data bases.  
The HIPDB and the NPDB merged  in 2013; therefore, we reviewed the reporting of adverse actions under  
NPDB requirements.  See 78 Fed. Reg. 20473 (April 5, 2013).    
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 16    
The Unit did not report 34  percent of its convictions to  OIG 
within 30  days of sentencing, and  several of  these were not 
reported  until  after we  identified  them  during  our review  
Of the Units 151  convictions during FYs 20172019, we found  that the Unit reported 
51  convictions (34  percent) to OIG more than 30 days after sentencing.  Specifically,  
the Unit reported 13 convictions within 31 to 60 days after sentencing, 6 convictions 
within 61 to  90 days after sentencing, and 32  convictions more than 90 days after 
sentencing.  Late  reporting of convictions to  OIG delays the initiation of the program 
exclusion process, which may result in improper payments to providers by the 
Medicaid program or other Federal health  care programs as well as possible harm 
to  beneficiaries.43  
Of the 32  convictions reported more than 90 days after  sentencing, we found that  
9  convictions had  still not  been reported to OIG at the time of our onsite review  
and  would not have been reported unless OIG identified them during  the  review.  
Unit  management explained that they incorrectly believed that the Unit  was not  
required to report any financial exploitation cases to OIG.  Subsequent to our onsite  
review, the  Unit reported that it  was in the process of reporting all  outstanding  
convictions to  OIG.   
 
The Unit did not report 77  percent of its adverse actions to the 
NPDB  within  30 days of  the adverse action, and most  of these 
were  not reported until  after we  identified  them during 
our  review  
We found that the Unit reported 117  of  its 151  adverse actions (77 percent) to the 
NPDB more than 30 days after the action occurred during FYs 20172019.44  Of the  
117  late reports, the Unit reported 5 adverse actions within 31 to 60 days after the 
action, 6 adverse actions within 61 to 90 days after the action, and 106  adverse 
actions more than 90 days after the action.   The  NPDB is intended to restrict the 
ability of physicians, dentists, and other health  care practitioners to move from State  
to State without disclosure or discovery of previous medical  malpractice and adverse 
actions.  If a  Unit fails to  report adverse actions to the NPDB, individuals may be able 
to find new  health  care employment with an organization that is not aware of the 
adverse action made against them.  
Of the 106  adverse actions reported  after 90 days of the action, we found that  
90  adverse actions had  still  not been reported to  the NPDB at the time of  our onsite 
_____________________________________________________________________________________________________________________________  
43  The 2012 OIG onsite review found that the Unit failed to report 58 percent (56 of 97) of its convictions  
to OIG, and Medicaid claims data showed that a single  provider, who had not been reported to OIG for 
program  exclusion, received $20,000 from the Medicaid program before being excluded.   
44  45 CFR 60.5. Examples of adverse actions include but are not limited to convictions, civil judgments  
(but not civil settlements), and program  exclusions.  See SSA  1128E(a) and (g)(1).    
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 17    
review.  Unit management explained that they incorrectly believed that OIGs new  
reporting portal system, which became active in April 2018, replaced the requirement  
of reporting  separately to OIG and  the  NPDB.  Thus,  the Unit did not submit any 
adverse actions to NPDB  after April  2018.   Following  our onsite visit, the Unit reported  
that it  was in the process of  reporting all  outstanding adverse actions  to the  NPDB.   
Newly hired  Unit  investigators  did  not  always  complete new 
employee trainings, which could  affect  the  Units  overall 
effectiveness  
Performance Standard  12(a)  states that  the Unit 
Performance  Standard 12(b): 
should maintain a training plan for all professional  
The  Unit  ensures  that  
disciplines (i.e., attorneys, auditors, and  
professional  staff  comply with  
investigators) that includes an annual minimum  their  training  plans  and  
number of training hours.  In reviewing the Units  maintain  records  of  their  
training records, we found that the Unit  maintained   staffs compliance.  
training  plans  for all professional disciplines.  Unit  
investigators generally met their minimum number of  training  hours in  their training  
plans.45   However,  newly hired Unit investigators did not  always complete  new  
employee trainings.46   Failure to ensure that investigative staff  receive all necessary 
training  could  limit the Units overall  effectiveness, especially for new Unit  
investigators who  did  not have any prior Medicaid fraud  experience.47  
According to the Units training plans, newly hired  investigators complete three 
trainings, including a 2-day in-house training program  provided by the MFCU, 
a  Medicaid  Fraud 101 course provided by the National Association  of  Medicaid Fraud  
Control Units (NAMFCU), and  a Basic  Investigator Course  provided by the ISP,  
in  addition to  continuing  education trainings  and working  alongside more 
experienced  investigators for at  least the first year.   The Units in-house training  
program is an introduction to  Medicaid fraud  for all new professional staff and  
includes information  on how to investigate specific types of  providers, Federal  
governing regulations, relevant State agencies, and data analysis.  The NAMFCU 
offers  MFCU employees several 3-day training courses  designed for MFCU  employees 
with  different levels of experience.  The Basic Investigator Course by ISP  provides 
_____________________________________________________________________________________________________________________________  
45  Per the Units training plans, all investigators complete (contingent upon available funds and travel 
approval) 16  hours of continuing education, annually, on topics related to Medicaid fraud,  investigative  
strategies, technical investigative services, or career development or certification requirements.   
Most  investigators met their annual training  hours in calendar years (CYs) 20172019, with training  
completions ranging from 92 to 100 percent among investigators.    
46  In our analysis, we included only staff who were  employed  with the Unit for at least 11 of 12 months  
during each CY.  Although we reviewed training records, we  did not otherwise evaluate staffs  
professional qualifications.   Not meeting the training plan requirements does not suggest that the  
professional staff are unqualified.    
47  None of the Units 32 investigators had prior Medicaid fraud experience, although Unit staff reported  
that 3 investigators had prior experience investigating other types of health care fraud.   
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 18    
all  investigators with basic investigative tools and is a component of the Field  
Training  Agent program, which includes guidance and direction from more  
experienced  investigators.  
The  Units training records showed that  not all  new investigators completed  the three  
trainings  within the specified  timeframes.48   Specifically, we found that 36 percent   
(4 of 11) of the new investigators did not complete the in-house training program,   
73 percent (8  of 11) did  not attend the NAMFCU Medicaid Fraud 101 course, and   
45 percent (5  of  11) did  not complete the Basic Investigator Course within specified  
timeframes (see  Exhibit 4).   Initial training is important to provide new investigators 
with on-the-job Medicaid fraud experience, given that many investigators lack such 
prior experience.  Until new investigators are sufficiently trained and gain hands-on  
experience, they will likely be unable to investigate complex fraud, which could affect  
the types of cases that the Unit is able to  investigate.  
Exhibit 4: Percentage of newly hired investigators who did not complete new 
employee trainings on time during CYs 20172019  
73% 
45% 
36% 
In-House  Training  NAMFCU  Medicaid  Fraud  101  Basic  Investigator  Course 
 
