Department of Health and Human Services 
 
 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
P S
ENNSYLVANIA  TATE 
 
 
M F C
EDICAID  RAUD  ONTROL 
 
 
U : 2015 O R  
NIT    NSITE  EVIEW
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin 
Deputy Inspector General  
for Evaluation and Inspections 
 
June 2016 
OEI-07-15-00360   
   
EXECUTIVE SUMMARY:  PENNSYLVANIA STATE MEDICAID FRAUD 
CONTROL UNIT:  2015 ONSITE REVIEW 
OEI-07-15-00360 
 
WHY WE DID THIS STUDY  
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit 
(MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units 
performance in accordance with the requirements of the grant.  As part of this oversight, 
OIG conducts periodic reviews of all Units and prepares public reports based on these 
reviews.  These reviews assess the Units adherence to the 12 MFCU performance 
standards and compliance with applicable Federal statutes and regulations. 
 
HOW WE DID THIS STUDY 
We conducted an onsite review of the Pennsylvania Unit in November 2015.  We based 
our review on an analysis of data from seven sources:  (1) policies, procedures, and 
documentation related to the Units operations, staffing, and caseload; (2) financial 
documentation for fiscal years (FYs) 2012 through 2014; (3) structured interviews with 
key stakeholders; (4) a survey of Unit staff; (5) structured interviews with the Units 
management; (6) a sample of files for cases that were open in FYs 2012 through 2014; 
and (7) observation of Unit operations. 
 
WHAT WE FOUND 
For FYs 2012 through 2014, the Pennsylvania Unit reported 130 criminal convictions, 
37 civil judgments and settlements, and combined criminal and civil recoveries of 
$80 million.  We found that the Pennsylvania Unit was generally in compliance with 
applicable laws, regulations, and policy transmittals, with one notable exception.  
Although Federal regulations require the Unit to employ a Chief Investigator to supervise 
and direct investigative activities, no one held this position prior to February 2016.  With 
respect to adherence to the Performance Standards, we found that the Unit does not 
document periodic supervisory reviews in its case files.  We also found that the Unit 
maintained proper fiscal control of its resources.  Last, we observed that legal barriers 
limit the Units ability to refer cases for civil recovery and pursue patient abuse cases.  
 
WHAT WE RECOMMEND  
We recommend that the Pennsylvania Unit implement policies and procedures to ensure 
it documents periodic supervisory reviews and explains investigative delays in the case 
files.  The Unit concurred with our recommendation. 
   
   
   
 
TABLE OF CONTENTS 
Objective ......................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................5 
For FYs 2012 through 2014, the Pennsylvania Unit reported 
130 criminal convictions, 37 civil judgments and settlements, 
and combined criminal and civil recoveries of $80 million ............5 
Prior to February 2016, the Unit lacked a Chief Investigator to 
supervise and direct investigative activities .....................................6 
The Unit does not document periodic supervisory reviews in its 
case files ...........................................................................................6 
The Unit maintained proper fiscal control of its resources ..............7 
Other observation:  Legal barriers limit the Units ability to refer 
cases for civil recovery and pursue patient abuse cases ..................7 
Conclusion and Recommendation .............................................................10 
Unit Comments and Office of Inspector General Response .......... 11 
Appendixes ................................................................................................12 
A:  2012 Performance Standards ...................................................12 
B:  Pennsylvania State Medicaid Fraud Control Unit Referrals by 
Referral Source for FYs 2012 Through 2014 ................................16 
C:  Investigations Opened and Closed By Provider Category 
for FYs 2012 Through 2014 ..........................................................17 
D:  Detailed Methodology .............................................................19 
E:  Unit Comments.........................................................................22 
Acknowledgments......................................................................................26 
 
