U.S. Department of Health and Human Services 
Office of Inspector General 
 
 
Missouri 
Medicaid Fraud 
Control Unit:  
2018 Onsite 
Inspection
 
 
OEI-12-18-00490  Suzanne Murrin 
January 2020  Deputy Inspector General 
  for Evaluation and Inspections 
oig.hhs.gov  Report in Brief  U.S. Department of Health and Human Services 
 
January 2020 
Office of Inspector General 
 
OEI-12-18-00490 
 
 
Unit Case Outcomes 
Missouri Medicaid Fraud Control Unit: 2018  FYs 201618 
Onsite Inspection    48 indictments 
  45 convictions  
  43 civil settlements and 
What OIG Found 
judgments 
The Missouri Medicaid Fraud Control Unit (MFCU or Unit) reported 48 indictments; 
  $42.1 million in recoveries 
45 convictions; 43 civil settlements and judgments; and $42.1 million in recoveries 
with $25.5 million from 
for fiscal years (FYs) 201618.  From the information we reviewed, we found that 
global* civil cases, 
the Unit generally operated in accordance with applicable laws, regulations, and 
$4.1 million from nonglobal 
policy transmittals.  However, we made four findings involving the Units 
civil cases, and $12.5 million 
adherence to the MFCU performance standards, one of which also involved 
from criminal cases 
compliance with Federal regulations:   
1.  Unit case files did not include all relevant facts, information, and significant  Unit Snapshot 
documents.   The Unit is a division of the Missouri 
  Attorney Generals Office.  
2.  The Unit lacked a policy requiring a specific frequency for periodic 
At the time of OIGs onsite 
supervisory reviews.  
inspection, the Unit had 21 staff 
 
located in its single office location 
3.  The Unit did not report all convictions and adverse actions to Federal 
in Jefferson City, Missouri.   
partners. 
   
4.  The Units training plan did not include an annual minimum number of 
*Global recoveries derive from civil 
training hours for Unit investigators.  settlements or judgments involving the U.S. 
Department of Justice and a group of State 
In addition to the findings, we made a number of observations regarding Unit  MFCUs and are facilitated by the National 
operations and practices.  For example, we highlight an observation regarding Unit  Association of Medicaid Fraud Control Units. 
staffing and a beneficial practice that may be of interest to other MFCUs, as 
 
follows: 
  The Unit experienced significant turnover among management and staff. 
    
  The Unit created in-house training videos to assist staff in Unit 
investigations and trials.  
What OIG Recommends 
To address the four findings, we recommend that the Unit take steps to (1) ensure 
that Unit case files include all relevant facts, information, and significant 
documents; (2) revise the Units policies and procedures manual to include a 
specific frequency for conducting periodic supervisory review of Unit case files, 
and take steps to ensure that case files include documentation of periodic 
supervisory reviews; (3) ensure that the Unit consistently reports convictions and 
adverse actions to Federal partners; and (4) establish training-hour requirements 
for Unit investigators and ensure that all investigators receive annual training.  The 
Unit concurred with all four recommendations. 
Full r eport: oig.hhs.gov/oei/reports/oei-12-18-00490.asp 
   
TABLE OF CONTENTS 
BACKGROUND  1 
PERFORMANCE ASSESSMENT  5 
Case Outcomes  5 
The Unit reported 48 indictments; 45 convictions; and 43 civil settlements and judgments 
for fiscal years 2016 through 2018 
The Unit reported total recoveries of $42.1 million for fiscal years 2016 through 2018 
Performance Standard 1:  Compliance with requirements  6 
From the information we reviewed, the Missouri Unit generally complied with applicable 
laws, regulations, and policy transmittals 
Performance Standard 2:  Staffing   6 
The Units staff levels were low in relation to the States Medicaid program expenditures 
The Unit experienced significant turnover among management and staff 
Performance Standard 3:  Policies and procedures     7 
The Unit maintained written policies and procedures 
Performance Standard 4:  Maintaining adequate referrals     7 
The Unit took steps to maintain an adequate volume and quality of referrals 
Performance Standard 5:  Maintaining a continuous case flow  8 
The Unit took steps to maintain a continuous case flow and to complete cases within an 
appropriate timeframe 
All case files contained documentation of supervisory approval to open the cases, and all 
closed case files contained documentation of supervisory approval to close the cases 
Performance Standard 6:  Case mix  9 
The Units caseload included fraud cases and patient abuse or neglect cases, covering a 
broad mix of provider types 
Performance Standard 7:  Maintaining case information     9 
Unit case files did not include all relevant facts, information, and significant documents 
The Unit lacked a policy requiring a specific frequency for periodic supervisory reviews 
Performance Standard 8:  Cooperation with Federal authorities on fraud cases  11 
The Unit investigated many cases jointly with the Office of Inspector General and actively 
participated in cases with the U.S. Attorneys Office 
The Unit did not report all convictions and adverse actions to Federal partners   
Performance Standard 9:  Program recommendations   12 
   
The Unit made written recommendations to the State Medicaid agency  
Performance Standard 10:  Agreement with Medicaid agency    12 
The Units memorandum of understanding with the State Medicaid agency reflected 
current practice, policy, and legal requirements 
Performance Standard 11:  Fiscal control  13 
In our limited review, we identified no deficiencies in the Units fiscal control of its 
resources 
Performance Standard 12:  Training  13 
The Units training plan did not include an annual minimum number of training hours for 
Unit investigators, and some investigators did not receive annual training  
The Unit created in-house training videos to assist staff in Unit investigations and trials 
CONCLUSION AND RECOMMENDATIONS   
Take steps to ensure that Unit case files include all relevant facts, information, and significant  14 
documents  
Revise the Units policies and procedures manual to include a specific frequency for  14 
conducting periodic supervisory reviews of Unit case files, and take steps to ensure that case 
files include documentation of periodic supervisory reviews      
Take steps to ensure that the Unit consistently reports all convictions and adverse actions to  14 
Federal partners 
Establish training-hour requirements for Unit investigators and ensure that all investigators  15 
receive annual training 
UNIT COMMENTS AND OIG RESPONSE  16 
APPENDICES   
A.  Medicaid Fraud Control Unit Performance Standards  17 
B.  Detailed Methodology  22 
C.  Unit Referrals by Source for Fiscal Years 2016 Through 2018  25 
D.  Point Estimates and 95-Percent Confidence Intervals of Case File Reviews  26 
E.  Unit Comments  27 
ACKNOWLEDGMENTS  30 
 
   
   
