Department of Health and Human Services 
OFFICE OF 
  
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
I S M
OWA  TATE  EDICAID 
 
F C U :   
RAUD  ONTROL  NIT   
 
 
2014 O R  
  NSITE  EVIEW 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
Suzanne Murrin  
Deputy Inspector General for 
Evaluation and Inspections 
 
November 2014 
OEI-06-14-00190   
   
EXECUTIVE SUMMARY  IOWA STATE MEDICAID FRAUD CONTROL UNIT:                                
2014 ONSITE REVIEW 
OEI-06-14-00190  
 
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 the onsite review in April 2014.  We based our review on an analysis from seven 
sources: (1) a review of policies, procedures, and documentation of the Units operations, 
staffing, and caseload; (2) a review of financial documentation; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Unit management 
and selected staff; (6) a review of a sample of cases worked by the Unit; and (7) an onsite 
observation of Unit operations. 
 
WHAT WE FOUND  
For fiscal years (FY) 2011 through 2013, the Iowa Unit reported 94 criminal convictions,  
38 civil judgments and settlements, and recoveries of nearly $44 million.  Our review found no 
evidence of significant noncompliance with applicable laws, regulations, or policy transmittals.  
However, we found that the 47 percent of the Units case files lacked documentation indicating 
periodic supervisory reviews. Further, the Units memorandum of understanding (MOU) with 
the State Medicaid agency did not reflect all current requirements.  Subsequent to our onsite 
review, the Unit revised the MOU to include these requirements. 
 
WHAT WE RECOMMEND 
We recommend that the Iowa Unit implement processes to ensure that supervisors conduct and 
document case reviews periodically, consistent with the Units revised practice.  The Unit 
concurred with our recommendation.   
     
   
TABLE OF CONTENTS 
Objective..................................................................................................................1 

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

Methodology............................................................................................................4 

Findings....................................................................................................................5 

For FYs 2011 through 2013, the Unit reported 94 criminal convictions,  

38 civil judgments and settlements, and recoveries of nearly $44 million  ..5 

Forty-seven percent of Unit case files lacked documentation indicating 

periodic supervisory reviews .......................................................................6 

The Units MOU with the State Medicaid agency did not reflect  

current requirements ....................................................................................6 

Conclusion and Recommendations ..........................................................................8 

Unit Comments and Office of Inspector General Response ....................................9 

Appendixes ............................................................................................................10 

A: 	Detailed Methodology .........................................................................10 

B: 	Referrals of Provider Fraud and Patient Abuse and Neglect to the 
                                        
Iowa Unit by Source, FYs 2011 Through 2013 ...................................12 

C: 	Investigations Opened and Closed by Provider Category and  

      Case Type, FYs 2011 Through 2013 ....................................................13 

D: 	Point Estimates and Confidence Intervals Based on Review of Case 

Files......................................................................................................15 

E: Unit Comments.....................................................................................16 

Acknowledgments..................................................................................................17 

     
   
OBJECTIVE 
To conduct an onsite review of the Iowa State Medicaid Fraud Control 
Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute fraud and patient abuse and neglect by Medicaid 
providers 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 (1) minimal Medicaid fraud exists in that State; and (2) the State 
has other, adequate safeguards to protect Medicaid beneficiaries from  
abuse and neglect.2  In Federal fiscal year (FY) 2013, combined Federal 
and State grant expenditures for the Units totaled $230 million. 3     
To carry out its duties in an effective and efficient manner, each Unit must 
employ an interdisciplinary staff that consists of at least an attorney, an 
auditor, and an investigator.4 Unit staff review referrals 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 reported 1,341 convictions, 879 civil settlements or 
judgments, and recoveries of approximately $2.5 billion.5    
Units are required to have either Statewide authority to prosecute cases or 
formal procedures to refer suspected criminal violations to an office with 
such authority.6  Currently, MFCUs operate in 49 States and in the District 
of Columbia.  Forty-four of the MFCUs are located within offices of State 
 