Source: OIG analysis of  Unit  training records during  CYs 20172019.   Our assessment of the  Units annual training  was  
by  CY  because that is how  the  Unit calculated its annual training hours.  
In  interviews, Unit management  reported  a number of  challenges  that affected the 
Units ability to ensure that investigators completed  new employee trainings.   For  
example, the  Unit explained that  the  in-house training program  relied  on outside 
agencies, such as HFS-OIG  and  State  Long-Term Care Ombudsmen,  and  that 
scheduling  those presenters every time the Unit hired a new  investigator was  time 
intensive.  The  Unit  also  reported  that in October 2019, the Illinois Governors Office 
issued travel restrictions for out-of-State trainings, such as those  offered by the 
NAMFCU, which  limited the number of staff  that could  attend such trainings.   The 
Unit  stated  that  with the new travel  restrictions,  the number of  staff  allowed  to  attend  
an out-of-State  NAMFCU training decreased from eight  to two.   Unit  management  
explained  that  there were exceptions to these restrictions  and  that the Governors 
Office  may  approve  more Unit  staff  to travel  out-of-State  if the  training meets certain 
criteria  (e.g.,  if  the training is required),  and the Unit requests approval  in advance.  
As  of  January  2020, all new  investigators  who had  yet to attend the  NAMFCU  
_____________________________________________________________________________________________________________________________  
48  New  investigators should complete the Basic  Investigator Course within 6 months of assignment to the  
Unit and the in-house training and NAMFCU  Medicaid Fraud 101 within 1 year of assignment to the Unit.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 19    
Medicaid  Fraud 101 training were on a waiting  list  for  approval  by the Governors 
Office  to attend that training.  
Although  the Unit  documented  its  periodic  supervisory reviews 
in  most of  its  case files, the Unit  had  difficulty adhering  to  its 
policy  of  conducting  the reviews  monthly    
According to Performance Standard 7(a),  supervisory reviews should be  conducted  
periodically, consistent with Unit  policies and procedures, and noted in the case files.   
The Units policies and procedures manual  states that the  Unit should conduct 
supervisory reviews  with a first-line supervisor every 30 days on  all open cases.49   
For  the cases that were  open longer than 30 days, we estimated that  48  percent of 
case files contained documentation of a  supervisory review  consistent with Unit policy 
(i.e., every 30 days or more frequently).  We  estimated  that the remaining  52  percent  
of  case files did not meet the Units  monthly supervisory review  policy;  45  percent  
lacked  documentation of  monthly supervisory reviews  (i.e.,  they were conducted  less 
frequently),  and  7 percent  lacked  documentation of  any supervisory review.50   Periodic  
supervisory reviews of case files are important  because  they provide  the Unit with 
oversight and can help ensure timely completion of cases.  However,  in OIGs 
experience,  conducting  and documenting official case file reviews as frequently  as  
monthly  may present an unwarranted burden on investigators, as well  as supervisors.   
We found that the intervals at  which the Unit aimed to conduct  supervisory reviews 
i.e., monthlywere  more frequent  than that of  other MFCUs, which typically  conduct 
their supervisory reviews on a quarterly basis, and  likely contributed to the Units 
difficulty in meeting its own  policy guidelines.   See  Appendix D for the point estimates 
and confidence intervals for the case  file  reviews.  
_____________________________________________________________________________________________________________________________  
49  The Unit also conducts regional reviews, on a quarterly basis, of a random sample of both acting 
and  pending cases, performed by  a command supervisor and the Unit director.  According to Unit policy,  
the intent of these reviews is to ensure accuracy of reporting and completeness  of all active case files.   
50  The 2012 OIG onsite review found that the Units case files lacked  documentation of supervisory  
reviews and recommended that the Unit ensure that periodic supervisory reviews be  documented.  
In  response, the Unit developed case opening and closing forms that require a supervisors approval 
and  signature  and clarified in  its policies and procedures that supervisory reviews should be conducted 
monthly and properly documented.    
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review  
OEI-06-19-00510   Findings  | 20    
RECOMMENDATIONS  
 
 
 