BACKGROUND 
Objective 
To examine the performance and operations of the Missouri 
Medicaid Fraud Control Unit  
Medicaid Fraud  Medicaid Fraud Control Units (MFCUs or Units) investigate (1) Medicaid 
Control Units  provider fraud and (2) patient abuse or neglect in facility settings, and 
prosecute those cases under State law or refer them to other prosecuting 
offices.1, 2  Under the Social Security Act (SSA), a MFCU must be a single, 
identifiable entity of State government, separate and distinct from the 
State Medicaid agency, and employ one or more investigators, attorneys, 
and auditors.3  Each State must operate a MFCU or receive a waiver.4  
Currently, 50 States, the District of Columbia, Puerto Rico, and the U.S. 
Virgin Islands operate MFCUs.5  Each Unit receives a Federal grant award 
equivalent to 90 percent of total expenditures for new Units and 75 percent 
for all other Units.6  In Federal fiscal year (FY) 2018, combined Federal and 
State expenditures for the Units totaled approximately $294 million.7   
 
1 SSA  1903(q)(3).  Regulations at 42 CFR  1007.11(b)(1) clarify that the Units responsibilities 
include the review of complaints of misappropriation of patients private funds in health care 
facilities. 
2 References to State in this report refer to the States, the District of Columbia, and the U.S. 
Territories. 
3 SSA  1903(q). 
4 SSA  1902(a)(61). 
5 The territories of American Samoa, Guam, and the Northern Mariana Islands have not 
established Units. 
6 SSA  1903(a)(6).  For a Units first 3 years of operation (currently applicable to North 
Dakota, Puerto Rico, and the U.S. Virgin Islands), the Federal Government contributes 90 
percent of funding, and the State contributes 10 percent.  Thereafter, the Federal 
Government contributes 75 percent, and the State contributes 25 percent. 
7 Office of Inspector General analysis of FY 2018 MFCU annual statistical reporting data.  
Federal FY 2018 was from October 1, 2017, through September 30, 2018. 
 
Missouri Medicaid Fraud Control Unit:  2018 Onsite Inspection  1 
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The Office of Inspector General (OIG) administers the grant award to each 
OIG Grant 
Unit and provides oversight of Units.8, 9  As part of its oversight, OIG reviews 
Administration 
and recertifies each Unit annually and conducts periodic onsite reviews or 
and Oversight  inspections, such as this inspection.   
of Medicaid  In its recertification review, OIG examines the Units reapplication, case 
Fraud Control  statistics, and questionnaire responses from the Units stakeholders.  
Through the recertification review, OIG assesses a Units performance, as 
Units 
measured by the Units adherence to published performance standards;10 
the Units compliance with applicable laws, regulations, and OIG policy 
transmittals;11 and the Units case outcomes.  (See Appendix A for MFCU 
performance standards, including performance indicators for each 
standard.)   
OIG further assesses Unit performance by conducting onsite Unit reviews or 
inspections that may identify findings and make recommendations for 
improvement.  During an onsite review or inspection, OIG also makes 
observations regarding Unit operations and practices, and may identify 
beneficial practices that may be useful to share with other Units.  Finally, 
OIG provides training and technical assistance to Units while onsite, as 
appropriate, and on an ongoing basis.  
Missouri  The Missouri MFCU is located in Jefferson City and is part of the Missouri 
Attorney Generals Office.  At the time of our November 2018 review, the 
Medicaid 
Unit employed 5 attorneys, 1 of whom was the director; 11 investigators 
Fraud Control 
(including a chief investigator who served as the Units liaison with Federal 
Unit  agencies regarding joint investigations); 1 auditor; 1 data analyst; 1 program 
analyst; and 2 legal secretaries.  During our review period of FYs 2016 
through 2018, the Unit spent $6,872,579 ($1,718,145 State share). 
Referrals.  The chief investigator reviews all referrals received by the Unit.  
After a preliminary review to determine whether the allegations are within 
the Units grant authority and are supported by claims data, the chief 
investigator, senior investigator, and director confer to determine whether 
the Unit should open an investigation. 
 
8 As part of grant administration, OIG receives and examines financial information from Units, 
such as budgets and quarterly and final Federal Financial Reports, which detail MFCU income 
and expenditures. 
9 The SSA authorizes the Secretary of Health and Human Services to award grants (SSA 
 1903(a)(6)) and to certify and annually recertify the Units (SSA  1903(q)).  The Secretary 
delegated these authorities to OIG in 1979. 
10 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).   
11 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  
Policy transmittals are located at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/index.asp.  
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Investigations and Prosecutions.  Unit management assigns at least one 
attorney and investigator to each open case.  The Units auditor is assigned 
to cases involving financial records and patient funds.  
The Missouri MFCU investigates and prosecutes (or refers for prosecution) 
cases of suspected Medicaid fraud.  Additionally, the Unit may prosecute 
violations of State laws related to the abuse, neglect, or exploitation of 
adults in health care facilities. 
The Unit may prosecute criminal and civil cases in State and Federal court.  
The Unit may prosecute criminal cases in State court by the county 
attorneys authority or when the county attorney declines to respond to a 
referral from the Unit.12  The Unit may pursue civil cases in State court under 
the State false claims statute.13  The Unit may also prosecute criminal and 
civil cases in Federal court.  The Unit may pursue those cases in 
collaboration with, or by referral to, the Missouri U.S. Attorneys Offices.    
Missouri  MO HealthNet.  The Missouri Medicaid program, MO HealthNet, provides 
care to 819,296 beneficiaries.14  Missouri contracts with three managed care 
Medicaid 
organizations (MCOs) to coordinate health care services for 72 percent of 
Program 
Missouris Medicaid beneficiaries.15  In FY 2018, total Missouri Medicaid 
expenditures were $10.7 billion.16   
OIG conducted a previous onsite review of the Missouri Unit in 2011.  In that 
Prior OIG 
review, OIG found that (1) the Unit did not establish annual training plans for 
Report 
the professional disciplines; (2) one-third of case files were missing 
documented supervisory approval for the opening of investigations, but 
only 1 percent of the closed case files did not include documented 
supervisory approval for case closure; (3) only 3 percent of case files 
 
12 Mo. Rev. Stat.  191.910 (2005).  In addition to the report of violation, the Unit also generally 
provides the county prosecutor with a binder containing an investigative summary, a draft 
probable cause statement, potential charges, witness statements, and a list of all discoverable 
material and supporting evidence. 
13 Mo. Rev. Stat.  191.905 (2017). 
14 Centers for Medicare & Medicaid Services, May 2019 Medicaid & CHIP Enrollment Data 
Highlights, https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-
enrollment-data/report-highlights/index.html.  
15 Missouri Department of Social Services, MO HealthNet Managed Care Health Plan Options, 
https://dss.mo.gov/mhd/participants/mc/managed-care-health-plan-options.htm.  Accessed 
on August 22, 2019.  Beneficiaries who are aged, blind, or disabled (including beneficiaries 
with developmental disabilities) are not included in the managed care system and continue 
to receive Medicaid fee-for-service provisions through the MO HealthNet program.  
16 OIG, MFCU Statistical Data for FY 2018, available at https://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/expenditures_statistics/fy2018-statistical-chart.pdf. 
 
