Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
O S M
  HIO  TATE  EDICAID 
 
F C U : 
  RAUD  ONTROL  NIT   
 
2014 O R  
  NSITE  EVIEW 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin  
Deputy Inspector General  
for Evaluation and Inspections  
 
April 2015 
OEI-07-14-00290   
   
EXECUTIVE SUMMARY:  OHIO STATE MEDICAID FRAUD CONTROL UNIT:  
2014 ONSITE REVIEW 
OEI-07-14-00290 
 
WHY WE DID THIS STUDY 
The Office of Inspector General (OIG) oversees the activities of all Medicaid Fraud 
Control Units (MFCUs or Units). As part of this oversight, OIG conducts periodic 
reviews of all Units and prepares public reports based on these reviews.  The reviews  
assess Unit performance in accordance with the 12 MFCU performance standards and 
monitor Unit compliance with Federal grant requirements. 
 
HOW WE DID THIS STUDY  
We conducted an onsite review of the Ohio Unit in April 2014.  We based our review on 
an analysis of data from seven sources:  (1) a review of policies, procedures, and 
documentation related to the Units operations, staffing, and caseload for fiscal 
years (FYs) 2011 through 2013; (2) a review of financial documentation for 
FYs 2011 through 2013; (3) structured interviews with key stakeholders; (4) a survey of 
Unit staff; (5) structured interviews with the Units management; (6) an onsite review of 
a sample of files for cases that were open in FYs 2011 through 2013; and (7) an onsite 
observation of Unit operations. 
 
WHAT WE FOUND 
For FYs 2011 through 2013, the Ohio Unit reported 403 criminal convictions and 
recoveries of nearly $214 million.  Our review found that the Unit did not consistently 
submit reports of convictions within the appropriate timeframe to OIG for the purpose of 
program exclusion.  Our review also found that 13 percent of case files lacked 
documentation of supervisory approval for the closing of cases; nearly all case files 
contained documentation of periodic supervisory review.  Finally, the Unit allowed 
non-Unit personnel to use its vehicles, resulting in unallowable expenditures.   
 
WHAT WE RECOMMEND   
We recommend that the Ohio Unit (1) submit reports of all convictions within the 
appropriate timeframe to OIG for the purpose of exclusion from Federal health care 
programs, (2) include documentation of supervisory approval for the closing of all case 
files, and (3) ensure that vehicles are used exclusively by Unit personnel and repay grant 
funds for unallowable vehicle-related expenditures.  The Unit concurred with our first 
and third recommendations and did not concur with our second recommendation, but said 
that it took action to address all of our recommendations.   
   
   
TABLE OF CONTENTS 
Objective......................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................6 

For FYs 2011 through 2013, the Ohio Unit reported  

403 criminal convictions and recoveries of nearly $214 million .....6 

The Unit did not consistently submit reports of convictions  

within the appropriate timeframe to OIG for the purpose of  

program exclusion ............................................................................7
  
Thirteen percent of case files lacked documentation of 

supervisory approval for the closing of cases; nearly all case  

files contained documentation of periodic supervisory review  .......7 

The Unit allowed non-Unit personnel to use its vehicles, resulting 

in unallowable expenditures ............................................................8 

Other observations ...........................................................................9 

Conclusion and Recommendations ............................................................11
  
Unit Comments and Office of Inspector General Response..........................13 

Appendixes ................................................................................................14 

A: 1994 Performance Standards ...................................................14 

B: 2012 Revised Performance Standards ......................................19 

C: Ohio Medicaid Fraud Control Unit Referrals by 

Referral Source for Fiscal Years 2011  Through 2013 ....................26 

D: Detailed Methodology .............................................................27 

E: Investigations Opened and Closed By Provider Category  

for Fiscal Years 2011 Through 2013 ..............................................31 

F: Point Estimates and 95-Percent Confidence Intervals Based 

on Reviews of Case Files...............................................................33 

G: Unit Comments ........................................................................34 

Acknowledgments......................................................................................39 

 
 
   
OBJECTIVE 
To conduct an onsite review of the Ohio State 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) 2013, combined Federal and State grant expenditures for 
the Units totaled $230 million.4, 5   That year, the 50 Units employed 
1,912 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 2013, the 50 Units 
collectively obtained 1,341 convictions and 879 civil settlements and 
______________________________________________________ 
1 Social Security Act (SSA)  1903(q).  

2 SSA   1902(a)(61).  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. 

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),  Medicaid Fraud Control Units Statistical 
 
Data for Fiscal Year 2013. Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-
control-units-mfcu/expenditures_statistics/fy2013-statistical-chart.htm on 

June 5, 2014. 

6 Ibid. 

7 SSA    1903(q)(6) and  42 CFR 1007.13. 

Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)   1 
   
   
judgments.8  That year, the Units reported recoveries of 
approximately $2.5 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 Ohio and 44 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   
Generally, Units located outside of an Attorney Generals Office 
must refer cases to other offices with prosecutorial authority.   
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 annually certify the Units 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    
______________________________________________________ 
8 OIG,  State Medicaid Fraud Control Units  Fiscal Year 2013 Grant Expenditures 

and Statistics. Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/index.asp on June 5,  2014. 

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 June  11, 2014. 
 
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 who 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). 

Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   2 
     
   
Pursuant to Title XIX of the SSA, States must operate Units that 
effectively carry out their statutory functions and meet program 
requirements.18   To clarify the criteria that OIG applies in assessing 
whether a Unit is effectively carrying out these functions and meeting 
program requirements, OIG developed and issued 12 performance 
standards.19  Examples of the standards include maintaining an 
adequate caseload through referrals from several sources, maintaining 
a training plan for all professional disciplines, and establishing policy 
and procedure manuals.  For a complete listing of the 1994 and 
2012 performance standards, see Appendixes A and B respectively.20  
When considering a Units eligibility for recertification, OIG reviews a 
recertification questionnaire along with quarterly and annual reports to 
determine the Units level of compliance with the 12 performance 
standards and whether Federal funding was effectively used in 
investigating and prosecuting cases.   
The Unit must also demonstrate that it is complying with laws, 
regulations, and policy transmittals.21  For example, as a part of the 
recertification process, OIG will review a Units MOU with the State 
Medicaid agency to confirm that the Unit is separate and distinct from  
the States Medicaid agency, as required by regulation.   
OIG also schedules periodic onsite reviews to help determine whether 
Units operate in accordance with the performance standards, as well as 
all applicable laws, regulations, and policy transmittals.  As a part of 
these reviews, OIG issues reports with findings and, as appropriate, 
recommendations.  OIG makes these reports available to the general 
public. 
______________________________________________________ 
18  SSA  1902(a)(61).  
19 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at 
http://www.gpo.gov/fdsys/pkg/FR-1994-09-26/html/94-23692.htm on 
August 29, 2014.  77 Fed. Reg. 32645 (June 1, 2012).  Accessed  at 
http://oig.hhs.gov/authorities/docs/2012/PerformanceStandardsFinal060112.pdf on  
May 30, 2014. 
20 OIG initially published performance standards in  1994 (59 Fed. Reg. 49080) and 
issued revised standards on June 1, 2012. (See 77 Fed. Reg. 32645.)  Although the 
1994 Performance Standards were in effect  during most of  the review period, we 
apply the 2012 performance standards where appropriate in  the findings and report  
recommendations.  
21  On occasion, OIG issues policy transmittals to provide guidance  and instructions 
to MFCUs.  The transmittals may also provide interpretations  of Federal 
regulations, statutes, and other policies as they apply to MFCUs. 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   3 
     
   
Ohio MFCU  
The Ohio Unit is located within the Office of Attorney General, and 
expended $7,344,992 in combined State and Federal funds in 
FY 2013.22  The Unit does not maintain any field offices; all 85 staff 
are located in Columbus.  The Unit management is composed of a 
director, an assistant director, a chief investigator known as the special 
agent in charge, and an assistant special agent in charge.  There are 
currently seven investigation teams:  five teams that investigate fraud 
and two that investigate abuse and neglect.  A typical team includes a 
special agent supervisor, seven special agents, and two assistant 
attorneys general.  The Unit also has a chief auditor, who supervises  
three intake officers, two nurse analysts, and a special projects team  
supervisor who supervises five fraud analysts, all of whom support the 
investigative teams.  
Referrals.   The Unit receives referrals from a variety of sources, 
including the State Medicaid agency,  the State Survey and Certification 
agency, the State Long-Term Care Ombudsman, and private citizens.  
Unit referrals by referral source for FYs 2011 through 2013 can be 
found in Appendix C.  Allegations of Medicaid fraud or patient abuse 
and neglect are recorded on a standardized intake form and reviewed 
by an intake committee.  This committee includes the director,  
assistant director, special agent in charge, assistant special agent in 
charge, chief auditor, intake officers, and bailiff/paralegal.  The 
committee meets twice a month to review all referrals and determine 
whether each referral should be opened for investigation.   
Investigations and Prosecutions.   When a case is opened, the assistant 
director (or his designee) assigns it to a team for investigation, and the 
team supervisor assigns it to a lead investigator.  The team supervisor 
meets with the lead investigator and attorneys to plan the investigation.  
Staff document investigative activities, time reporting, monthly 
reporting, and other statistical measurements using the Units case 
management database.   
The Ohio Unit opens all fraud cases as potential criminal 
investigations, but some cases may be closed by a civil settlement.  
State law grants the Unit original criminal jurisdiction to investigate 
and prosecute Medicaid provider fraud cases under Ohio Revised 
Code Section 109.85. State law requires thatfollowing an 
______________________________________________________ 
22 OIG, State Medicaid Fraud Control Units  Fiscal Year 2013 Statistical Chart. 
Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp  
on June 11, 2014. 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   4 
     
   
investigationall patient abuse and neglect cases be referred to a local 
(i.e., county or municipal) prosecuting attorney.23 The local 
prosecuting attorney may elect whether to prosecute or decline a case.  
If the local prosecuting attorney elects to decline a case, the Unit then 
makes a decision whether to prosecute the case in-house.   
METHODOLOGY 
We conducted the onsite review in April 2014.  We based our review 
on an analysis of data from seven sources:  (1) a review of policies, 
procedures, and documentation related to the Units operations, 
staffing, and caseload for FYs 2011 through 2013; (2) a review of 
financial documentation for FYs 2011 through 2013; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; 
(5) structured interviews with the Units management; (6) an onsite 
review of a sample of files for cases that were open at any time in 
FYs 2011 through 2013; and (7) an onsite observation of Unit 
operations. Appendix D provides a detailed 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. 
______________________________________________________ 
23 Ohio Revised Code 109.86  (2013). 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   5 
     
   
FINDINGS 
For FYs 2011 through 2013, the Ohio Unit reported 
403 criminal convictions and recoveries of nearly 
$214 million 
During the period we reviewed, the Unit obtained 403 criminal 
convictions, charged 400 individuals, closed 1,458 investigations, 
and reported 70 civil judgments and settlements.  Six cases were 
dismissed.  Details on investigations opened and closed by provider 
category for FYs 2011 through 2013 can be found in Appendix E. 
The Unit reported combined criminal and civil recoveries of nearly 
$214 million for FYs 2011 through 2013.  Most of the recoveries 
were obtained from global settlements, which accounted for 
81 percent of the Units recoveries during the period of our review.24   
(See Table 1 for details regarding criminal and civil recoveries for 
FYs 2011 thru 2013.) 
 
Table 1: Ohio Criminal and Civil Recoveries, FYs 20112013  
Type of Recovery   FY 2011   FY 2012   FY 2013   3-Year Total  
Criminal Recoveries  $3,333,680   $3,196,079  $5,944,122   $12,473,881 
Civil RecoveriesGlobal   $48,355,657   $86,230,829*   $38,678,399   $173,264,885 
Civil RecoveriesNonglobal   $26,815,561**   $436,537  $995,388   $28,247,486 
     Total Recoveries  $78,504,898   $89,863,445  $45,617,909   $213,986,252 
     Total Expenditures  $5,066,678   $6,712,714   $7,344,992   $19,124,384  
*The Civil RecoveriesGlobal amount in FY 2012 was higher than in FY 2011 or FY 2013 because of three 

large cases that were settled  during  2012. 