   
OBJECTIVE 
To conduct an onsite review of the Pennsylvania State Medicaid Fraud 
Control Unit (MFCU or Unit). 
BACKGROUND  
The mission of MFCUs is to investigate and prosecute Medicaid provider 
fraud and patient abuse or neglect under State law.1  The SSA requires 
each State to operate a MFCU, unless the Secretary of Health and Human 
Services (HHS) determines that (1) operation of a Unit would not be 
cost-effective because minimal Medicaid fraud exists in a particular State 
and (2) 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 MFCUs.3 
Each Unit must employ an interdisciplinary staff that consists of at least an 
investigator, an auditor, and an attorney.4  Unit staff review referrals of 
potential fraud and patient abuse or neglect to determine their potential for 
criminal prosecution and/or civil action.  In fiscal year (FY) 2015, the 
50 Units collectively reported 1,553 convictions, 795 civil settlements or 
judgments, and approximately $745 million in recoveries.5, 6 
Units must meet a number of requirements established by the SSA and 
Federal regulations.  For example, each Unit must: 
  be a single, identifiable entity of State government, distinct from 
the single State Medicaid agency;7   
  develop a formal agreement, such as a memorandum of 
understanding (MOU), which describes the Units relationship 
with the State Medicaid agency;8 and   
______________________________________________________ 
1 Social Security Act (SSA)  1903(q).  Regulations at 42 CFR  1007.11(b)(1) add that 
the Units responsibilities may include reviewing complaints of misappropriation of 
patients private funds in residential health care facilities. 
2 SSA  1902(a)(61).   
3 North Dakota and the territories of American Samoa, Guam, the Northern Mariana 
Islands, Puerto Rico, and the U.S. Virgin Islands have not established Units. 
4 SSA  1903(q)(6); 42 CFR 1007.13. 
5 Office of Inspector General (OIG), MFCU Statistical Data for Fiscal Year 2015.   
Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on February 16, 2016. 
6  All FY references in this report are based on the Federal FY (October 1 through     
September 30). 
7 SSA  1903(q)(2); 42 CFR  1007.5 and 1007.9(a). 
8 42 CFR  1007.9(d).  
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)  1 
   