1 Social Security Act (SSA)  1903(q)(3). 
 
2 Ibid.,  1902(a)(61) and  1903(q)(3).  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  Office of  Inspector General (OIG),  State Medicaid Fraud Control Units  Fiscal Year 

2013  Grant Expenditures and Statistics (February 11, 2014).  Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2013-statistical-chart.htm on  April 10, 2014. 
4 SSA  1903(q)(6) and  42 CFR   1007.13.  
5 OIG,  State Medicaid Fraud Control Units  Fiscal Year 2013 Grant Expenditures and 
Statistics (January 31, 2014).  Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-
control-units-mfcu/expenditures_statistics/fy2013-statistical-chart.htm on  April 10, 2014.  
Recoveries are defined as the amount  of money that defendants are required to pay as a 
result of a settlement, judgment, or pre-filing settlement in criminal and civil cases and  
may not reflect actual collections. 
6  SSA  1903(q)(1).  
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   1   
   
Attorneys General; the remaining 6 MFCUs, including Iowa, operate 
within other State agencies.7  Each Unit must be a single, identifiable 
entity of State government, distinct from the single State Medicaid agency, 
and must develop a formal agreement (i.e., memorandum of understanding 
(MOU)) that describes its relationship with that agency.8   
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.9   
All Units are currently funded by the Federal government on a 75-percent 
matching basis, with the States contributing the remaining 25 percent.10  To  
receive Federal reimbursement, each Unit must submit an initial application 
to OIG.11  OIG reviews the application and notifies the Unit whether it is 
approved and the Unit is certified. Approval and certification are valid for a 
1-year period; the Unit must be recertified each year thereafter.12    
Pursuant to Title XIX of the SSA, States must operate Units that effectively 
carry out their statutory functions and meet program requirements.13 OIG 
developed and issued 12 performance standards to define the criteria it 
applies in assessing whether a Unit is effectively carrying out statutory 
functions and meeting program requirements.14  Examples of standards 
include maintaining an adequate caseload through referrals from various 
sources, maintaining an annual training plan for all professional disciplines, 
and establishing policy and procedure manuals to reflect the Units 
operations.  
Iowa Medicaid Program 
The Iowa Medicaid program, known as Iowa Medicaid Enterprise, is a 
division of the Iowa Department of Human Services.  In FY 2013, the 
Iowa Medicaid program provided services to over 400,000 beneficiaries, 
 
7 OIG,  Medicaid Fraud Control Units.  Accessed at http://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/index.asp on  May 30, 2014. 

8 SSA  1903(q)(2);  42 CFR   1007.5 and 1007.9(d). 
  
9 The portion of funds reimbursed to States by the Federal  government for  its share of 
 
expenditures, including the MFCUs, is called Federal Financial Participation  . 

10 SSA  1903(a)(6)(B).  

11 42  CFR  1007.15(a). 
 
12 42  CFR  1007.15(b) and (c). 
 
13 SSA  1902(a)(61). 

14 77 Fed. Reg. 32645 (June 1, 2012).  Accessed at http://oig.hhs.gov/authorities/docs/ 

2012/PerformanceStandardsFinal060112.pdf  on  May 30, 2014.  Previous performance 

standards, established in 1994, are found at 59 Fed. Reg. 49080  (Sept. 26, 1994).  When 
 
referring to the performance standards,  we refer to the 2012  standards, unless otherwise 

noted.   

Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   2   
   
55 percent of whom were enrolled in managed care.15 The Iowa Medicaid 
program expanded Medicaid coverage under the Patient Protection and 
Affordable Care Act and estimates that Medicaid enrollment will increase  
to 680,000 beneficiaries in FY 2014 and 800,000 beneficiaries by 
FY 2015.16  Total Iowa Medicaid expenditures for FY 2013 were over  
$3.6 billion.17    
Iowa Unit   
The Iowa Unit is a component of the Department of Inspections and 
Appeals, the agency charged with coordinating and conducting audits, 
appeals, hearings, inspections, and investigations of Iowas public 
assistance programs.18 For FY 2013, the Unit expended a total of 
$1 million in combined State and Federal funds.19  At the time of our 
April 2014 review, the Unit employed 10 staff members1 director, 
1 assistant attorney general,20 1 investigative auditor, 6 investigators, 
and 1 administrative assistant.  The Unit headquarters is located in 
Des Moines. 
The Unit has the authority to investigate criminal cases of Medicaid fraud 
and patient abuse and neglect. However, the Unit does not have 
prosecutorial authority. County attorneys and the United States Attorneys 
Office have primary prosecutorial authority over the Units criminal cases 
and may afford prosecutorial authority to the Assistant Attorney General 
assigned to the Unit. The Assistant Attorney General assigned to the Iowa 
Unit also prosecutes civil cases of Medicaid fraud on behalf of the Iowa 
 
15 Iowa Department of  Human Services, Improving Iowans Health  Status, p. 3-3.   
Accessed at http://www.dhs.state.ia.us/uploads/15-6_Improve_Health_Status.pdf on  
April 18, 2014 and Iowa  Department of Human Services, Iowa Medicaid  Managed Care  
Fact Sheet, p. 1 (January 17, 2014).  Accessed at 
http://www.dhs.state.ia.us/uploads/IowaMedicaid_ManagedCare_FactSheet.pdf on    
April 29, 2014. 
16 CMS, Iowa Medicaid Moving Forward in  2014. Accessed at 
http://medicaid.gov/Medicaid-CHIP-Program-Information/By-State/iowa.html on     
May 27, 2014  and Iowa Department of Human Services, Improving Iowans Health  
Status, p. 3-2.   Accessed at http://www.dhs.state.ia.us/uploads/15-
6_Improve_Health_Status.pdf on  April 18, 2014. 
17 Ibid. 
18 Iowa Department of  Human Services, Department of Inspections and Appeals.  

Accessed at http://www.state.ia.us/government/dia/ on July 31, 2014. 

19  OIG,  State Medicaid Fraud Control Units  Fiscal Year 2013 Grant Expenditures and 

Statistics (February 11, 2014).  Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-
control-units-mfcu/expenditures_statistics/fy2013-statistical-chart.htm on  April 10, 2014.  
20 The Assistant Attorney General is an employee of the Attorney Generals Office who  
is detailed to the Iowa MFCU.  The Department of  Inspections and Appeals transfers  
money to the Attorney Generals Office to pay for the Assistant Attorney Generals 
salary. 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   3   
   
Attorney Generals Office. These civil cases include globali.e., 
multi-Stateand nonglobal cases. 21,  22  
Previous Review  
In 2007, OIG conducted an onsite review of the Iowa Unit. OIG found 
that the Unit was largely compliant with the 12 MFCU Performance 
Standards and the Federal regulations that govern its grant.  However, 
OIG identified two areas of concern. First, OIG found that the Unit did 
not have policies and procedures established for the creation and 
maintenance of its official case files. Second, OIG found that the official 
files did not include a file index to locate and identify documents 
contained within a file.  
During the April 2014 onsite visit, OIG reviewers observed that the Unit 
had addressed both previous onsite concerns.  The Unit had incorporated 
information about the creation and maintenance of case files in its policy 
and procedures manual.  Additionally, OIG reviewers observed 
improvements in the organization of documents within case files, which 
facilitated the Units ability to find and identify documents.   
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; (2) a review of financial documentation; (3) structured 
interviews with key stakeholders; (4) a survey of Unit staff; (5) structured 
interviews with the Unit director and supervisors; (6) an onsite review of a 
sample of case files; and (7) an onsite observation of Unit operations.  
Appendix A contains the details of our methodology.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
 
21 Global cases are coordinated through the National Association of Medicaid Fraud  
Control Units, typically through the involvement of attorneys from other MFCUs, to  
work with the  U.S.  Department of Justice on global civil false-claims cases. 
22 Iowa Code  685.  Nonglobal cases are specific to the State and may include civil 
settlements and  judgments. 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   4   
   