**The Civil RecoveriesNonglobal amount for 2011  included a large Ohio-specific civil recovery.
  
Source:  OIG analysis of Unit-submitted documentation, FYs 20112013. 

______________________________________________________ 
24 Global cases are civil false claims cases that are brought by the U.S. 
Department of Justice and involve a group of State MFCUs.  The National  
Association  of Medicaid Fraud Control Units facilitates the settlement of  global 
cases on behalf of the States. 
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The Unit did not consistently submit reports of 
convictions within the appropriate timeframe to
OIG for the purpose of program exclusion 
According to the 1994 Performance Standard 8(d), the Unit should 
transmit to OIG reports of all convictions for the purpose of 
exclusion from Federal health care programs within 30 days [of 
sentencing] or other reasonable time period.  The 2012 revised 
Performance Standard 8(f) states that it is the Units responsibility to 
transmit all pertinent information on MFCU convictions within 
30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
The Unit did not consistently submit reports of conviction 
information within the appropriate timeframe to OIG for the purpose 
of program exclusion.  Of the 403 reports of convictions that should 
have been sent to OIG for exclusion, the Unit reported 
320 convictions within the appropriate timeframe.  Eighty-three 
convictions were reported more than 45 days after sentencing.  
Fifty-two of these eighty-three convictions were submitted to OIG 
after the beginning of our review and more than 160 days after 
sentencing, with 13 of these submitted more than 1,000 days after 
sentencing. During onsite discussions, the Unit stated that it was 
revising its policies and procedures for reporting convictions to OIG.   
Thirteen percent of case files lacked 
documentation of supervisory approval for the 
closing of cases; nearly all case files contained 
documentation of periodic supervisory review 
According to 1994 Performance Standard 6(b) and 
2012 Performance Standard 5(b), Unit supervisors should approve 
the opening and closing of cases in part to ensure a continuous case 
flow and timely completion of cases.  Supervisory approval to open 
and close cases indicates that Unit supervisors are monitoring the 
intake and resolution of cases, thereby facilitating progress.  All case 
files in our review contained documentation indicating supervisory 
approval to open the case; however, 13 percent of the files for closed 
cases did not contain documentation indicating supervisory approval 
to close the case.  Unit management considered the 13 percent of 
case files to be adequately documented because they contained the 
record of court dispositions, such as convictions.  However, we did 
not consider the cases to be adequately documented because the 
court dispositions did not indicate that a supervisor had reviewed and 
approved the closing of the cases.  Including the closing 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   7 
     
   
documentation in such files would also allow Unit supervisors to 
monitor whether all appropriate administrative steps were taken in 
the case, such as reporting convictions to OIG for exclusion. 
According to 1994 Performance Standard 6(c) and 
2012 Performance Standard 7(a), supervisory reviews should be 
conducted periodically and noted in the case file to ensure timely 
case completion.25  The Units policy required that the special agent 
supervisor and prosecuting attorneys on each team review each case 
at least every 60 days. In addition to these reviews, the special agent 
supervisor and prosecuting attorneys (i.e., assistant attorneys 
general) on each team were responsible for conducting quarterly 
reviews of all closed case files.  Ninety-seven percent of files for 
cases that were open longer than 60 days contained documentation 
of periodic reviews. Related estimates and confidence intervals can 
be found in Appendix F. 
The Unit allowed non-Unit personnel to use its
vehicles, resulting in unallowable expenditures 
According to the 1994 Performance Standards 1 and 11 and the 
2012 Performance Standards 1 and 11, the Unit must conform to all 
applicable statutes, regulations, and policy directives and must  
exercise proper fiscal controls over its equipment, including 
vehicles.26  We also identified an internal Unit policy that specified 
that only Unit personnel may drive Unit vehicles.27 Further, Federal 
financial participation is limited to only the expenditures attributable 
to the establishment and operation of the Unit.28    
However, the Unit used Federal grant funds to purchase and 
maintain vehicles that were used by non-Unit staff.  Specifically, for 
______________________________________________________ 
25 For the purposes of this report, supervisory approval to  open and close a case 
does not constitute a periodic supervisory review.  Periodic supervisory review 
indicates that a supervisor reviewed a case more than  once between the cases 
opening and closing.  
26  2 CFR  part 225, Appendix A,  contains  the principles for determining the 
allowable costs incurred by State, local, and federally recognized Indian tribal  
governments (governmental units) under grants, cost  reimbursement contracts, and  
other agreements with the Federal  Government.  Section (C)(3)(a) of the  Appendix 
establishes the basic guideline that, to be allowable for Federal funding,  
expenditures must  be allocable, meaning that they must be charged and assigned to  
the cost objective in accordance with the relative benefits received.  
27 Ohio  Attorney General, Health Care Fraud Section, Medicaid Fraud Control  
Unit, Employee Handbook,  Section A-14, I.A., which states:  Only authorized 
Medicaid Fraud Control  Unit  (MFCU) personnel may drive MFCU  vehicles 
(effective March 24, 2008; last reissued March 1, 2013).  
28 42 CFR   1007.19(d)(1).  
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   8 
     
