Department of  Health  and  Human  Services
  
OFFICE OF
  
 
INSPECTOR GENERAL
  
 
 
 
 
 
 
 
D M
  ELAWARE  EDICAID 
 
 
F C U :
 
  RAUD  ONTROL  NIT   
 
2015  O R  
  NSITE  EVIEW
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin
  
Deputy  Inspector  General
   
for Evaluation  and  Inspections
  
 
February  2016
  
OEI-07-15-00240
    
   
EXECUTIVE  SUMMARY:   DELAWARE  MEDICAID FRAUD CONTROL UNIT:   
2015  ONSITE REVIEW  
OEI-07-15-00240  
 
WHY WE DID THIS  STUDY   
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit  
(MFCU or Unit) grant awards, annually  recertifies the Units, and oversees the Units 
performance in accordance with the requirements of the grant.   As part of this oversight, 
OIG conducts periodic reviews of all Units and prepares public reports based on these  
reviews.  The  reviews assess the Units performance in accordance with the 12 MFCU 
performance standards and their compliance with applicable  Federal requirements.  
 
HOW WE DID THIS  STUDY  
We conducted an onsite review  of the  Delaware  Unit  in June  2015.  We  based our review 
on an analysis of data from seven sources:  (1)  policies,  procedures, and documentation 
related to  the Units operations, staffing, and caseload for  fiscal years (FYs)  2012  through 
2014; (2)  financial documentation for FYs  2012 through 2014; (3) structured interviews 
with key stakeholders; (4) a survey of Unit staff; (5)  structured interviews with Unit  
management; (6)  a sample of files for  cases that were open  at any time in 
FYs  2012  through 2014; and (7)  observation  of Unit operations.  
 
WHAT WE FOUND  
For FYs  2012 through 2014, the Delaware  Unit reported 28 convictions,  47 civil 
judgments and settlements, and combined criminal and civil recoveries of $5 million.  
We identified areas where the Unit should improve its operations.  Specifically, the 
absence  of final written policies and procedures may  have  contributed to the lack of 
adherence to certain performance standards and noncompliance with certain Federal 
regulations.   The Unit did not report any  sentenced individuals to  OIG within required 
timeframes  and did not report any adverse  actions to the  National Practitioner Data  Bank 
(NPDB).  Forty-four  percent of case files open longer than 90 days lacked documentation 
of supervisory reviews.  The Unit investigated two sampled cases that were not eligible  
for Federal funding.  The Unit stored some  case  files in a location accessible to non-Unit 
staff.   Only a small portion of Unit fraud referrals came from the State Medicaid agency; 
however, the  Unit worked to increase the number  and quality of referrals.   Finally, the  
Units memorandum of understanding (MOU) with the State Medicaid agency did not  
reflect current practice.  
 
WHAT WE RECOMMEND   
We recommend that the Delaware  Unit:  (1) ensure that it reports convictions to OIG 
within 30 days of sentencing; (2) ensure that it reports adverse  actions to the NPDB; 
(3)  ensure that it conducts and documents supervisory  reviews of case files  open longer  
than 90 days; (4) repay  Federal matching  funds spent on cases ineligible for Federal 
funding; (5) secure  its case files; and (6) revise its MOU with the State  Medicaid agency  
to reflect current practice.   The Unit concurred with all six recommendations.  
   
   
TABLE OF CONTENTS  
Objective  ......................................................................................................1 
	
Background  ..................................................................................................1 
	
Methodology ................................................................................................4 
	
Findings........................................................................................................5 
	
From FY 2012 through FY 2014, the Unit reported 

28  convictions,  47  civil judgments and settlements, and
	 
combined criminal and civil recoveries  of  $5  million ........................5 
	
Prior to November 2015, the Unit lacked final written policies  
and procedures specific to its operations ............................................6 
	
The Unit did not report any  sentenced individuals to OIG within
	 
required timeframes ............................................................................7 
	
The Unit did not report any  adverse  actions to the  National  
Practitioner Data Bank  .......................................................................7 
	
Forty-four  percent of case files open longer than 90  days
	 
lacked documentation of periodic supervisory  reviews  .....................8 
	
The Unit investigated two sampled cases that were not eligible  
for  Federal funding .............................................................................9 
	
The Unit stored some case files in a location accessible to
	 
non-Unit staff  ...................................................................................10 
	
Only a small portion of Unit fraud referrals came from the State 
	
Medicaid agency; however, the Unit worked to increase the
	 
number and quality of referrals  ........................................................10 
	
The Units MOU with the State Medicaid agency  did not reflect 

current practice ................................................................................. 11 
	
Conclusion and Recommendations ............................................................12 
	
Unit Comments and Office of Inspector General Response  ...........14 
	
Appendixes  ................................................................................................15 
	
A:  2012  Performance Standards ......................................................15 
	
B:  Unit Referrals by Referral Source for  FYs 2012 Through
	 
2014 ..................................................................................................19 
	
C:  Investigations Opened and Closed By Provider Category
	 
for FYs 2012  Through 2014 .............................................................20 
	
D:  Detailed Methodology ................................................................22 
	
   
   
E:  Point Estimate and  95-Percent Confidence  Interval  Based 

on  Reviews of Case  Files  .................................................................26 
	
F:  Unit Comments  ...........................................................................27
	 
Acknowledgments......................................................................................30
	
   
OBJECTIVE  
To conduct an onsite review of the  Delaware  Medicaid Fraud 
Control Unit (MFCU or Unit).  
BACKGROUND   
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse  
and neglect under State law.1   Pursuant to Title XIX of the SSA, each 
State must maintain a certified Unit unless the Secretary of Health 
and Human Services  determines that operation of  a Unit would not  
be cost-effective because minimal Medicaid fraud exists in that State  
and that the  State has other adequate safeguards to protect Medicaid 
beneficiaries from abuse  and neglect.2   Currently, 49 States and the 
District of Columbia  (States) have  created such Units.3   In fiscal year 
(FY)  2014, combined Federal and State grant expenditures for the  
Units totaled $235  million.4,  5   That year, the 50  Units employed 
1,958  individuals.6    
To carry out its duties and responsibilities in an effective and 
efficient manner, each Unit must employ an interdisciplinary staff  
that consists of at least an investigator, an auditor, and an attorney.7   
Unit staff review complaints provided by the State Medicaid agency  
and other sources and determine their potential for criminal 
prosecution and/or civil action.  In FY  2014, the 50 Units  
collectively obtained 1,318  convictions and 874  civil settlements and 
______________________________________________________  
1  Social Security  Act (SSA)    1903(q).   Regulations  at 42  CFR    1007.11(b)(1)  
add  that the Units  responsibilities  may  include reviewing  complaints  of  
misappropriation  of  patients  private funds  in  residential health  care facilities.  
2  SSA    1902(a)(61).
    
3  North  Dakota and  the territories of  American  Samoa,  Guam,  the Northern 
 
Mariana Islands,  Puerto  Rico,  and  the U.S. Virgin  Islands  have not established
  
Units.
  
4  All FY references  in  this  report are based  on  the Federal FY (October  1  through 
 
September  30).
  
5  Office of  Inspector  General (OIG), MFCU  Statistical Data  for  Fiscal Year  2014.
   
Accessed  at  http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm  on  March  17,  2015.
  
6  Ibid. 
 
7  SSA    1903(q)(6);  42  CFR    1007.13. 
 
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)   1  
   
   
judgments.8   That year, the Units reported recoveries of 
approximately $2  billion.9  
Units are required to have either statewide authority to prosecute 
cases or formal procedures to refer suspected criminal violations to 
an agency with such authority.10   In Delaware  and 43  other  States, 
the Units are located within offices  of State Attorneys General; in the 
remaining  6  States, the Units are located in other State agencies.11,  12    
Each Unit must be a single, identifiable entity of State government, 
distinct from the single State Medicaid agency, and each Unit must 
develop a formal agreement (i.e.,  a memorandum of understanding  
(MOU)) that describes the Units relationship with that agency.13   
Oversight of the MFCU  Program  
The Secretary of Health and Human Services  delegated to OIG  the 
authority both to certify the Units on an annual  basis  and to administer  
grant awards to reimburse States for a percentage  of their costs of 
operating certified Units.14   All Units are currently funded by the  
Federal Government on a 75-percent matching basis, with the States 
contributing the remaining 25 percent.15   To receive Federal 
reimbursement, each Unit must submit an initial application to OIG.16   
OIG  reviews the application and notifies the Unit if the application is 
approved and the Unit is certified.  Approval and certification are for  a  
1-year  period; the Unit must be recertified each year thereafter.17   In 
addition  to annual recertification, OIG performs periodic onsite  
reviews of the Units.    
______________________________________________________  
8  OIG,  MFCU  Statistical Data  for  Fiscal Year  2014.   Accessed  at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm  on  March  17,  2015. 
 