 
From the  data we  reviewed, we identified  several  areas  in which the Unit should  
further improve its adherence to the MFCU performance standards  and for which we  
are issuing recommendations.  We found that the Units organizational structure 
within the ISP created  staffing  challenges and instability for the Unit, which affected  
its  ability to  make long-term improvements.  The Units placement within the ISP  
contributed to frequent turnover of the Unit director, affected  the Units ability to  
maintain staffing levels,  and  impeded the Units recruitment  of  sworn law  
enforcement officers  with health care fraud experience.   
We also found that the Unit  did not  always  work  effectively with its State and Federal  
partners.   Specifically, the Units referral  process with the Illinois Department of Public  
Health  led to the Unit  receiving  thousands of unscreened referrals of patient abuse 
and neglect, most of which did not result in  the Unit opening a case, diverting  time 
and resources from viable cases.  The  Unit  also  did not routinely  coordinate  on  cases 
with  Federal  partners  and  worked  few  cases jointly with them.   We found that the lack 
of joint cases was  a  missed opportunity  for  the Unit to  share resources and  train with  
other law enforcement agencies.  Further, the  Unit did not report all  of its  convictions 
and  adverse actions to Federal partners within the appropriate timeframes, potentially  
delaying the process for excluding providers from the Federal  health care  programs.   
Additionally, we  found that the Unit  did not  consistently  follow its  own policies.  
We  found that  several  of the Units investigators  hired during our review  period  did 
not always complete new employee trainings  as outlined in their training plans.  
We  also found that,  although the Unit documented its periodic supervisory reviews in 
most of  its case files, the Unit had difficulty adhering to its policy guidelines of  
conducting the  reviews  monthly.   
To address the issues identified in this report and further improve Unit operations,  
we  make six  recommendations  to  the Illinois MFCU.  
We recommend  that  the  Illinois  MFCU:  
Develop  and  implement  a  plan to  address  the challenges 
presented  by the Units  organizational structure   
The Unit should determine whether  its  current  organizational structure under  the ISP  
is the best arrangement  for its operations.   The Unit  should  work with  the Attorney 
Generals Office  or  other State  officials  to  develop a  plan  to address the challenges  
identified in this report.  If the Unit finds that its current structure under the ISP is not  
the most effective arrangement, the Unit should consider changes to its structure, 
including  whether placement in another State  agency, such as the State  Attorney 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Recommendations  | 21    
Generals Office, which is typical in most other States and  territories, would be more 
effective.   The  Unit  should  consult with OIG prior to  implementing the plan  to ensure 
that the Unit  complies with Federal regulations  and  addresses the findings in this 
report.  Once the plan is  implemented,  the Unit should work  with OIGs MFCU 
oversight division to ensure full adherence with  the plan.  
Establish  minimum criteria  for  referrals  of  patient  abuse and 
neglect  to  be  sent to  the  MFCU  
The Unit should  finalize  its MOU with the Department of Public Health to  establish  
minimum  criteria  for when the Department of Public Health should send referrals of  
patient abuse and neglect  to the MFCU.  The minimum criteria  would provide the 
Department of Public Health  with  the necessary tools to screen referrals (a common 
practice for  administrative agencies in other States)  and  to determine whether a 
referral should  be sent to the  Unit  or elsewhere.  We expect that establishing criteria  
for referrals will reduce the number of inaccurate and incomplete referrals  and  
thereby promote  Unit efficiency  and  case flow.   Once the minimum criteria are 
established,  the Unit should assess the  effectiveness of the minimum criteria and  
provide training or make revisions as  necessary.  
Establish  a  process  to coordinate on  cases  and  improve 
collaboration  with  Federal partners    
The Unit should establish a process  consistent with Federal regulations  for  ensuring  
that it coordinates and deconflicts all of  its cases  with  OIG.   Specifically, the Unit  
should share a list of all  of its  active cases with OIG on a regular basis.  In addition, the 
Unit should  investigate  more cases jointly with OIG and actively participate  in  more 
cases with the U.S. Attorneys  Office,  which could provide beneficial training  
opportunities for Unit  investigators on different  types of cases.   To further improve 
communication and encourage joint casework, the Unit should inquire  about  
receiving  trainings  from  OIGs Office of Investigations  and the U.S. Attorneys Offices.  
Take  steps  to  ensure that  Unit  staff  report  all convictions  and 
adverse actions  to  Federal partners  within the appropriate 
timeframes  
The Unit should  take steps  to ensure that it consistently reports all convictions to  OIG 
within 30 days of sentencing and all  adverse actions to the NPDB within 30 days of  
the action.   The  Unit could provide training  to staff  on reporting  convictions  and  
adverse actions to Federal  partners  and  could  implement automated reminders to  
alert Unit staff  when to  report the convictions or adverse actions.    
 
 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Recommendations  | 22    
Take steps  to  ensure that  newly hired  investigators  complete 
new  employee trainings  
The Unit should  monitor new investigators  training  plans to ensure that  they 
complete new employee trainings.  Training completion should  be documented  
in  a  way that allows  supervisors to  stay current on the status of staffs training.   
The  Unit  should also  work with the ISP  and other State authorities, as necessary,  
on  an  exemption to allow  the Unit  to  send more than two staff  at a time  to the 
NAMFCU  trainings.   
Take steps  to  ensure that  supervisory reviews  of  case files  are 
conducted  and  documented  in accordance with  Unit  policy  
The Unit should ensure that supervisors conduct and document reviews of case files 
consistent with Unit policy.  We  recognize that conducting case file reviews as 
frequently as monthly, which is the Units current  policy, may present an unwarranted  
burden on investigators and supervisors.  The Unit could consider changing, in its 
policies, the frequency of the supervisory reviews from a monthly to a quarterly 
schedule.  A schedule with less frequent case file reviews may assist the Unit in 
meeting internal policies but  would  not preclude the Unit from continuing to meet  
monthly to  discuss cases, which may be necessary when there are new investigators 
who  need training in health  care fraud. 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Recommendations  | 23    
UNIT COMMENTS AND OIG RESPONSE  
 