   
the period FY 2011 through 2013, we identified staff in other 
divisions of the Attorney Generals Office who used Unit-owned and 
Unit-maintained vehicles 149 times, totaling 20,074 miles.  The Unit 
claimed 100 percent of the vehicle expenditures for Federal 
reimbursement, resulting in unallowable expenditures of 
$11,092 (with a Federal share of $8,319 and a State share of $2,773). 
We did not identify any other weaknesses in fiscal controls relating 
to accounting, budgeting, personnel, procurement, property, and 
nonvehicle equipment.  
Other observations 
Program integrity groups and referrals 
According to 2012 Performance Standard 4(a), the Unit should take 
steps to ensure that the State Medicaid agency, managed care 
organizations, and other agencies refer to the Unit all cases of 
suspected provider fraud.  In an effort to improve the quantity and 
quality of referrals, the Unit developed two innovative program  
integrity groups. The Ohio Program Integrity Group (referred to as 
the PIG) combines the knowledge and resources of all the State 
agencies that are responsible for Medicaid program integrity, 
including the Unit; the Ohio Department of Job and Family Services 
Office of Ohio Health Plans and Surveillance and Utilization Review 
Section; the Zone Program Integrity Contractor, the Recovery Audit 
Contractor, and the Ohio Auditor of States Medicaid Contract Audit 
Section. The group meets monthly to craft data mining algorithms to 
identify aberrant Medicaid provider behavior, discuss data mining 
results, and coordinate an appropriate response to the results.  The 
Unit has also spearheaded the Managed Care Program Integrity 
Group (referred to as the McPIG), which meets quarterly and is 
composed of the Unit, the State Medicaid agencys Bureau of 
Managed Care, and representatives of Ohios five Medicaid 
managed care plans.  The purpose of meetings is to coordinate 
program integrity efforts and facilitate the exchange of information.   
Use of technology 
The Unit employs a special projects team to provide technical 
support to all of the investigative teams.  The team provides data 
analysis and tools for conducting undercover surveillance activities 
to assist in developing cases. During our onsite visit, we observed 
the teams use of technology and its ability to build in-house 
innovative tools that the Unit reported as having deployed 
successfully during investigations.  
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Initiation of investigative activity 
Although most cases appeared to be completed in an appropriate 
timeframe after the initiation of investigative activities (e.g., after the 
first interview), 15 of the 50 sampled cases selected for indepth 
review revealed a significant delay between when the referrals were 
reviewed during the intake process and when investigative activities 
were initiated. These delays ranged between 136 days and 642 days; 
the average delay was 285 days. In one such case, the referral was 
received in mid-May, the case was opened in late June, and 
investigative activity was not initiated until April of the following 
year. The Unit stated that it is in the process of adding 11 new staff 
over the next year and that it also refined its intake process to better 
evaluate the quality of referrals before opening cases.   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   10 
     
   
CONCLUSION AND RECOMMENDATIONS 
For FYs 2011 through 2013, the Unit closed 1,458 investigations and 
obtained 403 criminal convictions.  The Unit reported combined 
civil and criminal recoveries of nearly $214 million. 
Our review did not identify significant noncompliance with the 
performance standards; however, some opportunities for Unit 
improvement exist.  Specifically, our review found that the Unit did 
not submit reports of 83 convictions for purposes of program  
exclusion within the appropriate timeframe.  Our review also 
identified that the Units vehicles were used by non-Unit staff, 
resulting in unallowable expenditures.  Although all case files 
contained approval for the opening of cases, the files for 13 percent 
of closed cases (i.e., cases that were closed based on a conviction or 
other court disposition) lacked documentation of supervisory 
approval for the closing of cases, relying instead on court disposition 
documents.  The Units active participation in the Ohio PIG and 
McPIG work groups allowed it to better foster relationships and 
increase referrals. 
We recommend that the Ohio Unit: 
Submit reports of all convictions within the appropriate 
timeframe to OIG for the purpose of exclusion from 
Federal health care programs 
The Unit should ensure that all individuals convicted of fraud or 
patient abuse and/or neglect are reported to OIG within 30 days of 
their sentencing. 
Include documentation of supervisory approval for the 
closing of all case files    
Consistent with 2012 Performance Standard 5(b), the Unit should 
include closing documentation in every case file, including those for 
cases in which a conviction was obtained.  Closing documentation in 
such files would allow Unit supervisors to monitor whether all 
appropriate administrative steps were taken in the case, such as 
reporting convictions to OIG for exclusion, maintaining additional 
information regarding secondary disposition actions, and tracking 
other case subjects who were not convicted. 
   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   11 
     
   
Ensure that vehicles are used exclusively by Unit 
personnel and repay grant funds for unallowable  
expenditures 
The Unit should ensure that vehicles are used exclusively by Unit 
staff as required by Unit policy, and the Unit should work with OIG 
to repay grant funds for unallowable expenditures. 
    
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   12 
     
   
UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Unit concurred with our first and third recommendations and did 
not concur with our second recommendation, but said that it took 
action to address all of our recommendations. 
The Unit concurred with our recommendation that it submit reports 
of all convictions within the appropriate timeframe to OIG for the 
purpose of exclusion. The Unit stated that it believes it is currently 
in compliance and stated that it has recently amended its policies and 
procedures to ensure future compliance. 
The Unit did not concur with our recommendation that it include 
documentation of supervisory approval for the closing of all case 
files, but said that it had implemented the recommended procedure.  
The Unit stated that it believes including copies of the plea/judgment 
entry and sentencing entry in the master file for each case, combined 
with other information, is sufficient to meet the requirement.  
However, the Unit said that it has modified its internal  
policy/procedure to require closing documentation and supervisory 
approval for each case closed as a result of a criminal conviction.   
The Unit concurred with our recommendation that it ensure that 
vehicles are used exclusively by Unit personnel and that it repay 
grant funds for unallowable expenditures.  The Unit stated that it had 
notified the employees of the Workers Compensation Fraud Unit 
which, together with the MFCU, forms the Health Care Fraud 
Section of the Ohio Attorney Generals Officethat they are not 
permitted to use MFCU-owned vehicles.  The Unit also said that it 
took steps to ensure these individuals are not able to access the 
Units reservation system. 
The Unit also responded to OIG observations related to a significant 
delay between the intake of cases and the initiation of investigative 
activities for 15 of the sampled cases.   The Unit stated that it has 
seen an increase in case intakes over the last 5 years and has 
undergone four successive expansions to address the increased 
caseload and the Units capabilities in the area of patient abuse and 
institutional neglect. 
The full text of the Units comments is provided in Appendix G. 
   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   13 
     