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contained any documentation of periodic supervisory reviews; and (4) Unit 
practices left case files vulnerable to unauthorized access.17   
OIG recommended that the Unit (1) establish annual training plans for 
professional disciplines; (2) ensure that case files contain documented 
supervisory approval to open the case; (3) document periodic supervisory 
reviews; and (4) ensure that case files are not vulnerable to unauthorized 
access.   
In response to the recommendations, the Unit (1) implemented a training 
plan for all professional disciplines; (2) developed a case opening form to 
ensure that case openings were approved by a Unit supervisor and 
documented in Unit case files; (3) developed a periodic supervisory review 
form to ensure that periodic supervisory reviews were documented in Unit 
case files; and (4) implemented policies and procedures for ensuring that all 
Unit case files be kept in secure locations.  Based on information received 
from the Unit, OIG considered the recommendations implemented. 
Methodology  OIG conducted the onsite inspection of the Missouri MFCU in November 
2018.  Our review covered the 3-year period of FYs 2016 through 2018.  We 
based our inspection on an analysis of data and information from 7 sources: 
(1) Unit documentation; (2) financial documentation; (3) structured 
interviews with key stakeholders; (4) structured interviews with the Units 
managers; (5) a review of a simple random sample of 86 case files that were 
open at some point during the review period; (6) a review of all convictions 
submitted to OIG for program exclusion and all adverse actions submitted 
to the National Practitioner Data Bank (NPDB) during the review period; and 
(7) observation of Unit operations.  (See Appendix B for a detailed 
methodology.)  In examining the Units operations and performance, we 
applied the published performance standards in Appendix A, but we did not 
assess adherence to every performance indicator for every standard. 
Standards  We conducted this study in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.  These inspections differ from other OIG evaluations 
in that they support OIGs direct administration of the MFCU grant program, 
but they are subject to the same internal quality controls as other OIG 
evaluations, including internal and external peer review.   
 
17 OIG, Missouri State Medicaid Fraud Control Unit: 2011 Onsite Review, available at 
https://oig.hhs.gov/oei/reports/oei-07-11-00750.pdf on February 1, 2019. 
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PERFORMANCE ASSESSMENT 
In assessing the performance and operations of the Missouri Unit, OIG 
identified the Units case outcomes; found that the Unit generally complied 
with legal and policy requirements; and made findings and observations 
regarding the Units adherence to each of the performance standards, 
including highlighting a beneficial practice designed to assist staff in 
investigations and trials.  OIG also provided recommendations to improve 
the Units operations.    
CASE OUTCOMES   
 
Observations  The Unit reported 48 indictments; 45 convictions; and 43 civil 
settlements and judgments for FYs 2016 through 2018.  Of the 
45 convictions, 41 convictions involved provider fraud and 4 involved 
 
patient abuse or neglect. 
The Unit reported total recoveries of $42.1 million for 
FYs 2016 through 2018.  (See Exhibit 1 for the sources of those recoveries.)  
  Exhibit 1:  The Unit reported combined civil and criminal recoveries 
of $42.1 million (FYs 201618). 
 
Source: OIG analysis of Unit statistical data from FYs 201618. 
Note: Global civil recoveries derive from civil settlements or judgments in global cases, which are 
cases that involve the U.S. Department of Justice and a group of State MFCUs and that are facilitated by 
the National Association of Medicaid Fraud Control Units.   
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STANDARD 1  A Unit conforms with all applicable statutes, regulations, and policy 
  directives. 
Observation  From the information we reviewed, the Missouri Unit generally 
complied with applicable laws, regulations, and policy transmittals.  
However, we identified one compliance concern related to the Units 
reporting of adverse actions to Federal partners, as explained 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. 
Observations  The Units staff levels were low in relation to the States Medicaid 
program expenditures.  The Missouri Unit employed 22 staff at the end of 
FY 2018.  In FY 2018, Missouris State Medicaid expenditures were $10.7 
billion.  OIG observed that the size of the Unit was low compared to all 
other Units, as measured by Medicaid program expenditures.18   Despite the 
low number of Unit staff, OIG did not specifically observe that the number 
of staff negatively affected Unit operations. 
OIG also observed that the Units staffing level remained generally 
consistent during the review period, with 24 staff at the end of FYs 2016 and 
2017 and 22 staff at the end of FY 2018.  Those numbers were generally 
consistent with, but slightly less than, the numbers of staff approved in the 
Units budget. 
The Unit experienced significant turnover among management and 
staff.  Although total staff levels remained relatively consistent during the 
review period, the Unit experienced significant staff turnover.  During the 
3-year review period, 22 employees left the Unit, including the director and 
deputy director. 
Two Unit managers attributed the high turnover to the low salaries available 
to Missouri State employees, explaining that many experienced staff left the 
Unit for more competitive salaries in the private sector.  One manager 
described the turnover as beyond the MFCUs control.  
Unit managers spoke to us about the challenges associated with the high 
turnover.  One manager stated that because of the turnover, Unit 
management assigned more cases to the Units more experienced 
 