The Illinois MFCU concurred with all six  of  our recommendations.  
First, the  Unit  concurred  with our recommendation to develop and implement a plan 
to address the challenges presented by the Units organizational structure.   The  Unit  
reported  that it is  working on  revising  the job description and reporting structure for  
the  Units  deputy director, which will  establish additional responsibilities for the  
deputy director  that will  provide  the Unit with more stability and improve  its  working  
relationships  with  State and Federal  partners.  The Unit  also  reported  that it plans to  
engage with the Illinois Attorney Generals Office  regarding ideas that  could  further 
promote the Units success.   The Unit reported that to  improve recruitment of  
investigators, it plans  to enhance its visibility and promote its mission and 
accomplishments to other agencies within the ISP.   
Second,  the Unit  concurred with our recommendation to establish minimum criteria  
for  when the Department of  Public  Health should send referrals of patient abuse and  
neglect to the MFCU.   The  Unit  reported that in January 2020, the Unit  and the 
Department of Public Health finalized the minimum criteria for these referrals.   
Third,  the Unit  concurred with our recommendation to establish a process to  
coordinate on cases and improve collaboration with Federal partners.   The Unit  
reported  that it plans  to establish a  more formal process to communicate regularly 
and deconflict cases with Federal partners.   
Fourth,  the Unit  concurred with our recommendation to take steps to ensure that Unit 
staff report  all convictions and adverse actions to Federal partners  within the 
appropriate timeframes.   The Unit  reported that it  is  revising  its  notification protocol  
to help eliminate any  delay in reporting to OIG and the NPDB.  
Fifth,  the Unit  concurred with our recommendation to take steps to ensure that newly  
hired  investigators  complete new employee trainings.   The  Unit reported  that it has 
established  the technological capability  to host trainings remotely, which  will allow 
staff  across the State to receive training.  The Unit  also reported  that it has improved  
its  training logs to ensure  easy access, entry, and verification of training requirements.  
Sixth,  the Unit  concurred with our recommendation to take steps to ensure that 
supervisory reviews of case files are conducted and documented in accordance with 
Unit policy.   The Unit  reported that although supervisory reviews were conducted in 
accordance with  its  policy, the  supervisory reviews were not  always reflected in its  
case management system.  The Unit reported that it  will modify its case management  
system to make it easier for supervisors to document the 30-day supervisory reviews.    
For the full text of the Units comments, see Appendix E.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Agency Comments and OIG Response | 24    
 
APPENDIX A   
 
 
Performance Assessment  
We assessed the Illinois MFCUs  adherence to the 12 MFCU  performance standards,  
including its compliance with applicable laws, regulations, and policy transmittals.   
From  this review, we found that the Unit generally operated in accordance with 
applicable laws, regulations, and policy transmittals.  However, we made six findings 
regarding  the Units  adherence to the MFCU performance standards, two  of which 
also involved compliance with Federal regulations  (they are presented here and as 
findings in the report).  We also made observations about Unit operations and  
practices.  The  complete MFCU  performance standards, including performance 
indicators, were published  at  77 Fed. Reg. 32645 (June 1, 2012), and appear on  OIGs 
website  at  https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/.      
STANDARD 1   A Unit conforms with all applicable  statutes, regulations, and policy 
directives.  
 
Observation   From the information  we reviewed, the Illinois  MFCU generally 
complied with applicable laws, regulations, and  policy transmittals. 
However, we identified  compliance concerns related to the Units 
coordination with  Federal partners and with its reporting  of  convictions 
and  adverse actions to Federal partners, as described  under Performance 
Standard 8  below.   
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 Units organizational structure  created  several  staffing  challenges, 
raising concerns about  its  operational efficiencies.   See  page  10.  
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 policies and  procedures.  The Unit maintained a  
Policy  and  Procedures Manual  specific to the MFCUs functions and  
jurisdiction.  This manual is referred  to as the Medicaid  Fraud  Control  
Bureau  Handbook.  The Units handbook  is separate from the ISP-wide  
handbook  and addresses the Units specific requirements that are not  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix A  | 25    
addressed  in the ISP  handbook.  The Medicaid Fraud  Control Bureau 
Handbook is available to Unit staff electronically  and was last updated  on 
September 17, 2019.  
STANDARD 4   A Unit takes steps to maintain an adequate volume and quality of 
referrals from the State Medicaid agency and other sources.  
 
Finding   The  Units process for receiving  referrals of patient abuse and neglect 
led to the Units  screening  of  thousands of  referrals  that were 
unsuitable for investigation, diverting time and resources from viable 
cases.   See page 14.  
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   Nearly all case files contained documentation of 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 the investigation and  prosecution are completed in an 
appropriate timeframe.  Our review found that nearly all  of the sampled 
case files contained documentation of supervisory approval of case 
opening and closings.   An  estimated 99 percent of case files had 
supervisory approval to  open the case for investigation.  At the time of  
our review, 67 percent of cases were closed, and we found  that all of the  
closed cases had approval to close.  See Appendix D for the  point  
estimates and the confidence intervals for the case file reviews.  
STANDARD 6   A Units case mix, as practicable, covers all significant provider types 
and includes a balance of fraud and, where appropriate, patient 
abuse and neglect cases.  
 
Observations   The Units case mix included  both  cases of fraud and  cases  of  patient 
abuse or neglect, but  the Unit  worked a  disproportionate number of 
cases involving personal care services.   Of  the  986  cases that were open 
during  FYs  20172019, 86  percent (844  cases) involved provider fraud and  
14  percent (142 cases) involved patient abuse or neglect.   Although the 
Units open  criminal fraud cases covered 30 different provider types 
(e.g.,  nursing facilities, physicians), 70  percent of the  Units fraud cases 
involved  personal care services  (PCS)  attendants.   A common type of  
fraud  scenario involving  PCS  attendants is  a conflict case, in which a PCS 
attendant claims to have provided services, such as meal preparation or 
light  housework, to  a  Medicaid beneficiary during the same hours that the 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix A  | 26    
PCS attendant worked  at another place of employment  (e.g., doctors 
office, convenience store).51   
Unit management attributed the high number of  PCS  fraud cases to 
stakeholders referring  a disproportionate number of  PCS referrals  to the  
Unit.   While  investigation of  PCS fraud is important, Performance Standard  
6(c) states that  the Unit  should  allocate its resources  among provider 
types based  on levels of  Medicaid  expenditures or  other risk factors.  
Subsequent  to our review, the Unit reported taking steps to help increase 
a broader mix of provider fraud referrals  from its key stakeholders.   For  
example, the Unit  recommended  that the  State Medicaid  agency, HFS-
OIG,  allow MCOs to  simultaneously report referrals to the Unit and the 
HFS-OIG, which should increase the number and types of  fraud  referrals 
that the  Unit receives.    
The Unit  pursued few nonglobal civil fraud cases.   Performance Standard  
6(e) states that Units should seek to maintain, consistent with their legal  
authority, a  balance of criminal and  civil fraud cases.  Illinois  enacted a  
False  Claims Act in  1991, which provides the Unit with a basis to pursue its  
own nonglobal cases.52   However, only 1  percent of the Units  cases  
(10  of  849)  during FYs 20172019  were  nonglobal civil fraud  cases.53   
Nonglobal cases involve primarily State rather than Federal litigation;  are 
pursued separately by Units or with other law enforcement partners;  and  
are not coordinated by the NAMFCU.   In  interviews, Unit staff  reported  a 
willingness to work civil  fraud  cases and expressed  frustration  that despite 
receiving  referrals with potential for civil remedies, the Unit did not have 
more civil case outcomes.  Some staff had  the  perception that the 
Attorney Generals Office  was not  interested in pursuing civil  fraud  cases.  
STANDARD 7   A Unit maintains case files in an  effective manner and develops a  case 
management system  that allows efficient access to case information 
and other performance  data.  
 