FINDINGS 
For FYs 2011 through 2013, the Unit reported  
94 criminal convictions, 38 civil judgments and 
settlements, and recoveries of nearly $44 million  
The Unit reported 94 criminal convictions and 38 civil judgments and 
settlements during FYs 2011 through 2013.  See Table 1. The Units 
number of criminal convictions is high given the size of the Iowa Unit and 
size of the Iowa Medicaid program.23  
Table 1: Iowa MFCU Criminal Convictions and Civil Judgments and 
Settlements, FYs 2011 Through 2013  
Outcomes   FY 2011   FY 2012   FY 2013   Total  
Criminal Convictions  45  18  31  94 
Civil Judgments and  Settlements   13  12  13  38 
Source: OIG analysis of Unit Quarterly Statistical Reports, FYs 2011 through 2013.  
Although we are not able to specifically identify the causes that led to the 
high number of convictions, Unit officials pointed to several potential 
contributing factors. As described above, the Unit is located in an 
investigative division of State Government and does not have authority to 
prosecute criminal cases.  Rather, Iowas county attorneys prosecute most 
of the Units cases, working in partnership with the Unit staff who 
investigated the cases.  Unit officials expressed their belief that this 
arrangement allows MFCU staff to concentrate their attention in a more 
effective way on case investigations.  Further, Unit officials reported 
efforts over the last several years to build strong working relationships 
with Iowas 98 county attorneys. Unit officials viewed having so many 
county attorneys as partners as a substantial benefit, since the county 
attorneys effectively served as a large prosecutorial resource to pursue 
Unit cases. 
For FYs 2011 through 2013, the Unit reported combined criminal and civil 
recoveries of nearly $44 million.  During the review period, criminal 
recoveries ranged from over $150,000 to over $239,000.   
 
23 Among all MFCUs, the 94 convictions  over the 3-year period is an extreme high  
outlier based  on our analysis of convictions per Unit staff and convictions per Unit grant 
expenditures, and is a high  outlier based on our analysis of  convictions per Medicaid  
program expenditures.   We did not analyze the complexity or level  of resources  
associated  with the cases that resulted in the 94 convictions.  See Appendix A for details 
about analysis of Unit data to  identify outliers. 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   5   
   
See Table 2.  Civil recoveries included nearly $29 million in global 
recoveries and nearly $15 million in nonglobal recoveries.24    
Table 2: Iowa MFCU Recoveries, FYs 2011 Through 2013  
Total  
Recovery  Type   FY 2011   FY 2012   FY 2013  
Recoveries  
Criminal  $179,804  $239,399  $150,132   $569,335  
Global Civil  $2,580,294  $15,585,500  $10,467,411   $28,633,205  
Non-Global Civil  $13,823,229  $637,163  $100,000   $14,560,392  
Total  Recoveries   $16,583,327  $16,462,062  $10,717,543   $43,762,932  
Source: OIG analysis of Unit self-reported data, FYs 2011 through  2013.  
Forty-seven percent of Unit case files lacked 
documentation indicating periodic supervisory  
reviews  
According to Performance Standard 7(a), supervisors should conduct 
reviews periodically, and note them in the case files.  Our case file review  
found that overall 47 percent of cases had not received periodic 
supervisory reviews. Unit officials reported that the Units practice for 
conducting and documenting supervisory reviews changed during the 
course of our review period.25  Despite these changes, we identified many 
cases lacking evidence of supervisor reviews, both before and after the 
practice change. Additionally, the new practice was not included in the 
policy and procedures manual. 
The Units MOU with the State Medicaid agency did 
not reflect current requirements 
According to Performance Standard 10, the Unit should periodically 
review its MOU with the single State Medicaid agency to ensure it reflects 
current law and practice. The Unit last updated its MOU with the State 
Medicaid agency in June 2012. However, at the time of our 
April 2014 onsite review, the MOU did not include language to address 
 