   
  have either statewide authority to prosecute cases or formal 
procedures to refer suspected criminal violations to an agency with 
such authority.9   
MFCU Funding 
Each MFCU is funded jointly by its State and the Federal government.  
Federal funding for the MFCUs is provided as part of the Federal 
Medicaid appropriation, but it is administered by OIG.10  Each Unit 
receives Federal financial participation equivalent to 75 percent of its total 
expenditures, with State funds contributing the remaining 25 percent.11  In 
FY 2015, combined Federal and State expenditures for the Units totaled 
approximately $251 million, $188 million of which represented Federal 
funds.12   
Oversight of the MFCU Program 
The Secretary of HHS delegated to OIG the authority to administer the 
MFCU grant program.13  To receive Federal reimbursement, each Unit must 
submit an initial application to OIG for approval and be recertified each year 
thereafter. 
In annually recertifying the Units, OIG evaluates Unit compliance with 
Federal requirements and adherence to performance standards.  The Federal 
requirements for Units are contained in the SSA, regulations, and policy 
guidance.14  In addition, OIG has published 12 performance standards that it 
uses to assess whether a Unit is effectively performing its responsibilities.15  
The standards address topics such as staffing, maintaining adequate referrals, 
and cooperation with Federal authorities.  Appendix A contains the 
Performance Standards.  
OIG also performs periodic onsite reviews of the Units, such as this review 
of the Pennsylvania MFCU.  During these onsite reviews, OIG evaluates 
Units compliance with laws, regulations, and policies, as well as adherence 
______________________________________________________ 
9 SSA  1903(q)(1). 
10 SSA  1903(a)(6)(B). 
11 Ibid. 
12 OIG, MFCU Statistical Data for Fiscal Year 2015.  Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on February 16, 2016. 
13 The SSA authorizes the Secretary of HHS to award grants to the Units; the Secretary 
delegated this authority to the OIG.   
14 On occasion, OIG issues policy transmittals to provide guidance and instructions to 
MFCUs.   
15 59 Fed. Reg. 49080 (Sept. 26, 1994).  Accessed at http://oig.hhs.gov/fraud/medicaid-
fraud-control-units-mfcu/files/Performance%20Standards.pdf on January 5, 2016.  On 
June 1, 2012, OIG published a revision of the performance standards at  
77 Fed. Reg. 32645.  Because our review covered FYs 2012 through 2014, we applied 
the standards published on June 1, 2012. 
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to the 12 performance standards.  OIG also makes observations about best 
practices, provides recommendations to the Units, and monitors the 
implementation of the recommendations.  These evaluations differ from 
other OIG evaluations as they support OIGs direct administration of the 
MFCU grant program.  These evaluations are subject to the same internal 
quality controls as other OIG evaluations, including internal peer review. 
Additional oversight includes the collection and dissemination of data about 
MFCU operations and the provision of training and technical assistance. 
Pennsylvania Medicaid Program 
Pennsylvanias Medicaid program provides services to Medicaid enrollees 
through managed care and fee-for-service delivery systems.16, 17  As of July 
2011, over 80 percent of Medicaid beneficiaries in Pennsylvania were 
enrolled in managed care.18  As of August 2014, the State Medicaid agency 
contracted with 15 MCOs and paid them a fixed amount for each 
Medicaid enrollee.19  In FY 2015, combined Federal and State 
expenditures for Pennsylvanias Medicaid program were approximately 
$24 billion.20 
Pennsylvania MFCU 
The Pennsylvania Unit is headquartered within the criminal law division of 
the Pennsylvania Office of the Attorney General in Harrisburg, 
Pennsylvania.  The Unit also operates three regional offices which are 
located in Lemoyne, Norristown, and North Huntingdon. 
At the time of our review, the Unit employed 45 staff members including the 
director, the Chief Auditor, 5 supervisory agents, 22 agents, 7 attorneys, 
1 auditor, 2 analysts, and 6 support staff members. 
Referrals.  The Unit receives referrals from a variety of sources, including 
the State Medicaid agency, health care providers, local law enforcement, and 
______________________________________________________ 
16 Medicaid managed care is a type of health care delivery system that provides Medicaid 
health benefits and services to enrollees through contracted arrangements between State 
Medicaid agencies and managed care organizations (MCOs).  MCOs receive a set 
payment per member per month from the State Medicaid agency for these services.  
Fee-for-service is a type of health care delivery system in which health care providers are 
paid for each service provided to Medicaid enrollees. 
17 Pennsylvania Department of Human Services, Office of Medical Assistance Programs, 
September 2015. 
18 Centers for Medicare & Medicaid Services (CMS), Managed Care in Pennsylvania.  
Accessed at https://www.medicaid.gov/medicaid-chip-program-information/by-
topics/delivery-systems/managed-care/downloads/pennsylvania-mcp.pdf on 
October 29, 2015. 
19 Ibid. 
20 OIG, MFCU Statistical Data for Fiscal Year 2015.  Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2015-statistical-chart.htm on February 16, 2016. 
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OIG.  Appendix B depicts Unit referrals by referral source for 
FYs 2012 through 2014.  All referrals are reviewed in the regional office in 
which the referral originates.  An agent or analyst reviews referrals and is 
responsible for making a recommendation as to whether to open a case.  
Generally, a supervisory special agent and attorney review the 
recommendation before it is submitted to the director for approval.  The 
director ultimately decides whether to open a case.  
Investigations and prosecutions.  When a case is opened, it is assigned to 
an agent and attorney for investigation and, as appropriate, prosecution.  If 
warranted, an auditor also may be assigned to the case.  The Unit has 
statewide authority to pursue criminal cases of Medicaid fraud and patient 
neglect.  The Unit does not have authority to pursue civil monetary 
penalties nor does the State have a False Claims Act.  The State Medicaid 
agencys Bureau of Program Integrity does have authority to pursue civil 
monetary penalties.  Appendix C depicts investigations opened and closed 
during the review period. 
Previous OIG Onsite Review 
In 2009, OIG issued a report regarding its onsite review of the 
Pennsylvania Unit.  OIG did not note any instances of noncompliance with 
the applicable Federal regulations or with the 12 MFCU performance 
standards. 
METHODOLOGY 
We conducted an onsite review in November 2015.  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 for FYs 2012 
through 2014; (3) structured interviews with key stakeholders; (4) a survey 
of Unit staff; (5) structured interviews with the Units management; (6) an 
onsite review of files for cases that were open in FYs 2012 through 2014; 
and (7) onsite observation of Unit operations.  Appendix D provides 
details of our methodology.   
Standards 
These reviews are conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
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FINDINGS 
We found that the Pennsylvania Unit was generally in compliance with 
applicable laws, regulations, and policy transmittals, with one notable 
exception.  Specifically, the Unit did not employ a Chief Investigator to 
supervise and direct investigative activities prior to February 2016, 
contrary to Federal regulations.  With respect to adherence to the 
Performance Standards, we found that the Unit did not document periodic 
supervisory reviews in its case files.  We also found that the Unit 
maintained proper fiscal control of its resources.  Last, we observed that 
legal barriers limit the Units ability to refer cases for civil recovery and 
pursue patient abuse cases. 
For FYs 2012 through 2014, the Pennsylvania Unit 
reported 130 criminal convictions, 37 civil judgments 
and settlements, and combined criminal and civil 
recoveries of $80 million 
For FYs 2012 through 2014, the Unit reported 130 criminal convictions 
and 37 civil judgments and settlements.  See Table 1 for yearly 
convictions and civil judgments and settlements.  Of the Units 
130 convictions over the 3-year period, 126 involved provider fraud and 
4 involved patient neglect. 
Table 1:  Pennsylvania MFCU Criminal Convictions and Civil 
Judgments and Settlements, FYs 20122014 
3-Year 
Outcomes  FY 2012  FY 2013  FY 2014  Total 
Criminal Convictions  30  54  46  130 
Civil Judgments and Settlements  12  13  12  37 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
For the same period, the Unit reported combined criminal and civil 
recoveries of approximately $80 million, with average yearly recoveries of 
approximately $27 million.  See Table 2 for the Units yearly recoveries 
and expenditures.  Because the Unit does not have State authority to 
pursue civil Medicaid fraud cases, its reported civil recoveries were 
obtained from global cases.21  The Unit obtained 93 percent of its 
recoveries from global cases during the 3-year review period. 
   