Finding   Although the Unit  documented its  periodic supervisory reviews  in  most 
of its case files, the Unit had difficulty adhering  to its policy of 
conducting the  reviews  monthly.  See  page 20.  
Observation   The Unit  generally maintained case  files in an  effective  manner, but 
some practices did not  allow for efficient access to case information.  
According to Performance Standard 7(e), the Unit should have an 
_____________________________________________________________________________________________________________________________  
51  OIG,  MFCUs: Investigation and  Prosecution of Fraud and Beneficiary Abuse in Medicaid 
Personal Care Services, OEI-12-16-00500, December 2017.  Accessed at 
https://www.oig.hhs.gov/oei/reports/oei-12-16-00500.pdf  on October 20, 2020.  
52  Illinois State Statutes  740 ILCS 175/1-8.  
53  The Units nonglobal  civil recoveries totaled  $140 million.  Of those recoveries,  
$135  million derived from  a  case  that is part of a larger, ongoing 2005 lawsuit filed against 
47 pharmaceutical companies.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix A  | 27    
information management system that manages and tracks case 
information from initiation to resolution.  The Unit used an electronic case  
management  system to record and track all case information.  We  
determined  that overall,  the Unit  adequately maintained case files, but  we  
observed some practices that did not allow  for efficient access to case 
information.  For  example, we found  that  some case files lacked  
descriptive names, which made it difficult to locate specific  documents 
and fully review the Units investigation processes  in  their entirety.  We  
also  found that Unit staff  did not  consistently  label joint cases in the  
electronic system  and  that descriptive information  to document the 
involvement of the  joint  agency was sometimes missing.   Without such 
information, we found it  difficult to determine the level of involvement  of  
the partner agency  for  some cases.  Further, only an estimated  45  percent  
of case files included documentation  that the  Unit  communicated its 
closing decision to the referring agency.   Notifying the referring agency 
that the Unit  has closed  a case helps ensure that the referring agency can 
pursue other administrative actions, as appropriate.   See Appendix D for 
the point estimates and confidence intervals of  the case file reviews.   
STANDARD 8   A Unit cooperates  with  OIG and other Federal agencies in the 
investigation and prosecution  of Medicaid and  other health care 
fraud.  
 
Findings   The Unit  did not  always  coordinate on  or  actively participate in  cases 
with Federal partners, missing  opportunities for sharing resources  and 
training.   See page 15.    
The Unit  did not  always  report convictions  or  adverse actions to Federal 
partners  within  the appropriate timeframes.   See page 16.  
STANDARD 9   A Unit makes statutory or  programmatic recommendations, when 
warranted, to the State government.  
 
Observation   The Unit made several  recommendations to the State Medicaid agency 
during our review period.  The  Unit  recommended that the State  
Medicaid agency amend  its  contracts with the MCOs  to require  MCOs to  
cooperate with the Unit, particularly on issues  related  to methods for 
identifying, investigating, and referring  suspected  Medicaid  fraud.   To 
reduce  fraud in home health agencies, the Unit also recommended  that 
the State Medicaid agency  limit  the  number of  vendors approved to  sell  
electronic timekeeping  systems for health  care workers  used by home 
health agencies and to require home health employees to watch  an 
announcement about  Medicaid  fraud  before they submit  their weekly 
hours into  a vendors system.  None of these recommendations had been 
implemented  by the State Medicaid  agency  at the time of our review.   
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix A  | 28    
STANDARD 10   A Unit periodically reviews its Memorandum  of Understanding (MOU) 
with the State Medicaid agency to ensure that it reflects current 
practice, policy, and legal requirements.  
 
Observation   The Units intergovernmental  agreement with  the Medicaid agency 
reflected  current practice, policy, and legal requirements.   The ISP and  
the HFS, the Medicaid  agency,  had a current  intergovernmental  
agreement,  executed in January 2019.  The  agreement reflected all policy 
and legal requirements, as well as current practices, between the parties.  
STANDARD 11   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 Units 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.  
STANDARD 12   A Unit conducts training that aids in the mission of  the Unit.  
 
Finding   Newly hired  Unit investigators  did not  always  complete  new employee 
trainings, which could  affect  the  Units overall effectiveness.   See   
page 18.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix A  | 29    
APPENDIX B  
 