18 Although 22 staff were on board at the end of FY 2018, the Missouri Unit was approved for 
28 staff.  Both the Units actual staff level and approved staff level were low compared to 
State Medicaid expenditures.   
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investigators because the Units newer investigators were not yet prepared 
to investigate complicated Medicaid cases.  For example, the Units chief 
investigator had to divert his attention from supervisory duties to focus his 
time on two cases assigned to him during the review period.  The manager 
also stated that once some Unit employees were sufficiently trained in Unit 
work, they often left the Unit for other agencies or offices.  Further, the 
manager reported that the turnover affected the timeliness of Unit 
investigations.  Another manager said that the turnover affected the Units 
relationship with Federal partners because it was difficult for Federal 
investigators to establish relationships with Unit investigators when they so 
frequently left the Unit. 
STANDARD 3  A Unit establishes written policies and procedures for its operations 
  and ensures that staff are familiar with, and adhere to, policies and 
procedures. 
Observation  The Unit maintained written policies and procedures.  The Unit 
maintained a Medicaid Fraud Control Unit Procedures Manual that was 
available to Unit staff on the shared network drive.  The manual contained 
specific guidelines for Unit operations and casework.  The manual was 
updated in 2018. 
STANDARD 4  A Unit takes steps to maintain an adequate volume and quality of 
  referrals from the State Medicaid agency and other sources. 
Observation 
The Unit took steps to maintain an adequate volume and quality of 
referrals.  To encourage incoming referrals, the Unit engaged in several 
outreach and collaborative efforts with prosecutors and law enforcement 
agencies across the State.  For example, the Unit: 
  Participated in a working group with the State Medicaid agency and the 
Missouri MCOs.  The working group provided Unit managers with an 
opportunity to discuss potential case referrals arising in managed care 
settings with the State Medicaid agency and MCOs.   
  Attended quarterly Law Enforcement Intelligence Sharing meetings 
coordinated by the U.S. Attorneys Office for the Western District of 
Missouri.  These meetings allowed the Unit to share health care fraud 
information with local, State, and Federal law enforcement officers and 
to encourage these agencies to contact the Unit with information 
related to Medicaid fraud.    
  Participated in health care task force groups in the Eastern and Western 
Districts of Missouri.  The Unit exchanged information about emerging 
areas of fraud and recent fraud investigations with other members of 
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the task force groups, such as Assistant U.S. Attorneys, Federal Bureau 
of Investigation agents, OIG agents, and State Medicaid agency staff.  
The Unit received a steady number of referrals, amounting to 1,335 total 
referrals during the review period.  Of the 1,335 total referrals, 814 involved 
allegations of fraud, and the Unit opened 232 of these as active 
investigations.  The primary sources of fraud referrals to the Unit during the 
review period were private citizens, the State Medicaid agency, and 
providers.  The remaining 521 referrals received during the review period 
involved allegations of patient abuse or neglect.  The Unit opened 46 of 
these as active investigations.  The primary sources of patient abuse or 
neglect referrals to the Unit during the review period were private citizens, 
the State survey and certification agency, and other law enforcement.  
Appendix C identifies Unit referrals by source for FYs 2016 through 2018. 
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. 
Observations   
The Unit took steps to maintain a continuous case flow and to 
complete cases within an appropriate timeframe.  To maintain a 
continuous case flow and complete cases within an appropriate timeframe, 
the Unit director met monthly with the Unit attorneys, as a group, to 
review the status of cases.  Additionally, the Unit director met monthly with 
the Deputy Attorney General for Criminal Litigation to set and update Unit 
priorities and to discuss the progression of the Units priority cases. 
All case files contained documentation of supervisory approval to 
open the cases, and all closed case files contained documentation of 
supervisory approval to close the cases.  While examining the Units case 
flow, we also reviewed case files for documentation of supervisory 
approval to open and close cases.  According to Performance Standard 
5(b), supervisors should approve the opening and closing of all 
investigations.  Our review found that all case files contained supervisory 
approval of case opening, and all closed case files contained supervisory 
approval of case closing.19 
 
 
 
 
 
19 See Appendix D for further details on point estimates of the case file reviews. 
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STANDARD 6  A Units case mix, as practicable, covers all significant provider types 
  and includes a balance of fraud and, where appropriate, patient 
abuse and neglect cases. 
Observation 
The Units caseload included both fraud cases and patient abuse or 
neglect cases, covering a broad mix of provider types.  Of the 523 cases 
that were open during our review period, 88 percent (461 cases) involved 
provider fraud and 12 percent (62 cases) involved patient abuse or neglect.  
During the review period, the Units cases covered 45 provider types, 
including medical doctors, home health care providers, pharmaceutical 
manufacturers, and residential and nonresidential facilities. 
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. 
Findings  Unit case files did not include all relevant facts, information, and 
significant documents.  According to Performance Standard 7(b) and (c), 
case files should include all relevant facts, information, and significant 
documents.  The Unit used a case management system that it developed 
in house to record information about the Units investigations and to track 
Unit performance data.  While reviewing the Units case files, OIG found it 
difficult to locate documents such as interview notes and investigative 
summaries in Unit case files.  OIG was unable to locate interview summaries 
in 21 percent of the Units case files.  OIG found that important documents 
that should have been contained in the case file were instead stored in 
other locations, such as investigators email files or electronically in folders 
on the Units shared drive.   
Additionally, instead of creating a single case file for cases with multiple 
defendants, in some cases, the Unit created an individual case file for each 
defendant.  This practice of relying on multiple case files (instead of, for 
example, creating a single file for a case with subfiles for each of the 
defendants) made it difficult to locate all significant documents in the 
sampled case files.  For example, OIG found that in cases involving multiple 
defendants, some documents were stored in only one defendants case file 
and not in the case files for the other defendants.20   
The Unit lacked a policy requiring a specific frequency for periodic 
supervisory reviews.  According to Performance Standard 7(a), reviews by 
supervisors should be conducted periodically, consistent with the Units 
 
20 Unit management explained that they were in the process of revising the Units 
case-numbering conventions to identify multiple defendants involved in the same cases.   
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policies and procedures, and should be noted in the case file.  The Units 
procedures manual stated: Investigative teams will periodically meet with 
the Senior Investigator, Chief Investigator, Deputy Director and/or Director 
to discuss the status of open cases.  These supervisory case reviews will be 
documented regularly.   
The Units procedures manual did not include a specific frequency for 
periodic supervisory case reviews, which made it difficult for OIG to 
determine whether the Unit complied with its policy.  To assess whether the 
Unit was complying with its policy, we asked the Unit director how the 
periodic supervisory review requirement was applied.  The Unit director 
informed OIG that supervisors reviewed the Units case files approximately 
quarterly.  Because the Units policy lacked a specific frequency for periodic 
supervisory reviews and because the Unit director informed OIG that Unit 
supervisors conducted the reviews approximately quarterly, we chose to 
review Unit case files open longer than 90 days to determine whether they 
contained documentation of quarterly supervisory reviews.  We found that 
43 percent of case files open longer than 90 days lacked documentation of 
one or more periodic supervisory reviews.  Some case files contained no 
documentation of supervisory reviews or contained gaps of 2 years or more 
with no supervisory reviews documented in the file.21   
Periodic supervisory reviews provide supervisors and investigators the 
opportunity to discuss the status of and next steps for Unit investigations.  
The reviews also serve as tools for supervisors to hold investigators 
accountable for their case file documentation as investigations progress.  
The lack of a specific frequency for these reviews may make it difficult for 
managers to ensure that these discussions are occurring regularly and that 
cases are completed timely.  Additionally, ensuring that case files are 
reviewed at regular intervals can help Unit managers and staff ensure that 
cases progress timely even if there is turnover in the staff assigned to 
investigations (see pages 67). 
   