24 Global settlements originate from civil false claims cases involving the U.S. 
Department of Justice and other State MFCUs.  The Federal Government often represents  
multiple States in  global settlements.    
25 Prior to September 2011, the Units practice was to complete supervisory reviews 
informally, with  no set timeframe and  no expectation for documenting the review in case 
files. The Unit implemented a new practice in September 2011, such that supervisors 
were expected to conduct reviews every 23  months and to  document the occurrence in  
case files. 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   6   
   
the regulation requiring payment suspension of any Medicaid provider 
against whom there is a credible allegation of fraud.26  The Unit director  
reported that the Unit and State Medicaid agency had procedures related to 
such payment suspensions and routinely used these procedures, even 
though the MOU did not reflect the procedures.  Subsequent to our onsite 
review, the Unit and State Medicaid agency revised the MOU, effective 
July 25, 2014, to include language that addresses payment suspensions 
based on credible allegations of fraud. 
   
 
26 42 CFR    455.23 and 1007.9(e)(1).  
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   7   
   
CONCLUSION AND RECOMMENDATIONS 
For FYs 2011 through 2013, the Iowa Unit reported 94 criminal 
convictions, 38 civil judgments and settlements, and recoveries of nearly 
$44 million.  The Units number of criminal convictions is high given the 
size of the Iowa Unit and Iowa Medicaid program.   
Our review of compliance issues found no evidence of significant 
noncompliance with applicable laws or regulations.  However, we found 
one area for improvement in the Units operations.  Specifically, our case 
file review revealed that 47 percent of cases had not received periodic 
supervisory reviews. 
Therefore, we recommend that the Iowa Unit: 
Implement processes to ensure that supervisors conduct and 
document case reviews periodically, consistent with the Units  
revised practice 
The Unit should develop processes to ensure that cases are reviewed 
periodically, consistent with the Units revised practice for supervisory 
reviews that commenced in September 2011.  Processes could include 
automated reminders or other mechanisms to alert Unit staff when cases 
are due for periodic reviews.  Additionally, the Unit should include the 
revised practice and timeline for conducting periodic supervisory reviews 
in its policy and procedures manual. 
   
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   8   
   
UNIT RESPONSE AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The Iowa Unit concurred with our recommendation that the Unit should 
implement processes to ensure that supervisors conduct and document 
case reviews periodically, consistent with the Units revised practice.  The 
Unit reported that it revised the MFCU policies and procedure manual to 
ensure consistency with the Units current case file review practice, 
explain case review scheduling, and outline a method of documenting 
reviews. 
The full text of the Units comments is provided in Appendix E.  We did 
not make any changes to the report as a result of the Units comments. 
   
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   9   
   
APPENDIX A 
Detailed Methodology  
We used data collected from the seven sources below to describe the 
caseload and assess the performance of the Unit.  
Data Collection 
Review of Unit Documentation.  Prior to the onsite visit, we analyzed 
information regarding the Units investigation and referral for prosecution  
of Medicaid cases. We gathered this information from several sources, 
including the Units quarterly statistical reports, annual reports, 
recertification questionnaire, policies and procedures manuals, MOU with 
the State Medicaid agency, and the 2007 OIG report from onsite review.  
Additionally, we confirmed with the Unit director that the information we 
had was current as of April 2014, and as necessary, requested any 
additional data or clarification.  
Review of Financial Documentation. We reviewed the Units control over 
its fiscal resources to identify potential internal control weaknesses or 
other issues involving use of resources.  Prior to the onsite review, we 
reviewed the Units financial policies and procedures; its response to an 
internal control questionnaire; and documents (such as financial status 
reports) related to MFCU grants.  During the onsite review, we reviewed a 
sample of the Units purchase and travel transactions.  In addition, we 
reviewed vehicle records, the equipment inventory, and a sample of time  
and effort records.  
Interviews with Key Stakeholders. We conducted structured interviews 
with key stakeholders who were familiar with the operations of the Unit.  
Specifically, we interviewed staff  from Iowa Department of Human 
Services, Iowa Medicaid Enterprise; Department of Inspections and 
Appeals, Division Administrator; the Department of Health Facilities; an 
Assistant District Attorney; an Assistant U.S. Attorney; OIG special 
agents and an Assistant Special Agent in Charge who worked with the 
Unit during the review period; and one managed care organization 
(Magellan) that operates in Iowa.  These interviews focused on the Units  
interaction with external agencies.  
Survey of Unit Staff.  We administered an electronic survey to Unit staff in 
the weeks leading up to the onsite review.  We requested and received 
responses from all 7 nonmanagerial staff members, a 100-percent response 
rate. Our questions focused on operations, opportunities for improvement, 
and effective practices.   
Interviews with Unit Management and Selected Staff. We conducted 
structured interviews with the Unit director, the Assistant Attorney 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   10   
   