9  Ibid. 
 
10  SSA    1903(q)(1).
  
11  OIG,  Medicaid  Fraud  Control Units.   Accessed  at http://oig.hhs.gov/fraud/
  
medicaid-fraud-control-units-mfcu/index.asp  on  February  25,  2015. 
 
12  Among  those States  with  a Unit, the Unit shares  responsibility  for  protecting  the 

integrity  of  the Medicaid  program  with  the  section  of  the State Medicaid  agency 
 
that functions  as the Program  Integrity  Unit.  Some States also  employ  an  Office of 
 
Medicaid  Inspector  General that  conducts and  coordinates activities  to  combat 

fraud,  waste, and  abuse for  the  State agency.
  
13  SSA    1903(q)(2); 42  CFR    1007.9(d).
   
14  The portion  of  funds  reimbursed  to  States  by  the Federal Government for  its 
 
share of  expenditures for  the Federal Medicaid  program,  including  the MFCUs, is 
 
called  Federal Financial Participation.
  
15  SSA    1903(a)(6)(B).
   
16  42  CFR    1007.15(a).
  
17  42  CFR    1007.15(b)  and  (c).
  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    2  
     
   
Pursuant to Title XIX of the SSA, States must operate Units that 
effectively carry out their statutory functions and meet program 
requirements.18   OIG developed and issued 12 performance standards 
to define  further the criteria  it applies in assessing  whether a  Unit is 
effectively carrying out statutory functions and meeting program 
requirements.   Examples of standards include maintaining an 
adequate caseload through referrals from various sources, 
maintaining an annual training  plan for all professional disciplines, 
and establishing policy  and procedure manuals to reflect the Units 
operations.19   See Appendix A for a description of each of the  
12  performance standards.  
Delaware  Unit  
The  Delaware  Unit expended $1,944,099  in combined State and 
Federal funds in FY  2014.20   At the time of our review, the Units 
17  employees were located in a single office.  The Units  
management is  composed  of a director, a deputy  director, and a 
supervisory investigator.  The Unit also employs 6  investigators, 
3  attorneys, 2  administrative specialists, 1 auditor, 1 nurse analyst, 
and 1 paralegal.   Three months after the completion of our onsite  
review, the Unit director assumed a different position and another  
individual was appointed acting director.21   In November 2015, this 
individual became the permanent director.  
Referrals.   The Unit tracks and reviews referrals as they are received.  
The Unit receives referrals from a variety of sources  including, but not  
limited to,  the Delaware  Medicaid program (Division of Medicaid and 
Medical Assistance), the Delaware  Division of Long  Term Care  
Residents Protection, State and local police departments, and  the Units 
hotline.   An investigator screens incoming referrals  regarding patient 
abuse or neglect, financial exploitation, or drug diversion;  a 
supervisory investigator or Unit director screens fraud referrals.  Staff 
make a recommendation to the Unit director to either open an 
______________________________________________________  
18  SSA    1902(a)(61).  
19  The performance  standards  referred  to  in  this  report were published  on  
June  1,  2012,  and  were in  effect for  the majority  of  our  review  period.   
77  Fed.  Reg.  32645  (June 1,  2012).   Previous  performance  standards,  established  
in  1994,  are found  at 59  Fed.  Reg.  49080  (Sept. 26,  1994).   Accessed  at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/files/Performance%20Standards.pdf  on  April  27,  2015.      
20  OIG,  MFCU  Statistical Data  for  Fiscal Year  2014.   Accessed  at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm  on  March  17,  2015.  
21  All references  to  Unit director  in  this  report are to  the individual who  was the 
Unit director  during  our  onsite  review  in  June 2015.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    3  
     
   
investigation or close the referral.  The  Unit director reviews this 
recommendation and makes the final decision.   Appendix B depicts 
Unit  referrals by referral source,  for FYs 2012  through 2014.  
Investigations  and Prosecutions.   The Unit director and supervisory  
investigator discuss newly  opened cases and assign an attorney and 
investigator.  Unit attorneys prosecute all  Unit cases.  Cases that are  
deemed to lack prosecutorial merit are  referred to appropriate State 
administrative agencies (e.g., the  Division of Professional Regulation).   
See  Appendix  C for details on investigations opened and closed by  
provider category.  
Previous Review  
A 2009 OIG onsite  review of the Unit found that the  Unit was in full  
compliance with all applicable Federal rules and regulations that 
govern the  grant and the 12 performance standards.  
METHODOLOGY  
We conducted the onsite review in June  2015.  We based our review  
on an analysis of data from seven sources:  (1)  policies, procedures, 
and  documentation related to  the Units operations, staffing, and 
caseload for FYs 2012  through 2014; (2)  financial documentation for 
FYs 2012  through 2014; (3)  structured interviews with key  
stakeholders; (4)  a  survey  of Unit staff; (5)  structured interviews 
with Unit management; (6) a  sample of files for cases that were  open  
at any time in FYs  2012  through  2014; and (7) observation of Unit 
operations.  Appendix  D  provides details of our  methodology.   
Standards  
These reviews are conducted in accordance with the  Quality Standards 
for Inspection and Evaluation  issued by the Council of the  Inspectors 
General on Integrity and Efficiency.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    4  
     
   
FINDINGS  
The Delaware Unit reported  that it obtained 28 criminal convictions 
and 47 civil judgments and settlements during  FYs  2012  through 
2014.  We found  that the lack  of final written policies and 
procedures  may have been a factor in the Units nonadherence  to 
certain performance standards and noncompliance with Federal 
regulations.  
For  FYs  2012  through  2014,  the  Delaware  Unit  
reported  28  criminal  convictions,  47  civil  
judgments  and  settlements,  and  combined  
criminal  and  civil  recoveries  of  $5  million  
For FYs 2012 through 2014, the Unit reported 28  criminal 
convictions and 47  civil judgments and settlements.  See Table 1 for 
the Units yearly  criminal convictions and civil judgments and 
settlements.  Of the Units 28  convictions over the 3-year period, 
16  involved patient funds, 9 involved patient abuse and neglect, and 
3  involved provider fraud.    
Table  1:   Delaware  MFCU Criminal  Convictions  and  Civil  
Judgments  and  Settlements,  FYs  20122014  
3-Year 
Outcomes   FY  2012   FY  2013   FY  2014   Total  
Criminal Convictions   9   8   11   28  
Civil  Judgments  and  Settlements   14   8   25   47  
Source:  OIG analysis of Unit-submitted documentation, 2015.  
For the same period, the Unit reported combined criminal and civil 
recoveries of $5  million.  See Table 2 for the Units yearly  
recoveries and expenditures.  During the 3-year review period, 
global cases produced 88  percent of the recoveries.22  
   
______________________________________________________  
22  Global cases are civil false  claims  actions  involving  the U.S. Department of  
Justice and  other  State MFCUs.   The National Association  of  Medicaid  Fraud  
Control Units  facilitates  the settlement of  global cases.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    5  
     