   
APPENDIX A 
1994 Performance Standards29   
1. 	A Unit will be in conformance with all applicable statutes, 
regulations and policy transmittals.  In meeting this standard, 
the Unit must meet, but is not limited to, the following 
requirements:  
a. 	  The Unit professional staff must consist of permanent 
employees working full-time on Medicaid fraud and patient 
abuse matters. 
b. 	  The Unit must be separate and distinct from the State 
Medicaid agency. 
c. 	  The Unit must have prosecutorial authority or an approved 
formal procedure for referring cases to a prosecutor. 
d. 	  The Unit must submit annual reports, with appropriate 
certifications, on a timely basis.  
e. 	  The Unit must submit quarterly reports on a timely basis. 
f. 	  The Unit must comply with the Americans with Disabilities 
Act, the Equal Employment opportunity requirements, the 
Drug Free workplace requirements, Federal lobbying 
restrictions, and other such rules that are made conditions of 
the grant. 
2. 	A Unit should maintain st aff levels in accordance with 
staffing allocations approved in its budget. In meeting this  
standard, the following performance indicators will be 
considered: 
a. 	  Does the Unit employ the number of staff that was included 
in the Units budget as approved by the OIG? 
b. 	  Does the Unit employ the number of attorneys, auditors, and 
investigators that were approved in the Units budget? 
______________________________________________________ 
29 59 Fed. Reg. 49080, Sept. 26, 1994.   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   14 
     
   
c. 	  Does the Unit employ a reasonable size of professional staff 
in relation to the States total Medicaid program  
expenditures?   
d. 	  Are the Unit office locations established on a rational basis 
and are such locations appropriately staffed? 
3. 	A Unit should establish policies and procedures for its 
operations, and maintain appropriate systems for case 
management and case tracking.  In meeting this standard, the 
following performance indicators will be considered: 
a. 	  Does the Unit have policy and procedure manuals? 
b.	   Is an adequate, computerized case management and tracking 
system in place? 
4. 	A Unit should take steps to ensure that it maintains an  
adequate workload through referrals from the State 
Medicaid agency and other sources.  In meeting this standard, 
the following performance indicators will be considered:  
a. 	  Does the Unit work with the State Medicaid agency to ensure 
adequate fraud referrals? 
b.	   Does the Unit work with other agencies to encourage fraud 
referrals? 
c. 	  Does the Unit generate any of its own fraud cases? 
d.	   Does the Unit ensure that adequate referrals of patient abuse 
complaints are received from all sources? 
5. 	A Units case mix, when possibl e, should cover all significant 
provider types. In meeting this standard, the following 
performance indicators will be considered:  
a. 	  Does the Unit seek to have a mix of cases among all types of 
providers in the State? 
b.	   Does the Unit seek to have a mix of Medicaid fraud and 
Medicaid patient abuse cases? 
c. 	  Does the Unit seek to have a mix of cases that reflect the 
proportion of Medicaid expenditures for particular provider 
groups?  
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d.	   Are there any special Unit initiatives targeting specific 
provider types that affect case mix? 
e. 	  Does the Unit consider civil and administrative remedies 
when appropriate? 
6. 	A Unit should have a continuous case flow, and cases should 
be completed in a reasonable time. In meeting this standard, 
the following performance indicators will be considered:  
a. 	  Is each stage of an investigation and prosecution completed 
in an appropriate time frame? 
b.	   Are supervisors approving the opening and closing of 
investigations?   
c. 	  Are supervisory reviews conducted periodically and noted in 
the case file? 
7. 	A Unit should have a process for monitoring the outcome of 
cases.  In meeting this standard, the following performance 
indicators will be considered:  
a. 	  The number, age, and type of cases in inventory. 
b. 	  The number of referrals to other agencies for prosecution.  
c. 	  The number of arrests and indictments. 
d. 	  The number of convictions. 
e. 	  The amount of overpayments identified. 
f. 	  The amount of fines and restitution ordered. 
g. 	  The amount of civil recoveries. 
h. 	  The numbers of administrative sanctions imposed. 
8. 	A Unit will cooperate with the OIG and other Federal 
agencies, whenever appropriate and consistent with its 
mission, in the investigation and prosecution of health care 
fraud.  In meeting this standard, the following performance 
indicators will be considered: 
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a. 	  Does the Unit communicate effectively with the OIG and 
other Federal agencies in investigating or prosecuting health 
care fraud in their State? 
b.	   Does the Unit provide OIG regional management, and other 
Federal agencies, where appropriate, with timely information 
concerning significant actions in all cases being pursued by 
the Unit? 
c. 	  Does the Unit have an effective procedure for referring cases,  
when appropriate, to Federal agencies for investigation and 
other action? 
d.	   Does the Unit transmit to the OIG, for purposes of program  
exclusions under section 1128 of the Social Security Act, 
reports of convictions, and copies of Judgment and Sentence 
or other acceptable documentation within 30 days or other 
reasonable time period? 
9. A Unit should make statutory or programmatic 
recommendations, when necessary, to the State government.  
In meeting this standard, the following performance indicators 
will be considered:  
a. 	  Does the Unit recommend amendments to the enforcement 
provisions of the States statutes when necessary and 
appropriate to do so? 
b. 	  Does the Unit provide program recommendations to State 
Medicaid agency when appropriate? 
c. 	  Does the Unit monitor actions taken by State legislature or 
State Medicaid agency in response to recommendations? 
10. 	A Unit should periodically review its MOU with the State 

Medicaid agency and seek amendments, as necessary, to 

ensure it reflects current law and practice.  In meeting this 

standard, the following performance indicators will be 

considered: 
 
a. 	  Is the MOU more than 5 years old? 
b. 	  Does the MOU meet Federal legal requirements? 
c. 	  Does the MOU address cross-training with the fraud 

detection staff of the State Medicaid agency? 