 
21 As part of OIGs 2011 onsite review of the Unit, OIG also made a finding related to the 
Units periodic supervisory reviews.  Specifically, only 3 percent of the Units case files 
contained any documentation of periodic supervisory reviews.  OIG recommended that the 
Unit ensure that case files contain documented periodic supervisory reviews.  In response to 
OIGs recommendation, in 2012, the Unit developed a periodic supervisory review form on 
which the Unit director could note case details and an expected timeframe for completion.  
The forms were to be signed by the director, shared with the attorney and lead investigator 
of the case, and filed in the Units case files. 
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STANDARD 8  A Unit cooperates with OIG and other Federal agencies in the 
  investigation and prosecution of Medicaid and other health care fraud. 
Observation  The Unit investigated many cases jointly with OIG and actively 
participated in cases with the U.S. Attorneys Office.  During the review 
 
period, the Unit jointly investigated with OIG a total of 31 cases.  The Unit 
actively participated in cases with prosecutors from the Missouri U.S. 
Attorneys Office; some of these cases also involved OIG.  The Unit director 
is cross-designated as a Special Assistant U.S. Attorney and may prosecute 
cases in Missouri Federal District Court.   
Finding 
The Unit did not report all convictions and adverse actions to Federal 
partners.  According to Performance Standard 8(f), Units should transmit 
 
to OIGwithin 30 days of sentencingreports of all convictions so that 
convicted individuals can be excluded from Federal health care programs.22  
Although the Unit had procedures in place for reporting convictions to OIG, 
the Unit did not report 24 of its 45 convictions to OIG.  Additionally, of the 
Units reported convictions, it reported two to OIG more than 30 days after 
sentencing. 
Federal regulations require Units to report final 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 action.23  
Performance Standard 8(g) also states that the Unit should report qualifying 
cases to the NPDB.24  Although the Unit had procedures in place for 
reporting adverse actions to the NPDB, the Unit did not report 24 of its 
46 adverse actions to the NPDB.25  Additionally, the Unit reported five of its 
adverse actions to the NPDB more than 30 days after sentencing.   
Unit management explained that 23 of the 24 unreported convictions 
involved joint cases with OIG and reported that the Unit has never 
 
22 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. 
23 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). 
24 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). 
25 Of the 24 adverse actions that the Unit did not report to the NPDB, 23 involved 
convictions that the Unit did not report to OIG.  
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submitted reports of convictions for joint cases.  Although this may appear 
to be an understandable error, Performance Standard 8(f) makes no 
exception for joint cases with OIG, and OIG has provided guidance that 
Units should report all convictions to OIG.  OIG has explained that receiving 
reports of convictions in joint cases reduces the risk of system error and 
ensures that OIG has a complete and accurate record of all convicted 
parties, including full names and current addresses.   
STANDARD 9  A Unit makes statutory or programmatic recommendations, when 
  warranted, to the State government. 
Observation  The Unit made written recommendations to the State Medicaid agency.  
The Unit informed the State Medicaid agency of potential program 
deficiencies that the Unit had identified through MFCU investigations.  
During our review period, the Unit recommended (among other items) 
that the State Medicaid agency (1) require Medicaid provider applicants 
and their billing agents to attend Medicaid billing training prior to 
enrollment in the Medicaid program and annually thereafter; and 
(2) assign each personal care and home health provider a unique 
identification number and require that the number be included on each 
claim submitted to the State Medicaid agency.26  As a way to follow up 
on recommendations, the Unit, at the end of the fiscal year, transmitted 
a list of unimplemented recommendations to the State Medicaid agency. 
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 MOU with the State Medicaid agency reflected current 
practice, policy, and legal requirements.  The Missouri Office of the 
Attorney General and the Missouri Department of Social Services had a 
current MOU, executed June 2015.  The MOU reflected all policy and legal 
requirements as well as the current practices between the parties. 
 
 
26 At the time of OIGs inspection, the State Medicaid agency had not implemented these 
recommendations.  However, the State was developing a request for proposal for an 
electronic visit verification (EVV) system that would receive EVV data from Medicaid personal 
care service providers.  The EVV system would be used to verify the delivery of personal care 
services through telephone timekeeping; web or phone-based applications that use the 
Global Positioning System; or other electronic alternatives to paper timesheets.  As part of 
the EVV system, individual personal care attendants would be assigned a unique identifier.  
Missouri Medicaid Fraud Control Unit:  2018 Onsite Inspection  12 
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STANDARD 11  A Unit exercises proper fiscal control over its resources. 
 
Observation  In our limited review, we identified no deficiencies in the Units fiscal 
control of its resources.  From the responses to a detailed fiscal controls 
questionnaire and from follow-up with Unit management, 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 all 30 of the 30 sampled inventory items. 
STANDARD 12  A Unit conducts training that aids in the mission of the Unit. 
 
 
Finding  The Units training plan did not include an annual minimum number of 
training hours for Unit investigators, and some investigators did not 
receive annual training.  According to Performance Standard 12(a), Units 
should maintain a training plan for each professional discipline that includes 
an annual minimum number of training hours.  The Units training plan 
required Unit attorneys and auditors to complete an annual minimum 
number of training hours; however, it did not include an annual minimum 
number of training hours for Unit investigators.  The training plan did 
require Unit investigators to complete general training or interview training.   
Observation  The Unit created in-house training videos to assist staff in Unit 
investigations and trials.  The Units chief auditor created in-house training 
     Beneficial Practice 
videos for Unit investigators and attorneys.  The chief auditor designed the 
  videos to train Unit staff on helpful techniques that Unit staff had developed 
during Unit investigations.  One staff member explained that each of these 
training videos emerged from Unit investigations that concluded with 
successful trials.   
The videos contained step-by-step tutorials for creating and using 
investigative and trial tools.  For example, one training video instructed staff 
how to use Google Maps to visualize a defendants movements and to 
approximate travel times during time periods involved in investigations.  
Another training video showed staff how to use time studies to plot hours 
and days worked by providers to visualize overlaps in providers reported 
employment.  A Unit staff member commented that Unit staff used these 
training videos to develop investigative tools to use during case 
development and to create exhibits for trial.  
   