   
Table  2:   Delaware  MFCU Recoveries  and  Expenditures, 
FYs  20122014*  
Type of  Recovery   FY  2012   FY  2013   FY  2014   3-Year Total  
Global Civil   $2,009,957   $994,951   $1,842,817   $4,847,725  
Nonglobal Civil   $0   $0   $0   $0  
Criminal   $256,364   $273,958   $106,816   $637,139  
Total  Recoveries   $2,266,321   $1,268,909   $1,949,634   $5,484,864  
     Total  
$1,809,257   $1,877,814   $1,944,099   $5,631,171  
Expenditures  
Source:  OIG analysis of Unit-submitted documentation, 2015.  
* Due to rounding, dollar  figures for each category  of recoveries do not always  sum to the total recoveries.  
The Unit reported no recoveries from nonglobal civil cases during  
the 3-year review period.   The Unit has the authority to pursue such 
cases through their State  False Claims Act;23  however, only  4 of the  
Units 348  nonglobal cases open during the review period were civil 
cases.  The  Unit director reported that during the last 2 years, the  
Unit has placed more emphasis  on prosecuting  civil cases.  
Prior  to  November  2015,  the  Unit  lacked  final  
written  policies  and  procedures  specific  to  its  
operations  
The Unit director reported that the Units policies and procedures 
manual was in draft status for the entire  review period  (FYs 2012 
through 2014).  In our review, we found that  the  manual contained 
numerous placeholders and bracketed comments indicating  
incomplete areas of text.  Performance Standard 3 states that  a Unit 
should have written policies and procedures for its operations and 
should ensure that staff are familiar with, and adhere to, these  
policies and procedures.   
The Unit provided a 2004 File Processing Manual that addressed 
some aspects of conducting investigations (e.g., referrals, arrest 
warrants, closings).  However, the manual was outdated in that it 
referred to office locations that were no longer in operation and  
procedures that were no longer current Unit practice.   For example, 
the manual referred to the establishment of master, investigator, and 
prosecutor files for each case.  The Unit director reported that this 
practice had ended  in 2013; the draft policies and procedures manual 
referred only to the  establishment of a master case file.   In addition  
______________________________________________________  
23  Del.  Code tit. 6,    1201-1211.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    6  
     
   
to the 2004 manual, between 2010 and 2015 the Unit director 
provided staff with directives on various topics (e.g.,  evidence  room  
security, document management).   For items related to personnel, 
travel, and use of State resources, the Unit used the Delaware  
Department of Justices manual.   
The lack of  Unit-specific  final policies and procedures related to 
operations may  have  contributed  to the Units nonadherence to  
certain performance standards and noncompliance with Federal 
regulations.  Below we note  where the  impact of the  lack of final 
policies and procedures may have been  significant.   Subsequent to 
the onsite review, on  November 23, 2015, the Unit issued an official 
policies and procedures manual to staff.  
The  Unit  did  not  report  any  sentenced  individuals 
to  OIG  within  required  timeframes  
The Unit obtained 28  convictions during  the review period but  
reported only 2 of these  individuals to OIG for program exclusion, 
according to Unit data.  Performance Standard 8(f) states that  when 
an individual is sentenced, the Unit should report the conviction to 
OIG within 30  days of sentencing  for the purposes of  program 
exclusion.  The Unit did not report either of the two individuals 
within 30 days of sentencing.24   The Units draft policies and 
procedures manual states, For cases involving fraud where  a  
conviction was obtained, the prosecuting [attorney] shall  send the 
sentencing order to OIG.   However, the requirement to report 
convictions extends to any  type of case, not just those involving  
fraud.  In May 2015, subsequent to OIG notifying the Unit of the  
onsite review, the Unit reported that it submitted the  remaining  
26  convictions to OIG and that it had clarified its process for 
reporting convictions.  
The  Unit  did  not  report  any  adverse  actions  to  the  
National  Practitioner  Data  Bank  
The  National Practitioner Data Bank (NPDB)  seeks  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 other  adverse actions.  Pursuant to Federal 
______________________________________________________  
24  The Unit indicated  that one individual was  reported  nearly  2  months  after  
sentencing  and  the other  was  reported  more than  5  months  after  sentencing.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    7  
     
   
regulations, Units must report  any adverse  actions25  stemming from 
prosecutions of healthcare providers, to the NPDB.26   Delays in 
reporting individuals to the NPDB  could result in payments to 
providers with adverse actions.  The Units registration with the  
NPDB was not current during the  review period, and the Unit had 
not reported any  adverse  actions since 2007.   We  note that  the Unit  
did not address the reporting of adverse actions to the NPDB in its 
draft policies and procedures.  In May  2015, the Unit renewed its 
registration with the NPDB.  
Forty-four  percent of  case  files  open  longer  than  
90  days  lacked  documentation  of  periodic  
supervisory  reviews  
Forty-four  percent of the Units case files open longer than 90 days 
lacked documentation of periodic supervisory  reviews.  27   
Performance Standards  5(b) and 7(a)  state that supervisors should 
periodically review the progress  of cases, ensure that each stage of 
an investigation and prosecution is completed within an appropriate  
timeframe, and note  in the case  file that the reviews  take place.  The  
Units policy for supervisory  reviews, as written in the draft policies 
and procedures manual, states that on a quarterly basis, the director 
or deputy  director sets a due date for investigators and attorneys to 
prepare case summaries.  Case summaries should include a brief 
summary of the facts of the case, the investigative steps taken, and 
plans for investigation and prosecution.  Completed case summaries 
are  to be sent to the chief investigator and the administrative  
assistant.  The administrative assistant is to place  a copy in the  case  
file and provide  a hard copy to the director for review.  
The 44 percent of case files open longer than 90 days that lacked 
documentation of periodic supervisory reviews included (1) case  
files with one or more  gaps of more than 90 days between 
______________________________________________________  
25  SSA    1128E(g)(1); 45  CFR    60.3.   Examples of  adverse actions  include 
criminal  convictions; civil judgments  (but not civil settlements); exclusions; and  
other  negative actions  or  findings.  
26  Units  must report adverse actions  to  the NPDB  within  30  calendar  days  of  the 
date the final adverse action  was taken.   45  CFR    60.5.   In  addition  to  Federal 
regulations,  the Performance  Standards  also  require the Unit to  report to  NPDB.   
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.  We reviewed  the reporting  of  adverse 
actions  under  NPDB  requirements,  because the HIPDB  and  the NPDB  were 
merged  during  our  review  period  (FYs  2012  through  2014).   78  Fed.  Reg.  20473  
(April 5,  2013).  
27  Appendix  E  contains  the point estimate and  95-percent confidence  interval for  
the statistic  in  this  finding.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    8  
     
   
supervisory reviews, (2) case files in which  the last or most  recent 
supervisory review  occurred  more than 90 days prior to case closure  
or, for open cases, the date of our onsite review, and (3) case files 
with no documented supervisory reviews.  The Unit director 
attributed the lack of documentation of supervisory  reviews  to 
several factors.  The due  dates for the quarterly  case summaries are  
set to coincide with the dates of quarterly meetings with the State 
Medicaid agency program integrity unit.  From June 2012 through 
February 2013, the Unit  director was detailed away  from Unit  
director duties to a temporary appointment in the Office of Attorney  
General.  During this time, a Unit attorney served as acting Unit 
director.  The  Unit director explained that the acting  director did not  
continue  the quarterly meetings with the State Medicaid agency or 
ensure that case summaries were submitted during this time.  In 
addition, the Unit did not meet with the State Medicaid agency  
during the second quarter of 2015 due to staff  changes in the  
program integrity unit.  Therefore, the Unit did not generate  case  
summaries during this quarter.  
Subsequent to the onsite review, the Unit revised its policy for  
conducting  and documenting supervisory  reviews of cases.  The  
November 2015 policies and procedures manual states that 
investigative  staff will provide summaries for administrative staff to 
check against open case lists and that all case summaries will be 
reviewed and signed by the Unit director.  
The Unit investigated  two  sampled  cases that  
were  not eligible for  Federal  funding  
In our review of a sample of cases we  found that the Unit 
investigated two cases that were not eligible  for Federal matching  
funds.  In the first case, the Unit investigated a matter alleging  
Medicaid eligibility fraud that did not involve conspiracy with a 
provider.  Unless a recipient is  alleged to have engaged in a conspiracy  
with a provider, Federal funds are not available for Unit investigations  
of recipient fraud.28   In the  second case, the Unit investigated alleged 
mishandling of guardianship paperwork for a  nursing home resident  
that resulted in a  nursing  facility not receiving payment for services 
rendered.   The  case did not appear to involve provider fraud.  The  
Unit opened this case  as a patient funds case.  In less than 3 months, 
the Unit determined that  patient funds were not at risk.  Once the 
______________________________________________________  
28  42  CFR    1007.19(e)(5)  and  OIG State Fraud  Transmittal 2013-1, MFCU 
Authority in  Personal Care Waiver Cases  (Mar.  18,  2013).  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    9  
     