General, the senior investigative auditor, and a senior investigator.  We  
asked interviewees to provide information to better illustrate the Units 
operations, identify opportunities for improvement and effective practices, 
and clarify information we obtained from other data sources. 
Onsite Review of Case Files.  We selected a statistically valid, simple 
random sample of 100 case files from the 476 cases that were open at any 
point during FYs 2011 through 2013. From these 100 case files, we 
selected another simple random sample of 50 files for a more in-depth 
review. Our results project to the population of 476 cases. 
Of the 100 case files, we excluded 3 cases due to data collection system  
errors. We reviewed 97 sampled case files for documentation of actions 
including supervisory approval for the opening and closing of cases, and 
periodic supervisory reviews.  We reviewed 47 sample case files for 
selected issues, such as the timeliness of investigations and case 
development.  See Appendix D for point estimates and 95-percent 
confidence intervals.  
Onsite Review of Unit Operations. We reviewed the Units operations 
during our April 2014 onsite visit. Specifically, we reviewed the process 
for receiving referrals, electronic case management, security of case files,  
and general functioning of the Unit. 
Data Analysis  
We examined FYs 2011through FY 2013 data reported by all MFCUs 
about three types of Unit outcomes:  1) the number of criminal 
convictions, 2) the number of civil settlements and judgments, and 3) the 
amount of recoveries.  For each type of outcome, we calculated three 
metrics of Unit productivity:  1) outcome per Unit staff, 2) outcome per 
Unit grant expenditures, and 3) outcome per Medicaid program  
expenditures.  We analyzed this national data to identify whether the Iowa 
Unit had high outliers on any of these measures.  We considered the Units 
outcomes to be a high outlier if the Units outcome measure  
(e.g., convictions per Unit staff) was greater than the 75th percentile plus  
1.5 times the interquartile range, and an extreme high outlier if the 
measure was greater than the 75th percentile plus 3.0 times the 
interquartile range.  We reported only those measures identified as high or 
extreme high outliers. 27      
 
27 Known as Tukeys Method, this is a standard exploratory  method for identifying  
members of  a population with high values on  a given static compared to the rest of the 
population when no  established benchmark exists.  See J.W. Tukey,  Exploratory Data  
Analysis, Addison-Wesley, 1977. 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   11   
   
APPENDIX B 
Referrals of Provider Fraud and Patient Abuse and Neglect to the 
Iowa Unit by Source,  Fiscal Years 2011 Through 2013 
Table B-1: Referrals of Fraud and Abuse to MFCU 
Case Type   FY 2011   FY 2012   FY 2013  
Provider Fraud   139  185  229 
Patient Abuse and Neglect  878  412  335 
  Total   1,017   597  564 
 