Illinois  MFCU Referrals  Received,  by Source,  for FYs  20172019  
Exhibit B-1: Illinois Unit referrals received during FYs 20172019, separated by source and FY  
  FY  2017   FY  2018   FY  2019   3-Year  Total  
Abuse  &  Abuse  &  Abuse  &  Abuse  & 
Referral Source   Fraud   Fraud   Fraud   Fraud   Total  
Neglect1   Neglect   Neglect   Neglect  
Adult  Protective  
0  0  0  0  0  0  0  0  0 
Services  
Anonymous   0  1  0  0  0  0  0  1  1 
Dept. of  Human 
Services/Dept. of 
35  1  83  0  92  0  210  1  211 
Rehabilitation 
Services  (DHS/DORS)  
Dept.  of  Public  Health   6  1,368   6  1,402   2  1,582   14  4,352   4,366  
HHSOffice of 
Inspector  6  1  1  0  6  0  13  1  14 
General  (OIG)  
Local  Prosecutor   1  0  0  0  1  0  2  0  2 
Long-Term  Care 
1  0       0   0  0  0  1  0  1 
Ombudsman  
Managed Care 
0  10  0  14  0  9  0  33  33 
Organizations  
Medicaid Agency 
Program  Integrity  27  0  21  0  15  0  63  0  63 
Unit  (HFS-OIG)  
Other  Law  
4  2  4  3  1  4  9  9  18 
Enforcement  
Private  Citizens   108  25  89  27  114  53  311  105  416 
Private  Health  Insurer   0  0  0  0  1  1  1  1  2 
Provider   6  25  5  19  2  10  13  54  67 
Provider  Association   1  0  2  0  0  0  3  0  3 
Other   6  0  9  6  2  0  17  6  23 
Total   201   1,433   220   1,471   236   1,659   657   4,563   5,220  
Source:  OIG analysis  of Unit Annual Statistical Reports for FYs 20172019.   
1 The  category Abuse & Neglect  includes  referrals regarding misappropriation of patient funds.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix B  | 30    
 
APPENDIX C  
 
 
Detailed  Methodology  
We  collected and analyzed data from the eight sources below to examine an area of 
concern related to the organizational structure of the Illinois MFCU and  to assess the  
Units performance and operations.  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.   
Data Collection and Analysis  
Review of recertification data, case outcome data, and Unit documentation.   
Prior  to the onsite review, we analyzed the Units recertification data  for  
FYs  20172019, including (1)  the annual reports, (2) the Unit  directors recertification 
questionnaires, (3) the Units agreement  with the State Medicaid agency (HFS), 
(4)  the  Medicaid agencys program integrity director questionnaires  (HFS-OIG), and  
(5)the OIG Special Agent in Charge questionnaires.  We also reviewed the Units 
annual statistical reports, which allowed us to determine the  total number of the 
referrals that the Unit received from a variety of sources.  This  also allowed us  to 
determine the Units case outcomesindictments, investigations, criminal convictions, 
civil settlements and judgments, and monetary recoveries (criminal, global  civil, and  
nonglobal civil)for FYs  20172019.  We examined prior OIG findings and  
recommendations and reviewed the Units implementation of  those 
recommendations.  
As part of  our review of  Unit staff levels, we assessed the Units staff  levels using a  
simple linear regression model to compare Medicaid expenditures to actual staff.   
We  also examined other Unit documentation to  determine the length of each staff  
members employment with the Unit during our review period.  Additionally, we 
reviewed the Units annual training  to assess staffs adherence to the training plans 
and determine whether staff received adequate training.  
We also reviewed Unit policies and procedures and held discussions with Unit  
management during the onsite review to gain a  better understanding of  those 
documents.  We confirmed  with  the Unit  director that the information we had was 
current, and we requested any additional data and clarification as needed.  
Review of Unit financial documentation.   We conducted a limited review  of the Units  
control over its fiscal resources.  Prior to the onsite review, we analyzed the Units 
response to an internal-controls questionnaire and conducted a desk review of the 
Units financial status reports.  We followed up with Unit  officials to clarify issues 
identified in the internal-controls questionnaire.  We also selected a purposive sample 
of 30 items from the current inventory list of 676 items maintained in the Units office 
and verified  those items onsite.  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix C  | 31    
Interviews  with key stakeholders.  In October and November 2019, we interviewed  
nine key stakeholders, including officials in the HFS-OIG, Department of  Public Health, 
U.S. Attorneys Office, DHS/DORS, and Illinois  State Long-Term Care Ombudsman.  
We also  interviewed Special Agents from OIGs Office of Investigations in Chicago and  
Kansas City.  We focused these interviews on (1)  the  Units relationship and  
interactions with these entities, (2) any areas in which stakeholders believed the Unit  
had opportunities for improvement, and (3) practices that may be beneficial to the 
Units operations or to other Units.  After the onsite review, we followed up with 
stakeholders as  needed.  
Interviews with  Unit management.   We conducted structured onsite interviews with  
Unit management, including the director, attorneys, and investigative supervisors.   
We  also interviewed  attorneys from the Attorney Generals Office who  work on Unit  
cases.  Finally, we interviewed the Central Command Major,  who is the supervisor of  
the Unit director.  We asked them questions related to the following: (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.   
Subsequent  to the onsite review, we followed up with the Unit  director, in-house 
attorney, Central Command Major, and the Attorney General  Bureau Chief  to clarify  
certain data  we collected onsite and to gather additional  information.  
Survey of Unit staff.   In early November 2019, we conducted an online survey of  
35  Unit staff members within the Units professional disciplines (i.e.,  investigators, 
auditors, and attorneys), support staff, and attorneys from the Attorney Generals 
Office  who  work on Unit cases.  Our  questions focused on (1) operations of the Unit;  
(2)opportunities for improvement;  and (3) 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 asked the Unit to provide us with a list of cases that 
were open at any point  during FYs 20172019, and we asked the Unit to  include the 
current status of those  cases; whether the case was criminal, civil, or global; and the 
date on which the case was opened  and closed, if applicable.  The total number of  
cases that met these parameters was 863.  We then excluded a total  of 323  cases from 
our review because they were either global cases, cases involving fugitives, or 
duplicate cases.  We excluded the global cases because they are civil false claims 
actions that  typically involve multiple agencies, such as the U.S. Department of Justice 
and a group of  State MFCUs.  From  the 540  remaining case files, we selected a simple 
random  sample of  88  cases.  This sample allowed  us to make estimates of the overall  
percentage of case files with various characteristics with an absolute precision of   
+/- 10 percent at the 95-percent  confidence level.  While onsite, we found  two  
additional ineligible cases (i.e., global cases) that  we excluded from our review, which 
were not previously correctly categorized by the Unit.  With the assistance of OIG 
agents, we reviewed the Units processes for monitoring the opening, status, and  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix C  | 32    
outcomes of these  86 cases.  We  also reviewed the Units approach to investigating  
and prosecuting cases that were open at some point during  FYs 20172019.   
Review of Unit  submissions to OIG and  the NPDB.   We reviewed all convictions 
submitted to OIG for program exclusion  and all  adverse actions submitted to the 
NPDB during FYs 20172019 and assessed the timeliness of  these submissions.   
Onsite review  of Unit operations.   While onsite, we examined the Units workspace 
and operations to identify any instances of nonadherence to performance standards 
and/or instances of noncompliance with applicable Federal laws, regulations, and OIG  
policy transmittals.  We  also evaluated the security of  the Units case files and the  
functionality of the Units electronic case management system.  Our examination of  
the Units workspace and operations while onsite did not result in any findings.  
 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix C  | 33    
 