   
Unit determined that there was no misappropriation of patient funds, 
and thus insufficient potential for criminal prosecution, the case  
became ineligible for Federal funding.29   However, the case  remained 
open  for  3 years and 5  months.  
The  Unit  stored  some  case  files  in  a  location  
accessible  to  non-Unit  staff  
Federal regulation and OIG policy  require Units to safeguard the  
privacy rights of all individuals and [to]  provide safeguards to 
prevent the misuse of information under the  Units control.30   This 
includes securing case files containing potentially  sensitive 
personally identifiable information about witnesses, victims, 
suspects, and informants.   During our onsite review, we observed 
that some case files were stored in an unlocked file cabinet in an  
office, and  Unit staff confirmed that the file cabinet is not routinely  
locked.  Finally, non-Unit staff (e.g.,  other Office  of Attorney  
General staff, janitors) are  issued keycards providing  access to the 
same areas  to which the  Unit staff  has access.   
Only  a  small  portion  of  Unit  fraud  referrals  came  
from  the  State  Medicaid  agency;  however,  the  Unit  
worked  to  increase  the  number  and  quality  of  
referrals  
The Unit reported  that only 10 of the 305 fraud referrals (3 percent) 
received  by the Unit during the 3-year review period came from the 
State Medicaid agencys program integrity unit. Performance  
Standard 4 states that  the Unit should take steps to ensure that it  
maintains an adequate volume and quality of referrals from the State  
Medicaid agency and other sources.   
The Unit reported three  activities it had already  taken to increase  the 
number and quality of referrals.   First, staff from the entire Unit 
including attorneys, investigators, analysts, and management 
participate in quarterly meetings with  the State Medicaid agencys 
program integrity unit  and managed care organizations.  Topics 
discussed at these meetings include open cases, fraud trends, policy  
issues, and training.  Unit staff believe that discussion among  
individuals from the variety of disciplines and organizations 
represented at these meetings will lead to more  and higher quality  
referrals.  Second, the  Unit participated in the Request for Proposal 
______________________________________________________  
29  42  CFR    1007.11(b).
    
30  42  CFR    1007.11(f); OIG State Fraud  Policy Transmittal No.  99-02,  Public 

Disclosure Requests  and  Safeguarding  of Privacy  Rights  (Dec.  22,  1999).
  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    10  
     
   
process for managed care contracts.  The Unit provided input on 
several contract provisions, including  (1)  the process for reporting  
and investigating suspected fraud,  and  (2)  definitions for terms such 
as fraud  and critical incident (e.g.,  abuse or neglect occurring in 
nursing facilities).  Third, the Unit director reported that in 2013 the  
Unit revised its  referral form.  The Unit director believed  this 
revision will produce  higher quality, actionable referrals.    
The  Units  MOU  with  the  State  Medicaid  agency  
did  not  reflect  current  practice   
Performance Standard 10(a) requires the Unit  to document that it has 
reviewed its MOU with the State Medicaid agency  at least every  
5  years, and has renegotiated the MOU  as necessary, to ensure that it  
reflects current practice, policy, and legal requirements.  Although 
the Units MOU with the State Medicaid agency  has been renewed 
in the past 5 years, officials from both the Unit and the State  
Medicaid agency told us that they believed that the MOU should be  
renegotiated to more clearly define certain areas (e.g.,  managed care  
referrals, expectations related to content and contributions at  
quarterly meetings) to reflect current practice.   We note that the  
MOU  does not  incorporate by reference the Centers for Medicare  
&  Medicaid Services Performance Standard for Referrals of 
Suspected Fraud from a State Agency to a Medicaid Fraud Control 
Unit, as required by Performance Standard  10(e).  
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    11  
     
   
CONCLUSION  AND RECOMMENDATIONS  
Our review of the Delaware  Unit identified areas where the Unit 
should improve its operations.   Specifically, the Units policies and 
procedures for its operations were in draft status for the entire review  
period.  The lack of final written policies and procedures might  have  
contributed  to the lack of adherence to certain performance standards 
and Federal regulations.  The Unit reported only 2 of 28  convictions  
to the OIG, neither of which was  reported within the required 
timeframe, and did not report any  adverse actions to the NPDB.   
Other areas needing  improvement relate to case  files.   Forty-four  
percent of case files lacked documentation of supervisory reviews.  
In addition, the Unit investigated two cases that were not eligible for 
Federal funding.  Moreover, the Unit stored some case files in a 
location accessible to non-Unit staff.  
Further, officials from both the Unit and the State Medicaid agency  
reported the need to revise the existing  MOU to reflect current 
practice.  Finally, the Unit received only  a small portion of referrals 
from the State Medicaid agency; however, the Unit has taken steps 
to increase the number and quality of referrals.   In lieu of a  
recommendation, we will monitor the impact of these measures  on 
referral volume and quality.  
We recommend that the Delaware  Unit:  
Ensure that it reports convictions to OIG  within 30  days of 
sentencing  
The Unit should establish and follow a policy to report convictions  
in a timely  manner.  
Ensure that it reports adverse actions to the NPDB  
The Unit should maintain its registration  with the NPDB and ensure  
that  it reports all adverse  actions  generated by  investigations or 
prosecutions of healthcare providers  to the NPDB  as specified in 
Federal regulations.  
Ensure it conducts and documents  supervisory reviews  
of Unit case files  open longer than 90 days  
The Unit should conduct periodic supervisory  reviews of case files 
consistent with the Units newly implemented written policy.  These  
reviews should be documented in the case files.   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    12  
     
   
Repay Federal matching funds spent on the cases that 
were not eligible for Federal funding  
The Unit should work with OIG to identify the staff hours and 
expenditures  associated with the  two  ineligible cases and repay those 
Federal matching funds.  As for the patient funds case, the 
investigative costs  the Unit  incurred while  determining  whether there  
was substantial potential for criminal prosecution  are  allowable.  
Secure case files  
The Unit should store all case files and other documentation 
containing personally identifiable information in a locked room or in 
locked storage  cabinets.  
Revise the MOU with the State Medicaid agency to reflect 
current practice  
The Unit  should revise its MOU with the State Medicaid Agency so 
that the MOU reflects current practice.  The MOU should be revised 
to more clearly define  certain areas (e.g.,  managed care  referrals, 
expectations related to content and contributions at quarterly  
meetings) and include the revised referral form.  Further, the MOU  
should be revised to incorporate by reference the Centers for  
Medicare & Medicaid Services  Performance Standard for Referrals  
of Suspected Fraud from a State  Agency to a Medicaid Fraud 
Control Unit.  
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    13  
     
   
UNIT COMMENTS  AND OFFICE OF INSPECTOR GENERAL  
RESPONSE  
The Delaware Unit concurred with all six of our recommendations.  
Regarding the first recommendation, the Unit stated that it has 
reported all convicted individuals not previously  reported to OIG.  In 
addition, the Unit stated that it updated its policies and procedures 
manual to reflect  the requirement that  all  Unit-obtained convictions 
are to  be  reported to OIG within 30  days of sentencing.  
Regarding the second recommendation, the Unit stated that it has 
reported all individuals not previously reported to the NPDB.  In 
addition, the Unit stated that it  has updated its  policies and 
procedures manual to reflect the requirement that  the Unit  report  
adverse  actions to the NPDB.   We suggest that  the Unit include 
language in its policies and procedures manual to reflect the  
timeframes specified in 45  CFR    60.5.  
Regarding the third recommendation, the Unit stated that it  has 
updated its  policies and procedures manual to state that the Unit will  
set quarterly dates for submission of case summaries.  The Director 
will review and sign all quarterly case summaries.  Unit staff will 
ensure that case files contain a signed case summary  for each 
quarter.  
Regarding the fourth recommendation, the Unit  stated that it has 
instructed all staff on the  scope of the Units  jurisdiction.  The Unit is 
working  with OIG  to identify Unit costs associated with the two 
ineligible cases and repay  grant funds.  
Regarding the fifth recommendation, the Unit stated that it  has 
instructed staff to lock filing cabinets to prevent misuse of sensitive 
information in case files.  
Regarding the sixth recommendation, the Unit stated that it  has 
provided a draft revised MOU to the State Medicaid agency  and 
requested a deadline of April 1, 2016, for a final, signed version of  
the MOU.  
The Units comments are provided in Appendix F.    
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    14  
     