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d. 	  Does the MOU address the Units responsibility to make 
program recommendations to the Medicaid agency and 
monitor actions taken by the Medicaid agency concerning 
those recommendations? 
11. 	The Unit director should exercise proper fiscal control over 
the Unit resources.  In meeting this standard, the following 
performance indicators will be considered:  
a. 	  Does the Unit director receive on a timely basis copies of all 
fiscal and administrative reports concerning Unit 
expenditures from the State parent agency? 
b. 	  Does the Unit maintain an equipment inventory?  
c. 	  Does the Unit apply generally accepted accounting principles 
in its control of Unit funding?  
12. 	A Unit should maintain an annual training plan for all 
professional disciplines.  In meeting this standard, the 
following performance indicators will be considered:  
a. 	  Does the Unit have a training plan in place and funds 

available to fully implement the plan? 

b. 	  Does the Unit have a minimum number of hours training 
requirement for each professional discipline, and does the 
staff comply with the requirement? 
c. 	  Are continuing education standards met for professional 
staff?  
d. 	  Does the training undertaken by staff add to the mission of 
the Unit? 
   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   18 
     
   
APPENDIX B 
2012 Revised Performance Standards30   
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.  
______________________________________________________ 
30 77 Fed. Reg. 32645, June  1, 2012. 
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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. 
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 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   20 
     
   
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 practi cable, 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. 
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c. 	  The Unit seeks to allocate resources among provider types 
based on levels of Medicaid expenditures or other risk 
factors.  Special Unit initiatives may focus on specific 
provider types. 
d. 	  As part of its case mix, the Unit maintains a balance of fraud 
and patient abuse and neglect cases for those States in which 
the Unit has original jurisdiction to investigate or prosecute 
patient abuse and neglect cases. 
e. 	  As part of its case mix, the Unit seeks to maintain, consistent 
with its legal authorities, a balance of criminal and civil fraud  
cases. 
7. 	A Unit maintains case files in an effective manner and 
develops a case management system that allows efficient 
access to case information and other performance data. 
a. 	  Reviews by supervisors are conducted periodically, 
consistent with MFCU policies and procedures, and are noted 
in the case file.  
b. 	  Case files include all relevant facts and information and 
justify the opening and closing of the cases. 
c. 	  Significant documents, such as charging documents and 
settlement agreements, are included in the file.  
d.	   Interview summaries are written promptly, as defined by the 
Units policies and procedures. 
e. 	  The Unit has an information management system that 
manages and tracks case information from initiation to 
resolution.  
f. 	  The Unit has an information management system that allows 
for the monitoring and reporting of case information, 
including the following: 
1.	   The number of cases opened and closed and the 
reason that cases are closed. 
2.	   The length of time taken to determine whether to 
open a case referred by the State Medicaid agency or 
other referring source. 
3.	   The number, age, and types of cases in the Units 
inventory/docket. 
4.	   The number of referrals received by the Unit and the 
number of referrals by the Unit to other agencies. 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   22 
     
   
5. 	  The dollar amount of overpayments identified. 
6. 	  The number of cases criminally prosecuted by the 
Unit or referred to others for prosecution, the number 
of individuals or entities charged, and the number of 
pending prosecutions. 
7. 	  The number of criminal convictions and the number 
of civil judgments. 
8. 	  The dollar amount of fines, penalties, and restitution 
ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through 
civil judgments or prefiling settlements. 
8. 	A Unit cooperates with OIG and other Federal agencies in the 
investigation and prosecution of Medicaid and other health 
care fraud.  
a. 	  The Unit communicates on a regular basis with OIG and 
other Federal agencies investigating or prosecuting health 
care fraud in the State.  
b. 	  The Unit cooperates and, as appropriate, coordinates with 
OIGs Office of Investigations and other Federal agencies on 
cases being pursued jointly, 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. 
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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 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 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. 
   
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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. 
 
 
   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   25 
     
   
APPENDIX C 
Ohio Medicaid Fraud Control Unit (Unit) Referrals by  
Referral Source for FYs 2011 Through 2013 
FY 2011   FY 2012   FY 2013  
Abuse &   Patient  Abuse &   Patient  Abuse &   Patient 
Referral Source   Fraud   Fraud   Fraud  
Neglect   Funds   Neglect   Funds   Neglect   Funds  
Medicaid agency   
PI/SURS31   23  0  0  23  0  0  19  0  0 
Medicaid agency  
189  2  0  174  1  0  223  1  1 
other  
State survey and  
8  123  20  3  109  34  3  176  88 
certification agency 
Other State agencies  38  0  0  30  1  1  32  4  2 
Licensing board  8  2  0  11  2  1  1  0  0 
Law enforcement   57  5  4  45  1  1  46  1  0 
Office of Inspector 
13  0  1  21  4  1  7  5  0 
General 
Prosecutors  6  0  0  0  1  0  1  1  1 
Providers  15  1  1  28  4  0  30  1  1 
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  7  2  0  9  3  1 
ombudsman  
Adult protective 
0  0  0  0  0  0  0  0  0 
services  
Private citizens  149  48  2  158  52  0  140  114  4 
MFCU hotline   0  0  0  0  0  0  0  0  0 
Self-generated   12  0  0  6  1  0  5  4  0 
Other   17  5  0  24  3  0  20  1  0 
Total   535  186  28  530  181  38  536  311  98 
   Annual Total   749  749  945 
Source:  OIG analysis of Unit-submitted documentation, FYs 20112013. 
   