APPENDIX D  
 
 
Point  Estimates  and  95-Percent  Confidence Intervals  of  Case  
File  Reviews  
Exhibit D-1: Estimates for All Case File Reviews  
95-Percent 
Sample  Point  
Confidence Interval  
Estimate Description  
Size    Estimate  
Lower   Upper  
Percentage  of  All  Cases  That  Had  Supervisory  Approval  To  
86  98.8%   93.9%   99.8%  
Open   
Percentage of  All  Cases  Closed at  the Time of Our  Review    86  67.4%   57.2%   76.5%  
Percentage of  All  Closed Cases  That  Had Supervisory 
58  100.0%   94.1%   100.0%  
Approval  To  Close  
Percentage of  All  Cases  Open  Longer  Than  30  Days    86  96.5%   90.5%   99.2%  
Percentage of  All  Closed Cases  in  Which  the  Unit  
58  44.8%   32.6%   57.6%  
Communicated Its  Closing  Decision  to  Referring Agency   
Source:  OIG analysis  of Illinois  Unit  case files, 2019.  
Exhibit D-2: Estimates for Case Files Open Longer Than 30 Days  
95-Percent 
Sample  Point  
Confidence Interval  
Estimate Description  
Size    Estimate  
Lower   Upper  
Percentage of  All  Cases  Open  Longer  Than  30  Days  That 
Had  Documentation  of  Supervisory Reviews Consistent  With   83  48.2%   37.9%   58.5%  
Unit  Policy  (i.e.,  Every  30 Days or  More Frequently)  
Percentage of  All  Cases  Open  Longer  Than  30  Days  That  Did 
Not  Have  Documentation  of  Supervisory Reviews  Consistent   83  51.8%   41.5%   62.1%  
with Unit  Policy  
Percentage of  All  Cases  Open  Longer  Than  30  Days  That 
Lacked  Documentation  of  Monthly Supervisory Reviews   83  44.6%   34.4%   55.0%  
(i.e.,  They  Were  Conducted  Less Frequently)  
Percentage of  All  Cases  Open  Longer  Than  30  Days  That 
83  7.2%   2.9%   14.5%  
Lacked Documentation  of Any  Supervisory  Review   
Source:  OIG analysis  of Illinois  Unit case files, 2019. 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Appendix D |  34       APPENDIX E - Unit Comments
Illinois Medicaid Fraud Control Unit: 2019 
Onsite Review OEI-06-19-00510                                                       Appendix E | 35 MsS.u zaMnunrer in  Pag2e 
Mar2c,2h 0 21 
ThUen hiatas   foramgarle ewmiettnhhtI e l liAntotioGsrne enye rOaflfit'chseda  etd i1c1ap treoss ecutors 
tow orekx cluosniM veedliycF ariacdua ds Tehspe.r  osewciuttthhoA ert st oGrenneeyrO aflfic'cosem  ply 
witthhI en tergovAegrnrmeeenamtneafdnlo t r mal pwrroictewtdhewenr eteshb Aeyt  toGrneenye ral's 
Officaes sutmherese  sponsfiopbrri olsietcycu rtiimnaignn dca ilv mialt terasr iean nvdo livne d 
investicgaasrteei voitnerswa,si ,ann imdne ge twiinttghhsM e e dicagaeindc y ainndv oalogtvehenedcr i es. 
ThUen iotp'esr ationwailt ahsnait gnre unoccttyhtu ehrrtae hnS e t aAttet oGrneenye irsa la ppurnodperri ate 
fedeRreaglu laatntidho cenu s1,Ts etnrtuo cftt huUern ei t cwoimtp0h l01 i77e c.s()  T .h Uen wiitc loln tinue 
thcel owsoer krienlga tiihtoa nwssi httihhIpe l  liAntotoiGrnsee nye OrfafilMc'eesd  iFcraiaBduu dr eaanud  
wielnlg aignde i scussioindse tarhswea igtpla rlro dmitonhtcgeeo   ntisnuucecodeft s hUsen  it. 
ThUen icto nctuhroasrt g anizsattriuwocinttuathrlhie Aen g  enccoyub leid m proDvuerdit.nh rgee  view 
perioondDe,i  rehcetltodhrp e o sitiaopnp rfooxrit mharyteeeeala rynsu d,p  ohni rse tiJaeU mneintt , 
Lieutweannsaa nmt"e Adc ting uDnittrihenleec  wt orDi"wr aensca tmoeOrdf .t aenAn c tCionmgma nder 
wialsls urmees ponsdiubritilhnsieget  lieeocsfat r  ieopnl acbeuimtite os nn tla,nyi   ntedreismi gnlant ion. 
201t7h,Ue n it ctrhAeesa stiesBdtu arneCtah uip eofs ittohi eolinpm  prcoovnes isTtheAens csyi.s tant 
BureCalu1p ireofv sitdaebswi iltiththiyuen n  aintid m proved workiwnigtt hhsr ete alatanetd i onships 
fedepraarltt noae srssti hsDeti  recptoosrip'trsio ovnic doinntgiw niutiththiUyenn   iatnw di tsht aatned  
fedepraa,lt ners. 
Toa ddrtehsfesi  ndtihnUegn ,ir te vietwhAeesd s isBtuarneCtah ui ejfosdb e scrainprdte icoenn tly 
submiittttot e hIdel  liSntoaPtioesl  (iIcSeCP o)m matnoid n corapdodriattrieeo snpaoln stihbwaietlr iet ies 
noptr evinooutseTldhyp.e r  opjoosdbee ds craidpotapir toesnp  osrttriunwcgit tuthrhieIen S  TPa bolfe  
Organitzhaiatntic oltnuh adete tso prnoesyi atnido Snttsha et eSwuipdppeoo rsti TthiAeos ns.i Bsutraenatu  
Chipeofs itiaolnsc orw eaatstob e ead w  orkpiantgtw niettrhh1  e1I  lliAntotiosGr enneye rOaflfi'cse  
prosetchuaatrtode re sd ictaot Uetndhi et . 
ThUen cito nctuhrtashtd e e sisrteadfl feivnegln so bthe aemvnee tT .hU en wiitc loln ttimona ukee  requests 
forn on-spweorrns otnhnreoltu hgSeht  ate-cboundtgreoat!paJprerydop  vraolcae nsdrs e qufeosrt s 
additsiwoonprnae lr sotnhnreolu gMha nIaSgPe mIenan net f.f tooer xtp arnedc ruaintbmdre onatd en 
profesdseivoenlaotlph mUeen niwtti, l l ptrhwoeom rooktft e hU en tiott  hoet haegre nbcuyr etahuesr eby 
improavwianrge annetdsh vsei  siobfit lhUient ityto e  xperiiennvceesdt Tihgea tUonrsisut.b  mwiitl l 
highlainmgdih stssf iuonnc utsiioInnSgsDP  i viosfCi roinm Iinnvaels tiingtaeptrnuiabolln i cations. 
ThUen wiitrl el- esrtealbaltiiswohin ktsehshy ti apkse hionlcdleuFrdesid,nep gra arltw niettrhhDse i  rector, 
AssisBtuarneCtah uia enfcd,o  mmapnedr sonnel. 
Find#i2nT:gh  Uen iptr'osc feorsres c eirveifenno-gfpa  altsia ebnuatsne nd e glleetcdott  h Uen istc'rse eonfi ng 
thousoafrn edfesrt rhawaletsru  en suifotria nbvlees tdiigvaett1iitomainenn,r dg e  soufrormcv eisac balsee s. 
Recommen#d2aE:ts itoanmb ilniismhu m fcorrrei fetleolfrp' iaatalai sbe unastnen d e glteboec s tet nott h MeF CU. 
ConcTuhrUe:n  rjetc ogtnhirazetef def rrormta hlIesl  liDneopiasro tfPm eunbtl ic( IHDePwaHel)rtn eho  t 
screaedneeqdu caatueslaiynin, ng c revaosleuldma ec kniencge sasnrader lye ivnafnotr mTahtei oUnn.i t 
anIdD PfiHn altihzaeeg dr meiend imcurmi tfeorrir aet fheeor nJr aanlus3a 02r,0y 2 0. 
Find#i3nT:gh  Uen idti d anlowtac yoso rdoinon raa cttei pvaerltyii cnci apswaeitsteF h e depraatlt mniesrssi,n g 
oppuon1itftoisreh sa rriensgo uarncde st raining. 
Recommen#d3aE:ts itoanab p lriosctheoc s oso rdoincn aastaeensi d m prcoovlel abwoirtFahet dieporanar lt ners. 
Illinois Medicaid Fraud Control Unit: 2019 Onsite Review 
OEI-06-19-00510                            Appendix E | 36 Illinois Medicaid Fraud Control Unit: 2019 Onsite Review 
OEI-06-19-00510                                               Appendix E | 37  
ACKNOWLEDGMENTS AND CONTACT  
 