   
APPENDIX  A  
2012 Performance Standards31   
1.   A  UNIT  CONFORMS  WITH  ALL APPLICABLE  STATUTES,  REGULATIONS,  AND  POLICY  DIRECTIVES,  
INCLUDING:  
A.   Section  1903(q) of  the Social  Security  Act,   containing  the  basic  requirements  for operation  of  a MFCU;  
B.   Regulations  for  operation  of  a  MFCU  contained  in  42  CFR  part  1007;  
C.   Grant  administration  requirements  at  45  CFR  part  92  and  Federal cost  principles  at  2  CFR  part  225;  
D.   OIG  policy  transmittals  as  maintained  on  the  OIG Web  site;  and   
E.   Terms  and  conditions  of  the  notice  of  the  grant  award.  
2.   A  UNIT  MAINTAINS  REASONABLE  STAFF LEVELS  AND  OFFICE  LOCATIONS  IN  RELATION  TO THE  
STATES  MEDICAID  PROGRAM  EXPENDITURES  AND  IN  ACCORDANCE  WITH  STAFFING 
ALLOCATIONS  APPROVED  IN  ITS  BUDGET.    
A.   The  Unit  employs  the  number  of  staff  that  is  included  in  the  Units  budget  estimate  as  approved  by  OIG.  
B.   The  Unit  employs  a  total  number  of  professional staff  that  is  commensurate  with  the  States  total Medicaid 
program  expenditures  and  that  enables  the  Unit  to  effectively  investigate  and  prosecute  (or  refer  for  
prosecution)  an  appropriate  volume of  case  referrals  and  workload  for  both  Medicaid  fraud  and  patient  abuse  
and  neglect.  
C.   The  Unit  employs  an  appropriate  mix  and  number  of  attorneys,  auditors,  investigators,  and  other  
professional staff  that  is  both  commensurate  with  the  States  total Medicaid program  expenditures  and  that  
allows  the  Unit  to  effectively  investigate  and  prosecute  (or  refer  for  prosecution)  an  appropriate  volume  of  case  
referrals  and  workload  for  both  Medicaid fraud  and  patient  abuse  and  neglect.  
D.   The  Unit  employs  a  number  of  support  staff  in relation  to  its  overall  size  that  allows  the  Unit  to  operate  
effectively.  
E.   To  the  extent  that  a  Unit  maintains  multiple office  locations,  such  locations  are  distributed  throughout  the  
State,  and  are  adequately  staffed,  commensurate  with  the  volume  of  case  referrals  and  workload  for  each  
location.  
3.  A  UNIT  ESTABLISHES  WRITTEN  POLICIES  AND  PROCEDURES  FOR  ITS  OPERATIONS  AND  
ENSURES  THAT  STAFF ARE  FAMILIAR  WITH,  AND  ADHERE  TO,  POLICIES  AND  PROCEDURES.    
A.   The  Unit  has  written  guidelines  or  manuals  that  contain current  policies  and  procedures,  consistent  with  
these  performance  standards,  for  the  investigation  and  (for  those  Units  with  prosecutorial authority)  prosecution  
of  Medicaid  fraud  and  patient  abuse  and  neglect.   
B.   The  Unit  adheres  to  current  policies  and  procedures  in  its  operations.  
C.   Procedures  include  a  process  for  referring  cases,  when  appropriate,  to  Federal  and  State  agencies.   
Referrals  to  State  agencies,  including  the  State  Medicaid  agency,  should identify  whether  further  investigation  
or  other  administrative  action  is  warranted,  such  as  the  collection  of  overpayments  or  suspension  of  payments.  
D.   Written  guidelines  and  manuals  are  readily  available  to  all  Unit  staff,  either  online  or  in  hard  copy.  
E.   Policies  and  procedures  address  training  standards  for  Unit  employees.  
4.  A  UNIT  TAKES  STEPS  TO MAINTAIN  AN  ADEQUATE  VOLUME  AND  QUALITY  OF REFERRALS  FROM 
THE  STATE  MEDICAID  AGENCY  AND  OTHER  SOURCES.    
A.   The  Unit  takes  steps,  such  as  the  development  of  operational protocols,  to  ensure  that  the  State  Medicaid 
agency,  managed  care  organizations,  and  other  agencies  refer  to  the  Unit  all suspected  provider  fraud  cases.   
Consistent  with  42  CFR  1007.9(g),  the  Unit  provides  timely  written  notice  to  the  State  Medicaid  agency  when  
referred  cases  are  accepted  or  declined  for  investigation.  
______________________________________________________  
31  77  Fed.  Reg.  32645  (June  1,  2012).  
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B.   The  Unit  provides  periodic  feedback  to  the  State  Medicaid  agency  and  other  referral  sources  on  the  
adequacy  of  both  the  volume  and  quality  of  its  referrals.  
C.   The  Unit  provides  timely  information  to  the  State  Medicaid or  other  agency  when  the  Medicaid or  other  
agency  requests  information  on  the  status  of  MFCU  investigations,  including  when  the  Medicaid  agency  
requests  quarterly  certification  pursuant  to  42  CFR  455.23(d)(3)(ii).  
D.   For  those  States  in which  the  Unit  has  original jurisdiction  to  investigate  or  prosecute  patient  abuse  and  
neglect  cases,  the  Unit  takes  steps,  such  as  the  development  of  operational protocols,  to  ensure  that  pertinent  
agencies  refer  such  cases  to  the  Unit,  consistent  with  patient  confidentiality  and  consent.   Pertinent  agencies  
vary  by  State  but  may  include  licensing  and  certification  agencies,  the  State  Long  Term  Care  Ombudsman,  and  
adult  protective  services  offices.   
E.   The  Unit  provides  timely  information,  when  requested,  to  those  agencies  identified  in (D)  above  regarding  
the  status  of  referrals.  
F.   The  Unit  takes  steps,  through  public  outreach  or  other  means,  to  encourage  the  public  to  refer  cases  to  the  
Unit.  
5.  A  UNIT  TAKES  STEPS  TO MAINTAIN  A  CONTINUOUS  CASE  FLOW  AND  TO COMPLETE  CASES  IN  AN  
APPROPRIATE  TIMEFRAME  BASED  ON  THE  COMPLEXITY  OF THE  CASES.  
A.   Each  stage  of  an  investigation  and  prosecution  is  completed  in  an  appropriate  timeframe.  
B.   Supervisors  approve  the  opening  and  closing  of  all investigations  and  review  the  progress  of  cases  and  take  
action  as  necessary  to  ensure  that  each  stage  of  an  investigation  and  prosecution  is  completed  in an  
appropriate timeframe.  
C.   Delays  to  investigations  and  prosecutions  are  limited  to  situations  imposed  by  resource  constraints  or  other  
exigencies.    
6.   A  UNITS  CASE  MIX,  AS  PRACTICABLE,  COVERS  ALL SIGNIFICANT  PROVIDER  TYPES  AND  
INCLUDES  A  BALANCE  OF FRAUD  AND,  WHERE  APPROPRIATE,  PATIENT  ABUSE  AND  NEGLECT  
CASES.    
A.   The  Unit  seeks  to  have  a  mix  of  cases  from  all  significant  provider  types  in the  State.  
B.   For  those  States  that  rely  substantially  on  managed  care  entities  for  the  provision  of  Medicaid services,  the  
Unit  includes  a  commensurate  number  of  managed  care  cases  in  its  mix  of  cases.   
D.   As  part  of  its  case  mix,  the  Unit  maintains  a  balance  of  fraud  and  patient  abuse  and  neglect  cases  for  those  
States  in which  the  Unit  has  original jurisdiction  to  investigate  or  prosecute  patient  abuse  and  neglect  cases.  
C.   The  Unit  seeks  to  allocate  resources  among  provider  types  based  on  levels  of  Medicaid  expenditures  or  
other  risk  factors.   Special Unit  initiatives  may  focus  on  specific  provider  types.  
E.   As  part  of  its  case  mix,  the  Unit  seeks  to  maintain,  consistent  with  its  legal  authorities,  a  balance  of  criminal 
and  civil  fraud  cases.  
7.   A  UNIT  MAINTAINS  CASE  FILES  IN  AN  EFFECTIVE  MANNER  AND  DEVELOPS  A  CASE  
MANAGEMENT  SYSTEM THAT ALLOWS  EFFICIENT  ACCESS  TO CASE  INFORMATION  AND  OTHER  
PERFORMANCE  DATA.    
A.   Reviews  by  supervisors  are  conducted  periodically,  consistent  with  MFCU  policies  and  procedures,  and  are  
noted  in the  case  file.  
B.   Case  files  include  all  relevant  facts  and  information  and  justify  the  opening  and  closing  of  the  cases.  
C.   Significant  documents,  such  as  charging  documents  and  settlement  agreements,  are  included  in  the  file.   
D.   Interview  summaries  are  written  promptly,  as  defined  by  the  Units  policies  and  procedures.  
E.   The  Unit  has  an  information  management  system that  manages  and  tracks  case  information  from  initiation  to  
resolution.  
F.  The  Unit  has  an  information  management  system that  allows  for  the  monitoring  and  reporting  of  case  
information,  including  the  following:   
1.  The  number  of  cases  opened  and  closed  and  the  reason  that  cases  are  closed.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    16  
     