______________________________________________________ 
31 The abbreviation PI stands  for program integrity; the abbreviation  SURS 
stands for Surveillance and  Utilization Review Subsystem.  
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APPENDIX D 
Detailed Methodology 
Data collected from the seven sources below was used to describe 
the caseload and assess the performance of the Ohio State Medicaid 
Fraud Control Unit (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 statistical 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 January 2014, and as 
necessary, we requested any additional data or clarification. 
Review of Unit Financial Documentation. To evaluate internal 
control of fiscal resources, OIG auditors determined whether the 
Unit (1) claimed expenditures that represented allowable, allocable, 
and reasonable costs in accordance with applicable Federal 
regulations; and (2) maintained adequate internal controls related to 
accounting, budgeting, personnel, procurement, property, and 
equipment for FYs 2011 through 2013.  OIG auditors also obtained 
from the Unit its claimed grant expenditures for FYs 2011 through 
2013, which was used to: (1) reviewed quarterly and final financial 
status reports that the Unit submitted along with supporting 
documentation, (2) judgmentally selected and reviewed transactions 
within the direct cost categories, and (3) confirmed whether indirect 
costs were accurately reported using the negotiated and approved 
indirect cost rates during the period of our review.  Finally, auditors 
reviewed records in the Department of Health and Human Services 
Payment Management System (PMS), tested selected expenditures 
by reviewing supporting documentation, and determined whether 
there was any unallowable Federal Medicaid reimbursement. 
Interviews with Key Stakeholders. In April 2014, we interviewed key 
stakeholders, including officials in the United States Attorneys  
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Offices, the State Attorney Generals Office, and State Agencies that 
interacted with the Unit (i.e., Adult Protective Services, the Medicaid 
Program Integrity Unit, the Office of the State Long-Term Care 
Ombudsman, and the Professional Licensure Division).  We also 
interviewed supervisors from OIGs Region V offices who work 
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 January 2014, we conducted an online 
survey of all 72 nonmanagerial Unit staff within each professional 
discipline (i.e.,  investigators, auditors, and attorneys) as well as 
support staff.  The response rate was 100 percent. Our questions 
focused on operations of the Unit, opportunities for improvement, 
and practices that contributed to the effectiveness and efficiency of 
Unit operations and/or performance.  The survey also sought 
information about the Units compliance with applicable laws and 
regulations. 
Onsite Interviews with Unit Management.   We conducted structured 
interviews with the Units management in April 2014.  We  
interviewed the Unit director, assistant director (who also served as 
the Units lead attorney), special agent in charge, assistant special  
agent in charge, chief auditor, and the team supervisors.  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 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 2011 through 2013.  This list of 2,535 cases 
included, but was not limited to, 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 52 cases 
that were categorized as global and 2 cases that had been closed 
prior to the period of our review and thus should not have been 
included in the list.  We then selected a simple random sample of 
100 cases from the remaining 2,481 cases.  This sample of 100 cases 
included 89 cases that were open longer than 60 days and 80 cases 
that were closed at some point during our review.  We reviewed all 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   28 
     
   
100 sampled case files.  During the onsite review, one case file was 
determined to be a global case.  As a result, the number of eligible 
case files in our sample was reduced from 100 to 99.  To project the 
number of eligible case files in the entire population, we used the 
proportion of the eligible case files from our sample.  This resulted 
in a reduction of the eligible population from 2,481 to an estimated 
2,456 case files. Our estimates of the percentages of all case files 
with certain characteristics apply to the estimated population of 
2,456 files for nonglobal cases that were open during the period of 
our review.  All estimates and 95-percent confidence intervals for 
projections can be found in Appendix F.  From the initial sample of 
100 case files, we selected a further simple random sample of 
50 files for a more indepth review of selected issues by an OIG 
investigator, such as the timeliness of investigations and case 
development.  We did not estimate any population or subpopulation 
proportions from this additional sample of 50 case files.  
Onsite Review of Unit Operations. During our April 2014 site visit, 
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. We also checked to ensure that the Unit 
referred sentenced individuals to OIG for program exclusion and that 
the Unit reported adverse actions to the National Practitioner Data 
Bank (NPDB).32, 33    
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.34  In addition, we noted practices that appeared 
to be beneficial to the Unit.  We based these observations on 
______________________________________________________ 
32 The NPDB  was established by the Department of  Health and Human Services as 
a national health care fraud and abuse data collection  program... for the reporting  
of certain final adverse actions... against health care providers, suppliers, or 
practitioners. SSA  1128E(a) and 45 CFR    61.1(2012).  This information used 
to be housed in a separate databank called the Healthcare Integrity and Protection 
Databank (HIPDB).  The HIPDB and the NPDB were merged into  one databank in  
May 2013. 78 Fed.  Reg. 20473 (April 5, 2013). 
33 Examples of adverse actions  include criminal convictions; civil judgments (but  
not civil settlements); exclusions; and  other negative actions or findings, including  
...but not limited to, limitations  on the scope of practice, liquidations, injunctions 
and forfeitures. SSA  1128E(g)(1) and 45 CFR  61.3 (2012).  Current Unit 
requirements for reporting to the merged  NPDB are in  45 CFR pt. 60. 
34 All relevant  regulations, statutes, and  policy transmittals are available online at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu.  
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statements from Unit staff, data analysis, and our own judgment.  
We did not independently verify the effectiveness of these practices, 
but included the information because it may be useful to other Units 
in their operations. 
   
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APPENDIX E 
Investigations Opened and Closed By Provider Category  
for FY 2011 Through 2013 
Table E-1:  Fraud Investigations  
Provider Category   FY 2011   FY 2012   FY 2013  
Facilities   Opened  Closed   Opened  Closed   Opened   Closed 
 Hospitals  4  4  3  2  3  4 
     Nursing facilities  6  8  4  4  15  2 
     Other long-term-care  
3  1  2  3  4  1 
     facilities  
     Substance abuse treatment       
3  0  2  1  1  3 
centers 
     Other   0  0  0  0  0  0 
   Subtotal   16  13  11  10  23  10 
Practitioners   Opened  Closed  Opened  Closed  Opened   Closed 
     Doctors of medicine or  
37  26  40  36  47  25 
     osteopathy  
Dentists  13  11  15  11  10  9 
Podiatrists  3  2  1  1  2  1 
     Optometrists/opticians  0  1  1  0  2  1 
     Counselors/psychologists  4  2  11  6  9  4 
Chiropractors  1  2  2  2  1  0 
     Other   14  15  36  20  17  19 
   Subtotal   72  59  106  76  88  59 
Medical Support  Opened   Closed   Opened   Closed   Opened   Closed 
 Pharmacies 
16  7  13  12  5  7 
Pharmaceutical 
     manufacturers   32  11  13  7  14  11 
Suppliers of durable medical 
     equipment and/or supplies  18  9  11  10  10  13 
     Laboratories 
2  4  2  1  9  2 
     Transportation services 
28  19  19  21  18  18 
     Home health care agencies 
66  38  68  44  58  44 
     Home health care aides 
155  125  160  139  159  123 
     Nurses, physician assistants, 
     nurse practitioners, certified  
nurse aides   42  42  40  31  26  29 
Radiologists 
0  0  2  0  0  1 
     Medical supportother  
3  1  0  1  1  2 
   Subtotal   362  256  328  266  300  250 
continued on next page 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   31 
     
   
 
Table E-1 (Continued):  Fraud Investigations  
Program Related   Opened   Closed  Opened   Closed  Opened   Closed 
     Managed care    1  1  1  1  0  1 
     Medicaid program  
0  0  0  0  0  0 
administration 
     Billing company   0  0  0  0  2  0 
     Other  0  0  0  0  0  0 
   Subtotal   1  1  1  1  2  1 
   Total Provider Categories   451  329  446  353  413  320 
Source:  OIG analysis of  Ohio State Medicaid Fraud Control Unit (Unit)-submitted documentation, FYs 20112013.  
 