Acknowledgments  
Anthony Soto McGrath  served as the team leader for this study, and Anna Brown and 
Kristen Calille  served as the lead analysts.  Medicaid Fraud Policy and Oversight  
Division staff who  participated  in the review  include  Keith Peters.   Office of Evaluation  
and Inspections staff  who provided support include Kevin Farber  and  Christine  Moritz.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including  special agents  from the Office of Investigations.  
This report was prepared under the direction of  Ruth Ann Dorrill, Regional Inspector 
General for Evaluation and Inspections in the Dallas  regional  office, and Petra Nealy,  
Deputy Regional Inspector General, as well as in consultation with Richard Stern, 
Director of the Medicaid Fraud Control Policy and Oversight Division.  
Contact  
To obtain additional information concerning this report, contact the Office of Public 
Affairs at  Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found  
on the OIG website at  oig.hhs.gov.  
Office of Inspector General 
U.S. Department of Health and Human Services  
330 Independence Avenue, SW 
Washington, DC 20201  
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510   Acknowledgments and Contact | 38  
   
 
ABOUT THE OFFICE OF  INSPECTOR GENERAL  
 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-
452, as amended, is to protect the integrity of the Department of Health and Human 
Services (HHS) programs, as well as the health and welfare of  beneficiaries served by 
those programs.  This statutory mission is carried out through a nationwide network  
of audits, investigations, and inspections conducted by the following operating  
components:  
The Office of  Audit Services (OAS)  provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work  
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to  provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS.  
The Office of Evaluation and Inspections  (OEI)  conducts national  
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable  
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental  
programs.  To promote impact, OEI reports also  present practical  recommendations 
for improving program operations.  
The Office of Investigations  (OI)  conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and  
beneficiaries.  With investigators working in all 50 States and the District  of  Columbia, 
OI utilizes its resources by actively coordinating  with the Department of  Justice and  
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI often lead to criminal convictions, administrative sanctions, and/or civil  
monetary penalties.  
The Office of Counsel to the Inspector General (OCIG)  provides 
general legal services to  OIG, rendering advice and opinions on HHS programs and  
operations and providing all  legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also  negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities.  
 
Illinois Medicaid Fraud Control Unit: 2019 Onsite  Review  
OEI-06-19-00510    About OIG |  39