   
2.   The  length  of  time taken  to  determine  whether  to  open  a  case  referred  by  the  State  Medicaid agency  or  other  
referring  source.  
3.   The  number,  age,  and  types  of  cases  in  the  Units  inventory/docket  
4.   The  number  of  referrals  received  by  the  Unit  and  the  number  of  referrals  by  the  Unit  to  other  agencies.  
5.   The  number  of  cases  criminally  prosecuted  by  the  Unit  or  referred  to  others  for  prosecution,  the  number  of  
individuals  or  entities  charged,  and  the  number  of  pending  prosecutions.  
6.   The  number  of  criminal convictions  and  the  number  of  civil  judgments.  
7.   The  dollar  amount  of  overpayments  identified.  
8.   The  dollar  amount  of  fines,  penalties,  and  restitution  ordered  in a  criminal  case  and  the  dollar  amount  of  
recoveries  and  the  types  of  relief  obtained  through  civil  judgments  or  prefiling  settlements.  
8.   A  UNIT  COOPERATES  WITH  OIG AND  OTHER  FEDERAL AGENCIES  IN  THE  INVESTIGATION  AND  
PROSECUTION  OF MEDICAID  AND  OTHER  HEALTH  CARE  FRAUD.    
A.   The  Unit  communicates  on  a  regular  basis  with  OIG and  other  Federal agencies  investigating  or  prosecuting  
health  care  fraud  in  the  State.  
B.   The  Unit  cooperates  and,  as  appropriate,  coordinates  with  OIGs  Office  of  Investigations  and  other  Federal 
agencies  on  cases  being  pursued  jointly,  cases  involving  the  same suspects  or  allegations,  and  cases  that  have  
been  referred  to  the  Unit  by  OIG or  another  Federal agency.   
C.   The  Unit  makes  available,  to  the  extent  authorized  by  law  and  upon  request  by  Federal investigators  and  
prosecutors,  all  information  in  its  possession  concerning  provider  fraud  or  fraud  in  the  administration  of  the  
Medicaid program.  
D.   For  cases  that  require  the  granting  of  extended  jurisdiction  to  investigate  Medicare  or  other  Federal health  
care  fraud,  the  Unit  seeks  permission  from OIG  or  other  relevant  agencies  under  procedures  as  set  by  those 
agencies.   
E.   For  cases  that  have  civil  fraud  potential,  the  Unit  investigates  and  prosecutes  such  cases  under  State  
authority  or  refers  such  cases  to  OIG or  the  U.S.  Department  of  Justice.  
F.   The  Unit  transmits  to  OIG,  for  purposes  of  program  exclusions  under  section  1128  of  the  Social Security  Act,  
all  pertinent  information  on  MFCU  convictions  within 30  days  of  sentencing,  including  charging  documents,  plea  
agreements,  and  sentencing  orders.  
G.   The  Unit  reports  qualifying  cases  to  the  Healthcare  Integrity  &  Protection  Databank,  the  National Practitioner  
Data  Bank,  or  successor  data  bases.  
9.  A  UNIT  MAKES  STATUTORY  OR  PROGRAMMATIC  RECOMMENDATIONS,  WHEN  WARRANTED,  TO 
THE  STATE  GOVERNMENT.    
A.   The  Unit,  when  warranted  and  appropriate,  makes  statutory  recommendations  to  the  State  legislature  to  
improve  the  operation  of  the  Unit,  including  amendments  to  the  enforcement  provisions  of  the  State  code.  
B.   The  Unit,  when  warranted  and  appropriate,  makes  other  regulatory  or  administrative  recommendations  
regarding  program  integrity  issues  to  the  State  Medicaid  agency  and  to  other  agencies  responsible for  Medicaid 
operations  or  funding.   The  Unit  monitors  actions  taken  by  the  State  legislature  and  the  State  Medicaid  or  other  
agencies  in response  to  recommendations.   
10.  A  UNIT  PERIODICALLY  REVIEWS  ITS  MEMORANDUM  OF UNDERSTANDING (MOU)  WITH  THE  
STATE  MEDICAID  AGENCY  TO ENSURE  THAT IT  REFLECTS  CURRENT  PRACTICE,  POLICY,  AND  
LEGAL REQUIREMENTS.    
A.   The  MFCU  documents  that  it  has  reviewed  the  MOU  at  least  every  5  years,  and  has  renegotiated  the  MOU  
as  necessary,  to  ensure  that  it  reflects  current  practice,  policy,  and  legal requirements.  
B.   The  MOU  meets  current  Federal legal requirements  as  contained  in law  or  regulation,  including  
42  CFR  455.21,  Cooperation  with  State  Medicaid fraud  control  units,  and  42  CFR 455.23,  Suspension  of  
payments  in cases  of  fraud.  
C.   The  MOU  is  consistent  with  current  Federal and  State  policy,  including  any  policies  issued  by  OIG  or  the  
Centers  for  Medicare  &  Medicaid  Services  (CMS).  
D.   Consistent  with  Performance  Standard  4,  the  MOU  establishes  a  process  to  ensure  the  receipt  of  an  
adequate  volume  and  quality  of  referrals  to  the  Unit  from  the  State  Medicaid agency.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    17  
     
   
E.   The  MOU  incorporates  by  reference  the  CMS  Performance  Standard  for  Referrals  of  Suspected  Fraud  from  
a  State  Agency  to  a  Medicaid Fraud  Control Unit.  
11.  A  UNIT  EXERCISES  PROPER  FISCAL CONTROL OVER  UNIT  RESOURCES.    
A.   The  Unit  promptly  submits  to  OIG its  preliminary  budget  estimates,  proposed  budget,  and  Federal financial 
expenditure  reports.    
B.   The  Unit  maintains  an  equipment  inventory  that  is  updated  regularly  to  reflect  all  property  under  the  Units  
control.  
C.   The  Unit  maintains  an  effective  time and  attendance  system and  personnel activity  records.  
D.   The  Unit  applies  generally  accepted  accounting  principles  in its  control of  Unit  funding.  
E.   The  Unit  employs  a  financial  system in  compliance  with  the  standards  for  financial management  systems  
contained  in 45  CFR  92.20.  
12.  A  UNIT  CONDUCTS  TRAINING THAT AIDS  IN  THE  MISSION  OF THE  UNIT.    
A.   The  Unit  maintains  a  training  plan  for  each  professional  discipline  that  includes  an  annual  minimum number  
of  training  hours  and  that  is  at  least  as  stringent  as  required  for  professional certification.   
B.   The  Unit  ensures  that  professional staff  comply  with  their training  plans  and  maintain records  of  their  staffs  
compliance.  
C.   Professional  certifications  are  maintained  for  all  staff,  including  those  that  fulfill  continuing  education  
requirements.  
D.   The  Unit  participates  in MFCU-related  training,  including  training  offered  by  OIG and  other  MFCUs,  as  such  
training  is  available and  as  funding  permits.  
E.   The  Unit  participates  in  cross-training  with  the  fraud  detection  staff  of  the  State  Medicaid agency.   As  part  of  
such  training,  Unit  staff  provide  training  on  the  elements  of  successful fraud  referrals  and  receive  training  on  the  
role and  responsibilities  of  the  State  Medicaid agency.   
 