Source: Iowa MFCU response to OIG data request. 
Table B-2: Referrals to MFCU, by Referral Source  
FY 2011   FY 2012   FY 2013  
Referral Source   Patient  Patient  Patient 
Provider  Provider  Provider 
Abuse and   Abuse and   Abuse and  
Fraud   Fraud   Fraud  
Neglect   Neglect   Neglect  
Medicaid Agency  76  0  72  0  107  0 
State Survey/Certification   9  874  8  408  6  333 
State Agencies  Other   8  1  15  0  9  0 
Licensing Boards  0  0  5  0  2  0 
Law  Enforcement  1  1  1  0  1  1 
HHS OIG  3  0  3  0  4  0 
Prosecutors  1  1  0  0  7  0 
Providers  4  0  1  1  0  0 
Private Health Insurers  3  0  2  0  1  0 
Ombudsman   0  0  0  0  0  0 
Adult Protective Services  0  0  0  0  0  0 
Private Citizens  17  1  23  2  18  1 
MFCU Hotline  4  0  0  0  0  0 
Other   13  0  55  1  74  0 
  Total Referrals Received   139  878  185  412  229  335 
 
Source: Iowa MFCU response to OIG data request. 
 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   12   
   
APPENDIX C 
Investigations Opened and Closed by Provider Category and Case 
Type, Fiscal Years 2011 through 2013 
Table C-1: Annual Opened and Closed Investigations  
FY 2011   FY 2012   FY 2013  
Case Type  
Opened   Closed  Opened   Closed  Opened   Closed 
Provider Fraud   63  122  137  56  144  85 
Patient Abuse and Neglect  24  64  24  29  32  17 
Total    87  186  161  85  176  102 
 
Source: Iowa MFCU response to OIG data request. 
Table C-2: Investigations of Patient Abuse and Neglect  
FY 2011   FY 2012   FY 2013  
Provider Category  
Opened  Closed  Opened  Closed  Opened   Closed 
Nursing Facilities   0  0  0  0  0  0 
Other Long-Term-Care Facilities   0  0  0  0  0  0 
Nurses/Physicians Assistants/Nurse  12  31  15  19  27  15 
Practitioners/Certified Nurse Aides 
Home Health Aides  1  6  0  1  1  0 
Other   11  27  9  9  4  2 
Total   24  64  24  29  32  17 
 
Source: Iowa MFCU response to OIG data request. 
 
 
 
 
 
 
 
 
 
   
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   13   
   
Table C-3: Investigations of Provider Fraud  
Provider Category   FY 2011   FY 2012   FY 2013  
Facilities   Opened  Closed   Opened  Closed   Opened  Closed  
Hospitals  0  2  2  0  2  1 
Nursing Facilities   1  6  3  2  5  0 
Other Long-Term-Care Facilities   1  4  2  2  0  0 
Substance Abuse Treatment Centers  0  0  0  0  0  0 
Other  Facilities   1  1  3  2  4  1 
Practitioners   Opened  Closed  Opened  Closed  Opened  Closed 
Doctors of Medicine or Osteopathy   1  3  2  2  1  1 
Dentists  0  2  5  1  3  5 
Podiatrists  0  0  0  0  0  0 
Optometrist/Opticians  0  0  0  0  0  0 
Counselors/Psychologists  10  9  5  2  12  7 
Chiropractors  0  11  0  2  0  0 
Other Practitioners  0  1  1  0  0  0 
Medical Support  Opened  Closed   Opened  Closed   Opened  Closed  
Pharmacies  1  1  9  2  5  1 
Pharmaceutical Manufacturers  13  13  33  9  42  20 
Suppliers of Durable Medical  2  0  4  1  8  1 
Equipment 
Laboratories  0  1  2  0  5  0 
Transportation Services  0  0  1  1  3  0 
Home Health Care Agencies  9  16  13  4  16  11 
Home Health Care Aides  17  48  46  23  32  34 
Nurses/Physicians Assistants/Nurse 
1  0  0  1  0  0 
Practitioners/Certified Nurse Aides 
Radiologists  0  0  0  0  0  0 
Other Medical Support   2  1  4  0  5  2 
Program  Related   Opened  Closed  Opened  Closed  Opened  Closed 
Managed Care   0  0  0  0  1  1 
Medicaid Program  Administration  0  0  0  0  0  0 
Billing Company  0  0  0  0  0  0 
Other Program Related  4  3  2  2  0  0 
All Fraud Investigations   Opened  Closed   Opened  Closed   Opened  Closed  
Total   63  122  137  56  144  85 
 
Source: Iowa  Unit response to OIG data request. 
 