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CONCLUSION AND RECOMMENDATIONS 
From the information we reviewed, we determined that the Missouri Unit 
complied with applicable legal requirements and generally adhered to 
performance standards, but we identified four areas in which the Unit 
should improve its adherence to standards.  We found that the Units case 
files did not include all relevant facts, information, and significant case 
documents, and that the Units case files lacked consistent documentation 
of periodic supervisory reviews.  Additionally, we found that the Unit did not 
report all convictions and adverse actions to Federal partners.  Finally, we 
found that the Units training plan did not include an annual minimum 
number of training hours for Unit investigators.     
We also made observations regarding Unit operations and practices, 
including a beneficial practice employed by the Unit that may serve as a 
model for other Units: The Unit created in-house training videos to assist 
staff in Unit investigations and trials. 
We recommend that to address the four findings, the Missouri Unit: 
 
Take steps to ensure that Unit case files include all relevant 
facts, information, and significant documents  
The Unit should take steps to ensure that case files include all relevant facts; 
information; and significant documents, such as interview summaries.  For 
example, the Unit could incorporate into its policy manual a requirement 
that staff include all relevant facts, information, and significant documents in 
Unit case files.  The Unit could also provide training to staff regarding the 
importance of storing all relevant case information in the case files rather 
than in email or separately on the Units network drive. 
Revise the Units policies and procedures manual to include a 
specific frequency for conducting periodic supervisory reviews 
of Unit case files, and take steps to ensure that case files 
include documentation of periodic supervisory reviews  
The Unit should revise its policies and procedures manual to include a 
specific frequency for conducting periodic supervisory reviews.  Additionally, 
the Unit should take steps to ensure that periodic supervisory reviews of 
cases files are documented in the Units case files. 
Take steps to ensure that the Unit consistently reports all 
convictions and adverse actions to Federal partners  
The Unit should take steps to ensure that it consistently reports all 
convictions obtained in any case investigated by the Unit to OIG within 
30 days of sentencing and adverse actions to the NPDB within 30 days of 
Missouri Medicaid Fraud Control Unit:  2018 Onsite Inspection  14 
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the action, or as soon as practicable if the Unit encounters delays in 
receiving the necessary information from the court.  The Unit could inform 
staff that all convictions, including those obtained in joint cases with OIG, 
must be reported to Federal partners.  Additionally, the Unit could 
implement automated reminders that alert Unit staff about when to report 
convictions and adverse actions to Federal partners. 
Establish training-hour requirements for Unit investigators and 
ensure that all investigators receive annual training 
The Unit should revise its training plan to include an annual minimum 
number of training hours for Unit investigators.  Additionally, the Unit 
should ensure that all Unit investigators receive annual training.   
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UNIT COMMENTS AND OIG RESPONSE 
The Missouri Unit concurred with all four of our recommendations.  
First, the Unit concurred with our recommendation to take steps to ensure 
that Unit case files include all relevant facts, information, and significant 
documents.  The Unit stated that it has implemented document 
management software and standardized the Units electronic case files. 
Second, the Unit concurred with our recommendation to revise the Units 
policies and procedures manual to include a specific frequency for 
conducting periodic supervisory reviews of Unit case files and to take steps 
to ensure that case files include documentation of periodic supervisory 
reviews.  The Unit stated that it now records and maintains documentation 
of periodic supervisory reviews electronically.  Additionally, the Unit stated 
that it updated its policy and procedure manual to require quarterly 
periodic supervisory reviews.      
Third, the Unit concurred with our recommendation to take steps to ensure 
that the Unit consistently reports all convictions and adverse actions to 
Federal partners.  The Unit stated that it updated its electronic case 
management system to ensure that all convictions are reported timely.  
Finally, the Unit concurred with our recommendation to establish 
training-hour requirements for Unit investigators and ensure that all 
investigators receive annual training.  The Unit stated that its training plan 
now requires Unit investigators to obtain at least 13 hours of training 
annually.   
For the full text of the Units comments, see Appendix E. 
   
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APPENDIX A:  Medicaid Fraud Control Unit 
Performance Standards27 
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;28 
D)  OIG policy transmittals as maintained on the OIG website; and 
E)  Terms and conditions of the notice of the grant award. 
2)  A Unit maintains reasonable staff levels and office locations in relation 
to the States Medicaid program expenditures and in accordance with 
staffing allocations approved in its budget. 
A)  The Unit employs the number of staff that is included in the Units budget 
estimate as approved by OIG. 
B)  The Unit employs a total number of professional staff that is commensurate 
with the States total Medicaid program expenditures and that enables the 
Unit to effectively investigate and prosecute (or refer for prosecution) an 
appropriate volume of case referrals and workload for both Medicaid fraud 
and patient abuse and neglect. 
C)  The Unite employs an appropriate mix and number of attorneys, auditors, 
investigators, and other professional staff that is both commensurate with 
the States total Medicaid program expenditures and that allows the Unit to 
effectively investigate and prosecute (or refer for prosecution) an 
appropriate volume of case referrals and workload for both Medicaid fraud 
and patient abuse and neglect. 
D)  The Unit employs a number of support staff in relation to its overall size 
that allows the Unit to operate effectively. 
E)  To the extent that a Unit maintains multiple office locations, such locations 
are distributed throughout the State, and are adequately staffed, 
commensurate with the volume of case referrals and workload for each 
location. 
3)  A Unit establishes written policies and procedures for its operations and 
ensures that staff are familiar with, and adhere to, policies and 
procedures. 
A)  The Unit has written guidelines or manuals that contain current policies and 
procedures, consistent with these performance standards, for the 
investigation and (for those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect. 
 