 
 
 
 
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    18  
     
   
APPENDIX B  
Table  B-1:   Unit Referrals by Referral Source for FYs  2012  
Through 2014  
  FY  2012   FY  2013   FY  2014  
Abuse  &   Patient   Abuse  &   Patient   Abuse  &   Patient  
Referral  Source   Fraud   Fraud   Fraud  
Neglect   Funds   Neglect   Funds   Neglect   Funds  
State  Medicaid 
6   0   0   2   0   0   2   0   0  
agency  
Medicaid agency    
0   0   0   0   0   0   1   0   0  
other  
State  survey  and  
0   0   0   0   0   0   0   0   0  
certification  agency  
Other  State  
4   220   48   5   140   35   0   135   34  
agencies32  
Licensing  Board   2   0   0   0   2   0   0   6   0  
Law  enforcement   4   7   9   0   8   0   1   7   1  
Office  of  Inspector  
0   0   0   0   0   0   0   0   0  
General  
Prosecutors   7   0   2   0   0   0   1   5   0  
Providers   0   0   0   0   0   0   0   0   0  
Provider  
0   0   0   0   0   0   0   0   0  
associations  
Private  health  
0   0   0   0   0   0   0   0   0  
insurer  
Long-term-care  
0   0   0   0   0   0   0   0   0  
ombudsman  
Adult  protective  
0   0   0   0   0   0   0   0   0  
services  
Private  citizens   116   7   1   77   2   0   64   1   0  
MFCU  hotline   0   1   0   3   0   0   2   1   0  
Other   1   1   0   4   2   0   3   0   0  
   Total   140   236   60   91   154   35   74   155   35  
   Annual  Total   436   280   264  
Source:  OIG analysis of Unit-submitted documentation, FYs  20122014, 2015.  
   
______________________________________________________  
32  The Unit reported  that referrals from  the Delaware Division  of  Long  Term  Care 
Residents  Protection  make up  the majority  of  these referrals.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    19  
     
   
APPENDIX C  
Investigations Opened and Closed by Provider Category  
for FYs 2012 Through 2014  
Table C-1:  Fraud Investigations  
Provider  Category   FY  2012   FY  2013   FY  2014  
Facilities   Opened   Closed   Opened   Closed   Opened   Closed  
     Hospitals   0   0   1   0   1   0  
     Nursing  facilities   3   0   2   1   0   1  
     Other  long-term-care   
0   1   0   0   0   0  
     facilities  
     Substance  abuse  treatment             
0   0   0   0   0   0  
     centers   
     Other    0   0   0   0   2   1  
   Subtotal   3   1   3   1   3   2  
Practitioners   Opened   Closed   Opened   Closed   Opened   Closed  
     Doctors  of  medicine  or   
5   3   2   1   6   4  
     osteopathy  
     Dentists   0   0   2   0   0   1  
     Podiatrists   0   0   0   0   0   0  
     Optometrists/opticians   0   0   0   1   0   0  
     Counselors/psychologists   0   0   2   0   1   1  
     Chiropractors   0   0   0   0   0   0  
     Other    3   0   2   1   1   0  
   Subtotal   8   3   8   3   8   6  
Medical  Support   Opened   Closed   Opened   Closed   Opened   Closed  
     Pharmacies   6   1   3   1   4   0  
     Pharmaceutical  
34   12   37   8   29   20  
     manufacturers  
     Suppliers  of  durable medical  
10   1   17   0   19   3  
     equipment  and/or  supplies  
     Laboratories   5   0   9   1   11   1  
     Transportation  services   0   1   1   0   0   0  
     Home health  care  agencies   0   0   0   0   0   0  
     Home health  care  aides   0   0   0   0   0   0  
     Nurses,  physician  assistants,   
     nurse  practitioners,  certified    3   2   0   0   1   0  
     nurse  aides  
     Radiologists   0   0   0   0   0   0  
     Medical supportother    7   1   7   0   9   2  
   Subtotal   65   18   74   10   73   26  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    20  
     
   
 
Table C-1 (Continued):  Fraud Investigations  
Program  Related   Opened   Closed   Opened   Closed   Opened   Closed  
     Managed  care    0   0   0   0   0   0  
     Medicaid program   
0   0   0   0   0   0  
     administration  
     Billing  company   0   0   0   0   0   0  
     Other   0   0   0   1   0   0  
   Subtotal   0   0   0   1   0   0  
   Total  Provider  Categories   76   22   85   15   84   34  
Source:  OIG analysis of Unit-submitted documentation, 2015.  
 
Table C-2: Patient  Abuse and Neglect Investigations  
Provider  Category   FY  2012   FY  2013   FY  2014  
  Opened   Closed   Opened   Closed   Opened   Closed  
     Nursing  facilities   0   2   0   0   0   2  
     Other  long-term-care  facilities   0   0   0   0   0   0  
Nurses,  physicians  
assistants,  nurse     
16   14   18   9   25   27  
practitioners,  certified  nurse            
aides  
     Home health  aides   0   0   0   0   1   0  
     Other   30   29   30   25   60   43  
   Total   46   45   48   34   86   72  
Source: OIG analysis of Unit-submitted documentation, 2015.  
 
Table C-3: Patient Funds Investigations  
Provider  Category   FY  2012   FY  2013   FY  2014  
  Opened   Closed   Opened   Closed   Opened   Closed  
     Nondirect  care   16   12   7   9   6   8  
Nurses,  physicians  
assistants,  nurse     
1   0   1   0   3   1  
practitioners,  certified  nurse            
aides  
     Home health  aides   1   0   0   1   0   0  
     Other   12   2   4   8   5   6  
   Total   30   14   12   18   14   15  
Source: OIG analysis of Unit-submitted  documentation, 2015.  
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    21  
     
   
APPENDIX D  
Detailed Methodology  
We used data collected from the seven sources below to describe the 
caseload and assess the performance of the Delaware Unit.   
Data Collection  
Review of Unit Documentation. Prior to the onsite visit, we analyzed 
information from several sources regarding the Units investigation 
of Medicaid cases, including information about the number of 
referrals the Unit received, the number of investigations the Unit 
opened and closed, the outcomes of those investigations, and the 
Units case mix.  We also collected and analyzed information about 
the number of cases that the Unit referred for prosecution and the 
outcomes of those prosecutions.  We gathered this information from 
several sources, including the Units quarterly status reports, its 
annual reports, its recertification questionnaire, its policy and 
procedures manuals, and its MOU with the State Medicaid agency.  
Additionally, we confirmed with the Unit director that the 
information we had was current as of May  2015.  
Review of Unit Financial Documentation.   We reviewed the Units 
control over its fiscal resources to identify any internal control issues 
or other issues involving  use of resources.   Prior to the onsite review, 
we reviewed the Units financial policies and procedures; its 
response to an internal control questionnaire; and documents (such 
as financial status reports) related to MFCU grants.  
We reviewed three purposive samples to assess the Units internal 
control of fiscal resources.  All three samples were limited to the 
review period of  FYs 2012 through 2014.  The three samples 
included the following:  
1.   To assess the Units expenditures, we selected a purposive  
sample of 24 items from the Units 2,460 expenditure  
transactions.   We selected routine and nonroutine  
transactions representing  a variety of budget categories and 
payment amounts.    
2. 	  To assess the Units travel expenditures, we selected a  
purposive sample of 24 items from the Units 772  travel 
transactions.   We  selected eight  travel related transactions for  
each FY.   We  selected  a variety of travel expenditure  
categories such as hotel stays, airfare, conference  expenses, 
rental cars, and meals.   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    22  
     