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   14   
   
APPENDIX D 
Point Estimates and Confidence Intervals Based on Review of Case 
Files 
95-Percent  
Sample  Point  Confidence Interval  
Estimate Characteristic  
Size  Estimate  
Lower  Upper  
Case files containing documentation 
97  100.0%   96.5%   100.0%  
of supervisory approval for opening  
Case files containing documentation 
72  100.0%   95.3%   100.0%  
of supervisory approval for closing 
Case files with no documentation of 
73  46.6%   34.8%   58.6%  
periodic supervisory  review* 
*We excluded from this analysis 8 sample cases that were closed within 90 days of opening and 16 sample 

cases that were sent to prosecution within 90 days of first investigative activity.
  
Source: OIG analysis of Unit case files, 2014. 

 
 
 
 
 
   
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   15  APPENDIX E 
Unit Comments 
INVUSTIGATIONS DIVISI<)N 
Lt1cns State Office Huilding 
321 P..Mt 12h Street 
Des 1foin.-s, L\ 5031 ') 0083 
(SIS) 231-5714 
TfliRY F.. BAANSTAD  RODNEY A. ROIU:RTS, D!RCTOR 
GOVERNOR 
KIM REYNOLDS 
lT.GOWI\NOR 
October 16, 2014 
Stmmnc Murrin 
Deputy Inspector General lor Evnluationnnd Inspections 
U.S. Dcpnrtment of Health and Human Services 
Office oflnspector Gcncml 
Room 5660, Cohen Building 
330 Indepemlcncc J\ venue, SW 
Washington, DC 2020 I 
RE:  Iowa MFCU 2014 Onsitc Review, OEJ-06-14-00190 
Dear Ms. Murrin: 
Thnnk you t(w the opportunity to comment on the 2014 Onsite Review findings.  The HHS-OlG team 
who conducted the review exhibited exceptional professionalism and the Iowa MFCU appreciated 
working with them. We offer the following comments on the recommendation made in the report 
Rec<>mmendation 
Implement Processes to ensure that supervisors conduct nnd document case file reviews periodically, 
consistent with the Unit's revised practice. 
Comments 
We concur with the recommendation. Upon receiving the ~ommcndation, the MPCU Director 
immcdintcly bcgnn work on revising the MFCU Policy and Procedure Manual to ensure consistency with 
the MFCU's current case tile review practice.  The new policy explains case review scheduling and 
includes a clear method ofdocumenting these reviews by botlt the Investigator and Director. The 
me 
scheduling and dm:umcntation will ensure that case  reviews arc conducted on uti cases. 
The Iowa MFCU appreciates the efforts ofliiiS-010 in providing recommendations to n.ctsist us in 
achieving higher standnrds.  Thank you for the time and effort you spent on thls review. 
Sincerel)'\ 
,%shun J. Happe 
Djtector, Iowa Medicaid Fraud Control Unit 
Iowa State Medicaid Fraud Control Unit: 2014 Onsite Review (OEI-06-14-00190)  16   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Kevin Golladay, Regional 
Inspector General for Evaluation and Inspections in the Dallas regional office; 
Blaine Collins, Deputy Regional Inspector General; and Ruth Ann Dorrill, Deputy 
Regional Inspector General. 
Lyndsay Patty served as the team leader for this study and Maria Balderas served 
as the lead analyst. Other Office of Evaluation and Inspections staff who 
provided support include Ben Gaddis. Office of Investigations staff who provided 
support includes Jennifer Whitaker.  Central office staff who provided support 
include Susan Burbach, Kevin Farber, Christine Moritz, and Richard Stern.  
Iowa State Medicaid Fraud Control Unit:  2014 Onsite Review  (OEI-06-14-00190)   17   
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.