27 77 Fed. Reg. 32645 (June 1, 2012). 
28 For FYs 2016 and later, grant administration requirements are found at 45 CFR pt. 75. 
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B)  The Unit adheres to current policies and procedures in its operations. 
C)  Procedures include a process for referring cases, when appropriate, to 
Federal and State agencies.  Referrals to State agencies, including the State 
Medicaid agency, should identify whether further investigation or other 
administrative action is warranted, such as the collection of overpayments 
or suspension of payments. 
D)  Written guidelines and manuals are readily available to all Unit staff, either 
online or in hard copy. 
E)  Policies and procedures address training standards for Unit employees. 
4)  A Unit takes steps to maintain an adequate volume and quality of 
referrals from the State Medicaid agency and other sources. 
A)  The Unit takes steps, such as the development of operational protocols, to 
ensure that the State Medicaid agency, managed care organizations, and 
other agencies refer to the Unit all suspected provider fraud cases.  
Consistent with 42 CFR 1007.9(g), the Unit provides timely written notice to 
the State Medicaid agency when referred cases are accepted or declined 
for investigation. 
B)  The Unit provides periodic feedback to the State Medicaid agency and 
other referral sources on the adequacy of both the volume and quality of 
its referrals. 
C)  The Unit provides timely information to the State Medicaid or other agency 
when the Medicaid or other agency requests information on the status of 
MFCU investigations, including when the Medicaid agency requests 
quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii). 
D)  For those States in which the Unit has original jurisdiction to investigate or 
prosecute patient abuse and neglect cases, the Unit takes steps, such as the 
development of operational protocols, to ensure that pertinent agencies 
refer such cases to the Unit, consistent with patient confidentiality and 
consent.  Pertinent agencies vary by State but may include licensing and 
certification agencies, the State Long Term Care Ombudsman, and adult 
protective services offices. 
E)  The Unit provides timely information, when requested, to those agencies 
identified in (D) above regarding the status of referrals. 
F)  The Unit takes steps, through public outreach or other means, to 
encourage the public to refer cases to the Unit. 
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. 
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6)  A Units case mix, as practicable, covers all significant providers types 
and includes a balance of fraud and, where appropriate, patient abuse 
and neglect cases. 
A)  The Unit seeks to have a mix of cases from all significant provider types in 
the State. 
B)  For those States that rely substantially on managed care entities for the 
provision of Medicaid services, the Unit includes a commensurate number 
of managed care cases in its mix of cases. 
C)  The Unit seeks to allocate resources among provider types based on levels 
of Medicaid expenditures or other risk factors.  Special Unit initiatives may 
focus on specific provider types. 
D)  As part of its case mix, the Unit maintains a balance of fraud and patient 
abuse and neglect cases for those States in which the Unit has original 
jurisdiction to investigate or prosecute patient abuse and neglect cases. 
E)  As part of its case mix, the Unit seeks to maintain, consistent with its legal 
authorities, a balance of criminal and civil fraud cases. 
7)  A Unit maintains case files in an effective manner and develops a case 
management system that allows efficient access to case information and 
other performance data. 
A)  Reviews by supervisors are conducted periodically, consistent with MFCU 
policies and procedures, and are noted in the case file. 
B)  Case files include all relevant facts and information and justify the opening 
and closing of the cases. 
C)  Significant documents, such as charging documents and settlement 
agreements, are included in the file. 
D)  Interview summaries are written promptly, as defined by the Units policies 
and procedures. 
E)  The Unit has an information management system that manages and tracks 
case information from initiation to resolution. 
F)  The Unit has an information management system that allows for the 
monitoring and reporting of case information, including the following: 
1)  The number of cases opened and closed and the reason that 
cases are closed. 
2)  The length of time taken to determine whether to open a case 
referred by the State Medicaid agency or other referring 
source. 
3)  The number, age, and types of cases in the Units 
inventory/docket. 
4)  The number of referrals received by the Unit and the number 
of referrals by the Unit to other agencies. 
5)  The dollar amount of overpayments identified. 
6)  The number of cases criminally prosecuted by the Unit or 
referred to others for prosecution, the number of individuals 
or entities charged, and the number of pending prosecutions. 
7)  The number of criminal convictions and the number of civil 
judgments. 
8)  The dollar amount of fines, penalties, and restitution ordered 
in a criminal case and the dollar amount of recoveries and the 
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types of relief obtained through civil judgments or prefiling 
settlements. 
 
8)  A Unit cooperates with OIG and other Federal agencies in the 
investigation and prosecution of Medicaid and other health care fraud. 
A)  The Unit communicates on a regular basis with OIG and other Federal 
agencies investigating or prosecuting health care fraud in the State. 
B)  The Unit cooperates and, as appropriate, coordinates with OIGs Office of 
Investigations and other Federal agencies on cases being pursued jointly, 
case involving the same suspects or allegations, and cases that have been 
referred to the Unit by OIG or another Federal agency. 
C)  The Unit makes available, to the extent authorized by law and upon request 
by Federal investigators and prosecutors, all information in its possession 
concerning provider fraud or fraud in the administration of the Medicaid 
program. 
D)  For cases that require the granting of extended jurisdiction to investigate 
Medicare or other Federal health care fraud, the Unit seeks permission 
from OIG or other relevant agencies under procedures as set by those 
agencies. 
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. 
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B)  The MOU meets current Federal legal requirements as contained in law or 
regulation, including 42 CFR 455.21, Cooperation with State Medicaid 
fraud control units, and 42 CFR 455.23, Suspension of payments in cases 
of fraud. 
C)  The MOU is consistent with current Federal and State policy, including any 
policies issued by OIG or the Centers for Medicare & Medicaid Services 
(CMS). 
D)  Consistent with Performance Standard 4, the MOU establishes a process to 
ensure the receipt of an adequate volume and quality of referrals to the 
Unit from the State Medicaid agency. 
E)  The MOU incorporates by reference the CMS Performance Standard for 
Referrals of Suspected Fraud From a State Agency to a Medicaid Fraud 
Control Unit. 
11)  A Unit exercises proper fiscal control over Unit resources. 
A)  The Unit promptly submits to OIG its preliminary budget estimates, 
proposed budget, and Federal financial expenditure reports. 
B)  The Unit maintains an equipment inventory that is updated regularly to 
reflect all property under the Units control. 
C)  The Unit maintains an effective time and attendance system and personnel 
activity records. 
D)  The Unit applies generally accepted accounting principles in its control of 
Unit funding. 
E)  The Unit employs a financial system in compliance with the standards for 
financial management systems contained in 45 CFR 92.20. 
12)  A Unit conducts training that aids in the mission of the Unit. 
A)  The Unit maintains a training plan for each professional discipline that 
includes an annual minimum number of training hours and that is at least 
as stringent as required for professional certification. 
B)  The Unit ensures that professional staff comply with their training plans and 
maintain records of their staffs compliance. 
C)  Professional certifications are maintained for all staff, including those that 
fulfill continuing education requirements. 
D)  The Unit participates in MFCU-related training, including training offered by 
OIG and other MFCUs, as such training is available and as funding permits. 
E)  The Unit participates in cross-training with the fraud detection staff of the 
State Medicaid agency.  As part of such training, Unit staff provide training 
on the elements of successful fraud referrals and receive training on the 
role and responsibilities of the State Medicaid agency. 
 
   
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APPENDIX B:  Detailed Methodology 
Data Collection and Analysis 
We collected and analyzed data from the seven sources below to identify 
any opportunities for improvement and instances in which the Unit did not 
adhere to the performance standards or was not operating in accordance 
with laws, regulations, or policy transmittals.29  We also used the data 
sources to make observations about the Units case outcomes as well as the 
Units operations and practices concerning the performance standards. 
Review of Unit Documentation.  Prior to the onsite inspection, we reviewed 
the recertification analysis for FYs 2016 through 2018, which involved 
examining the Units recertification materials, including (1) the annual 
reports; (2) Unit Directors recertification questionnaires; (3) the Units 
memorandum of understanding (MOU) with the State Medicaid agency; 
(4) the Program Integrity Directors questionnaires; and (5) the OIG Special 
Agent in Charges questionnaires.  We also reviewed the Units policies and 
procedures manual and the Units self-reported case outcomes and referrals 
included in its FY 201618 annual statistical reports.  Appendix C lists Unit 
referrals by source for FYs 2016 through 2018.  We also examined the 2011 
OIG onsite review recommendations and 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 both actual and approved staff.   
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 responses to an internal controls questionnaire and 
conducted a desk review of the Units quarterly financial 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 187 items maintained in the Units office 
and verified those items onsite. 
Interviews with Key Stakeholders.  In October and November 2018, we 
interviewed key stakeholders, including officials in the Missouri State 
Medicaid Program Integrity Unit; the Missouri Department of Health and 
Senior Services; and the U.S. Attorneys Offices.  We also interviewed the 
agents from OIGs Office of Investigations who work regularly with the Unit.  
We focused these interviews on the Units relationship and interaction with 
 