   
3. 	  To assess employees time and effort, we selected a sample  
of three  pay periods, one  from each FY.   We then requested 
and reviewed documentation (e.g., time card records) to 
support the time and effort of  Unit  staff during the selected 
pay periods.    
We also reviewed a  purposive sample of the Units supply inventory, 
including vehicles.  Specifically, we selected and verified a  
purposive sample of 18 items from the current inventory list of 
112  items.   To ensure a variety in our inventory sample, we included 
larger items such as computers and vehicles as well as a mix of other  
items such as radios and cameras.  
Interviews with Key Stakeholders.  In May and June 2015, we  
interviewed key stakeholders, including officials in the United States 
Attorneys Office (Criminal and Civil Divisions), the Federal Bureau 
of Investigation,  the State Attorney  Generals Office, and State  
Agencies that interacted with the Unit (i.e.,  Adult Protective Services, 
Delaware State Police, Division of Long  Term Care Residents 
Protection, Division of Medicaid and Medical Assistance Program 
Integrity  Unit, Division of Professional Regulation, and Long Term 
Care Ombudsman).  We  also interviewed a supervisor from OIGs 
Region  III  office  who works regularly with the Unit.  We focused these  
interviews on the Units relationship and interaction with OIG and 
other Federal and State authorities, and we identified opportunities for  
improvement.  We  used the information collected from these  
interviews to develop subsequent interview questions for Unit 
management.  
Survey of Unit Staff.   In  April and May 2015, we  conducted an online  
survey of all 14 nonmanagerial Unit staff within each professional 
discipline (e.g.,  attorneys, investigators) as well as support staff.  We  
received completed surveys from 12 of 14 staff, or 86 percent.   The  
survey focused on operations  of the Unit, opportunities for  
improvement, and practices that contributed to the effectiveness and 
efficiency of Unit operations and/or performance.  The survey also 
sought information about the Units compliance with applicable laws 
and regulations.   
Onsite Interviews with Unit Management.   We conducted structured 
interviews with the Units management during our onsite review.  We  
interviewed the Units director, deputy director, and chief  
investigator.  We asked these individuals to provide information  
related to (1)  the Units operations, (2) Unit practices that 
contributed to the effectiveness and efficiency of Unit operations 
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    23  
     
   
and/or performance, (3)  opportunities for the Unit to improve its 
operations and/or performance, and (4) clarification regarding  
information obtained from other data sources.  
Onsite Review of Case Files and Other Documentation.  We  
requested that the  Unit provide us with a list of cases that were open 
at any point during  FYs 2012 through 2014.  The  Unit provided a  list 
of 876  cases that were open during the review period.  For each of 
these 876 cases, the Unit provided data including:   the current status 
of the case; whether the case was criminal, civil, or global; and the  
date on which the  case was opened.  From this list of cases, we  
excluded 528  cases that were  categorized as global,  leaving a  
population of 348 cases that were open at any point during the 
review period.  
We then selected a simple random sample of 100 cases from the 
population of open  cases.   We  determined that 87 of these  
100  sample cases were open longer than 90 days, and therefore  
required periodic supervisory  review.   Based on the percentage of 
cases in our sample that were open longer than 90 days, we  
estimated  the subpopulation of all cases open longer than  90 days. 
We estimate this subpopulation is composed of approximately  
303  case files within the 348 submitted.  Table D-1 provides the 
sample size, the estimated subpopulation, and the 95-percent 
confidence interval for the estimate of the number of case  files that 
were open longer than 90 days.  
Table D-1:  Estimate of Subpopulation Size  
Estimated  
Sampled   95-percent  
Subpopulation  Description   Number  of  
Case  Files   Confidence  Interval  
Case  Files  
Case  files  open  longer  than  90  
87   303   278321  
days  
Source:  OIG analysis of case files, 2015.  
We reviewed the 87 sample cases to determine whether  
documentation for all required supervisory reviews was 
present.  Using the results of our review, we reported an estimate  of 
the number of case  files that did not contain documentation of  
supervisory review for the above subpopulation.  The point estimate  
and its 95-percent confidence intervals are in Appendix  E.  
From the initial sample of 100  case  files, we selected a further 
simple random sample of 50  files for an OIG investigator to conduct 
an indepth review of selected issues, such as the timeliness of  
investigations and case development.  We did not estimate any  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    24  
     
   
population or subpopulation proportions from this additional sample  
of 50 case  files.  
Onsite Review of Unit Operations.  During our June 2015 site visit, 
we observed the Units offices and meeting spaces; the security of 
data and case files; location of select equipment; and the general 
functioning of the Unit.  We also determined whether the Unit 
referred sentenced individuals to OIG for program exclusion and 
whether the Unit reported adverse  actions to the NPDB.  
Data  Analysis  
We analyzed data to identify any opportunities for improvement and 
any instances in which the Unit did not fully meet the performance  
standards or was not operating in accordance  with laws, regulations, 
or policy transmittals.33   We based  our findings on data analysis, 
statements from Unit staff, and our own judgment.  
   
______________________________________________________  
33  All relevant regulations,  statutes, and  policy  transmittals  are  available online at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu.  
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    25  
     
   
APPENDIX E  
Table  E-1:   Point Estimate and 95-Percent  Confidence  
Interval Based on Reviews of Case Files  
95-Percent  Confidence  
Sample   Point   Interval   
Estimate  Characteristic  
Size    Estimate  
Lower   Upper  
Case  files  open  longer  than  90  days  that  did  
not  contain documentation  of  periodic   87   43.7%   34.3%   53.1%  
supervisory  review  
Source:  OIG analysis of case files, 2015.  
 
 
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    26  
     
   
APPENDIX F  
Unit Comments  
 
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    27  
     
   
 
   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    28  
    Recommendation #6: Revise the MOU with the State Medicaid agency to reflect current 
practice. 
1.[nit comment:  The Unit concurs ~vith this rccomme11dation.  On November 30, 2015, 
Unit management had a teleconference with the State Medicaid agency PIU Director and 
Systems Utilization and Review Unit Administrator to discuss revisions to the MOU. The Unit 
and agency agreed lo update the MOU. As of the date of this submission, the Unit sent a draft 
revised MOU to the State Medicaid agency. The agency provided a deadline of April l, 2016 for 
a final, signed version of the MOU. 
While no specific recommendations were made with respect to the finding that only a 
small portion of Unit fraud referrals came from the State Medicaid agency, the Unit has made 
significant efforts to improve the referral process with the State Medicaid agency. Notable 
strides include the Unit soliciting referrals from the agency, the Unit stressing the imp01tance of 
maintaining quarterly meetings between the Unit and the Systems Utilization and Review Unit of 
the State Medicaid agency's Program Integrity Unit, and re-instating monthly Unit and PIU 
manager meetings. The Unit is also working with the Medicaid agency to provide cross-training 
between the Unit and the agency. Finally, in early 2016, Unit managers will be attempting lo 
set-up meetings with the Medicaid agency's su~jecl mutter experts to open a dialogue in the 
hopes of soliciting more referrals from the various provider disciplines. 
Thunk you again for the opportunity lo formally comment and report on the significant 
advances the MPCU has made since the onsite review. The Unit greatly appreciates the 
guidance and insight provided by the review team. We look forward to working with OIG/HHS 
as we pursue the mission of this Unit to investigate and prosecute Medicaid fraud and patient 
abuse and neglect. 
Sincerely, 
Kate S. Keller 
Director 
Medicaid Fraud Control Unit 
Delaware Department of Jtistice 
cc: Jordan Clementi 
(Via Email) 
Delaware Medicaid Fraud Control Unit: 2015 Onsite Review (OEl-07-15-00240)  29   
   
 
ACKNOWLEDGEMENTS  
This report was prepared under the direction of  Brian T. Whitley, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City  regional office.   
Tricia Fields  served as the  project  leader for this study.  Other Office  
of Evaluation and Inspections staff who conducted the study include  
Teresa  Dailey  and Dennis J. Tharp.  Other Office  of Evaluation and 
Inspections staff who contributed to this study include Conswelia  
McCourt and Michala Walker.  Office of Investigations staff  also 
participated in the review.  Central office staff who contributed 
include  Jordan R. Clementi, Kevin Farber, Lonie Kim, 
Joanne  Legomsky, and Andrew VanLandingham.   
Delaware  Medicaid Fraud  Control Unit:   2015  Onsite  Review  (OEI-07-15-00240)                                    30  
     
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
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 assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
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.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
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.