Table E-2:  Patient Abuse and Neglect Investigations  
Provider Category   FY 2011   FY 2012   FY 2013  
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nursing facilities  38  30  49  33  104  36 
     Other long-term-care facilities   3  3  1  0  0  1 
Nurses, physicians 
assistants, nurse     
102  78  107  82  134  89 
practitioners, certified nurse      
aides 
     Home health aides  0  0  0  0  0  0 
     Other   5  3  0  4  2  1 
   Total   148  114  157  119  240  127 
Source: OIG analysis of Unit-submitted documentation, FYs 20112013. 
 
Table E-3:  Patient Funds Investigations  
Provider Category   FY 2011   FY 2012   FY 2013  
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nondirect care   9  7  9  8  12  7 
Nurses, physicians 
assistants, nurse     
7  15  7  5  18  7 
practitioners, certified nurse      
aides 
     Home health aides  0  0  0  0  0  0 
     Other   10  14  18  5  56  28 
Total   26  36  34  18  86  42 
Source: OIG analysis of Unit-submitted documentation, FYs 20112013.  
   
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   32 
     
   
APPENDIX F 
Point Estimates and 95-Percent Confidence Intervals 
Based on Reviews of Case Files 
95-Percent Confidence 
Sample  Point  Interval  
Estimate  
Size*  Estimate  
Lower  Upper  
Percentage of case files containing  
documentation of supervisory approval for  99  100%   96.4%   100%  
opening  
Percentage of closed-case files that did not 
contain documentation of supervisory approval  80  12.5%   6.9%   21.7%  
for closing 
Percentage of files for cases that were open 
longer than 60 days that contained  89  96.6%  90.1%  98.9%  
documentation of periodic supervisory review  
*We found at  the time of our review that one case file was for a global case, and we thus  excluded this case  from 
our analysis of  review questions. 
Source:  OIG analysis of  Ohio State MFCU case  files, 2014. 
 
 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   33 
     
   
APPENDIX G 
Unit Comments 
 
 
 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   34 
     
   
 
 
 
 
 
 
 
 
 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   35 
     
   
 
 
 
 
 
 
 
 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   36 
     
   
 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   37 
    4. 	 The  Unit  allowed  non-Unit  personnel  to  use  its  vehicles,  resulting  in 
unallowable expenditures. 
We concur with the audit finding, and assert that it was an unintentional oversight.  By 
way of background, the Health Care Fraud Section of the Ohio Attorney General's Oftice 
("AGO") is comprised of two (2) units:  The Medicaid Fraud Control Unit ("MFCU") 
and the Workers' Compensation Fraud Unit ("WCFU").  The MFCU has one hundred 
one (101) employees, while the much smaller WCFU has only eight (8) employees. Both 
units share space on the 17'h floor ofthe 150 East Gay Street building in Columbus, Ohio. 
In 2008, the AGO purchased a number ofpool vehicles tor the Health Care fraud Section 
using state-only funds, and made these pool vehicles available to members of both the 
MFCU and the WCFU.  The vehicles in the Health Care Fraud Section fleet were then, 
and are today, separate and distinct fiom those in the AGO main fleet.  Over time, these 
vehicles in the Health Care Fraud Section fleet were replaced with new pool vehicles, the 
acquisition and maintenance of which was funded, in part, by federal  grant dollars. 
However, members of the WCFU continued to use these pool vehicles, unaware of the 
funding restrictions. 
Our  independent  analysis  confirmed  the  reported  one  hundred  f01ty-nine  ( 149) 
reservations by members of the WCFU, and we do not contest either the 20,074 miles or 
the $11,092 attributed to same.  We would note that these one hundred forty-nine (149) 
reservations represent roughly  1.5% of the nine thousand seven hundred  fifty-eight 
(9,758)  vehicle  reservations  made  during  time  period  under  review  (10/01/10  
09/30113).  That said, we concur with the audit recommendation.  By way of corrective 
action, we have notified the employees of the WCFU that they are not permitted to usc 
the Section's pool vehicles, and we have locked these employees out of the application 
by which  these vehicles are reserved.  As an  alternative,  we have directed  these 
employees to usc only those pool vehicles in the AGO main fleet.  We arc confident, 
moving forward, that only MFCU staff will have access to and will use the pool vehicles 
funded with federal grant dollars. 
Thank you for the opportunity to comment.  Should you have questions or concerns 
regarding any of our comments, please feel free to contact me or our Special Agent-In-Charge, 
Lloyd Early, at the number provided below. 
Sincerely, 
MikeDeWinc 
Attorney General 
Keesha R. Mitchell 
Section Chief 
Health Care Fraud Section 
(614) 466-0722 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review (OEl-07-14-00290)  38   
   
 
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.   
Michael Barrett served as the project leader for this study.  Other 
Office of Evaluation and Inspections staff who conducted the study 
include Michael J. Brown and Conswelia McCourt.  Office of 
Investigations staff also participated in the review.  Central office 
staff who provided support include Susan Burbach, Kevin Farber, 
Christine Moritz, and Andrew VanLandingham.  Office of Audit 
Services staff who contributed to this study include Tate Clark, 
Michael Cullen, and Lee Gibson. 
Ohio State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-07-14-00290)                                   39 
     
Office of Inspector General
http://oig.hhs.gov  
 
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 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 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 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.