29 All relevant regulations, statutes, and policy transmittals are available online at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.  
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the stakeholders as well as opportunities for improvement.  We used the 
information collected from these interviews to develop subsequent 
interview questions for Unit management. 
Onsite Interviews with Unit Management.  We conducted structured onsite 
interviews with the Units management in November 2018.  We interviewed 
the Unit director, deputy director, senior investigator, and chief auditor.  
Prior to our onsite visit, we also interviewed the Units chief investigator.  We 
asked these individuals to provide information related to (1) Unit operations; 
(2) Unit practices that contributed to the effectiveness and efficiency of Unit 
operations and/or performance; (3) opportunities for the Unit to improve its 
operations and/or performance; (4) clarification regarding information 
obtained from other data sources; and (5) the Units training and technical 
assistance needs.   
Onsite Review of Case Files.  To craft a sampling frame, we requested that 
the Unit provide us with a list of cases that were open at any time during 
FYs 2016 through 2018 and to include the status of the case; 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 was 456.   
We excluded all global cases from our review of the Units case files because 
global cases are civil false claims actions that typically involve multiple 
agencies, such as the U.S. Department of Justice and a group of State 
MFCUs.30  We excluded 50 global cases, leaving 406 case files.   
We then selected a simple random sample of 86 case files from the 
population of 406 case files.  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.  We 
reviewed the 86 case files for adherence to the relevant performance 
standards and compliance with statute, regulation, and policy transmittals.  
During the onsite review of the sampled cases, we consulted MFCU staff to 
address any apparent issues with individual case files, such as missing 
documentation.  Through our case file review, we also determined that 7 of 
the 86 sampled cases were global cases that the Unit had mistakenly 
labeled as nonglobal on the list that it provided to OIG.  We excluded these 
case files from our analysis.  
Review of Unit Submissions to OIG and the National Practitioner Data 
Bank.  We also reviewed all convictions submitted to OIG for program 
exclusion during the review period and all adverse actions submitted to the 
 
30 Global cases are cases that involve the U.S. Department of Justice and a group of 
MFCUs.  The National Association of Medicaid Fraud Control Units facilitates the settlement 
of global cases on behalf of States. 
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National Practitioner Data Bank (NPDB) during the review period.  We 
reviewed whether the Unit submitted information on all sentenced 
individuals to OIG for program exclusion and all adverse actions to the 
NPDB for FYs 2016 through 2018.  We also assessed the timeliness of the 
submissions to OIG and the NPDB. 
Onsite Review of Unit Operations.  During the onsite inspection, we 
observed the Units workspace and operations of the Units office in 
Jefferson City, Missouri.  We observed the Units offices and meeting spaces; 
security of data and case files; location of select equipment; and the general 
functioning of the Unit. 
   
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APPENDIX C:  Unit Referrals by Source for Fiscal 
Years 2016 Through 2018 
  FY 2016  FY 2017  FY 2018  Grand Total 
Abuse &  Abuse &  Abuse &  Abuse & 
Referral Source  Fraud  Fraud  Fraud  Fraud 
Neglect1  Neglect  Neglect  Neglect 
Adult Protective Services  0  0  1  1  0  0  1  1 
Anonymous  7  0  6  0  10  0  23  0 
Office of Inspector General  12  1  18  5  8  1  38  7 
Licensing Board  0  0  2  0  1  0  3  0 
Local Prosecutor  0  0  0  0  0  0  0  0 
Long Term Care Ombudsman  0  0  0  0  0  0  0  0 
Managed Care Organizations  25  0  7  0  0  0  32  0 
Medicaid Agency Other  3  0  9  1  1  0  13  1 
Medicaid Agency SURS or PI Unit2  54  1  72  1  67  0  193  2 
Other  15  1  4  2  9  2  28  5 
Law Enforcement  9  3  21  3  15  1  45  7 
Private Citizen  84  112  88  120  104  154  276  386 
Private Health Insurer  0  0  1  0  0  0  1  0 
Provider  50  0  35  3  53  1  138  4 
Provider Association  0  0  0  0  0  0  0  0 
Other State Agency  8  3  9  1  1  1  18  5 
State Survey and Certification  3  35  0  40  2  28  5  103 
Total  270  156  273  177  271  188  814  521 
Annual Total  426  450  459  1335 
Source:  OIG analysis of Unit Annual Statistical Reports, FYs 201618. 
1 The category of patient abuse and neglect referrals includes referrals regarding misappropriation of patients private funds. 
2 The abbreviation PI stands for program integrity; the abbreviation SURS stands for Surveillance and Utilization Review Subsystem.   
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APPENDIX D: Point Estimates and 95-Percent 
Confidence Intervals of Case File Reviews 
 
95-Percent Confidence 
Point  Interval 
Estimate Description  Sample Size  
Estimate 
Lower  Upper 
Percentage of All Cases Closed at the Time 
81  65.4%  55.2%  74.6% 
of Our Review 
Percentage of All Cases That Had 
81  100%  95.8%  100% 
Supervisory Approval To Open 
Percentage of All Closed Cases That Had 
53  100%  94.0%  100% 
Supervisory Approval To Close  
Percentage of All Cases Opened Longer 
80  95.0%  88.4%  98.4% 
Than 90 Days 
Percentage of All Case Files (1) Opened 
Longer Than 90 Days and (2) Lacked  76  43.4%  33.1%  54.0% 
Periodic Supervisory Review 
Percentage of Applicable Case Files That 
47  21.3%  11.3%  34.2% 
Lacked Documented Interview Summaries 
Source: OIG analysis of Missouri MFCU case files, 2019. 
   
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APPENDIX E:  Unit Comments 
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ACKNOWLEDGMENTS 
Jordan Clementi of the Medicaid Fraud Policy and Oversight Division served 
as the team leader for this inspection.  Keith Peters of the Medicaid Fraud 
Policy and Oversight Division also participated in the inspection.  Two 
agents from the Office of Investigations also participated in the 
inspection.  Office of Evaluation and Inspections staff who provided support 
include Kevin Farber, Ben Gaddis, and Christine Moritz.   
This report was prepared under the direction of Richard Stern, Director of 
the Medicaid Fraud Policy and Oversight Division.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.
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ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.   
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the health care industry concerning 
the anti-kickback statute and other OIG enforcement authorities.