______________________________________________________ 
21 Global cases are civil false claims actions involving the U.S. Department of Justice and 
other State MFCUs.  The National Association of Medicaid Fraud Control Units 
facilitates the settlement of global cases. 
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Table 2:  Pennsylvania MFCU Recoveries and Expenditures, 
FYs 20122014* 
Type of Recovery  FY 2012  FY 2013  FY 2014  3-Year Total 
Global Civil  $41,792,261  $28,062,504  $4,352,940  $74,207,705 
Nonglobal Civil  $0  $0  $0  $0 
Criminal  $1,462,832  $2,666,616  $1,354,491  $5,483,939 
     Total Recoveries  $43,255,094  $30,729,120  $5,707,431  $79,691,645 
     Total Expenditures  $4,442,013  $4,724,526  $5,270,842  $14,437,382 
Source:  OIG analysis of Unit-submitted documentation, 2016. 
* Due to rounding, dollar figures for each category of recoveries do not always sum to the total recovery amount. 
Prior to February 2016, the Unit lacked a Chief 
Investigator to supervise and direct investigative 
activities 
Prior to February 2016, the Unit did not employ a Chief Investigator to 
supervise and direct investigative activities.  Rather, the Units five 
supervisory agents reported to a Special Agent in Charge (SAC) who was 
not employed by the Unit.22  The SAC headed the Bureau of Criminal 
Investigations within the Attorney Generals office, and is responsible for 
overseeing the investigative activities in six divisions, including the Unit.  
Federal regulations require a Unit to employ sufficient professional, 
administrative, and support staff to carry out its duties.  The required staff 
must include a senior investigator with substantial experience in 
commercial or financial investigations who is capable of supervising and 
directing the investigative activities of the [U]nit.23  In February 2016, the 
Unit promoted one of its supervisory agents to the Chief Investigator 
position.   
The Unit does not document periodic supervisory 
reviews in its case files 
For FYs 2012 through 2014, the Unit reported that its policy and practice 
was to conduct supervisory reviews on a monthly basis; however, its 
policy did not require these reviews to be documented in the case files.  
Unit staff said that supervisory reviews occurred monthly, but that the 
reviews were not documented in the case files.  As a result, none of the 
Units case files included documentation of supervisory reviews.  
Performance Standard 7(a) states that supervisory reviews should be 
conducted periodically and noted in the case file.  Periodic supervisory 
______________________________________________________ 
22 The SACs salary is not paid by the MFCU grant nor is the position included on the 
Units organizational chart. 
23 42 CFR  1007.13(a)(3). 
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reviews can help to ensure timely completion of cases and may identify 
potential issues during the investigation. 
Three reviewed cases had investigative delays of 6 months or more.  None 
of these cases included documentation in the case file explaining the 
delays.24  Moreover, none of these three case files included documentation 
of supervisory reviews.  Such documentation might have explained the 
investigative delays and helped supervisors monitor the progress of the 
investigation. 
The Unit maintained proper fiscal control of its 
resources  
The Unit maintained proper fiscal control of its resources during the 
review period, in accordance with Performance Standard 11.  The Units 
financial documentation indicated that the Units requests for 
reimbursement for FYs 2013 through 2015 represented allowable, 
allocable, and reasonable costs.  In addition, the Unit maintained adequate 
internal controls related to accounting, budgeting, personnel, procurement, 
property, and equipment. 
Other observation:  Legal barriers limit the Units 
ability to refer cases for civil recovery and pursue 
patient abuse cases 
Pennsylvania law limits the Units ability to refer and pursue some cases.  
Specifically, the Unit cannot share criminal investigative information with 
the State Medicaid agency, which may affect referrals for civil recoveries.  
Further, the Unit does not have authority to pursue patient abuse cases. 
The Unit cannot share investigative information with 
noncriminal justice agencies, which may affect civil recoveries 
The Unit cannot share criminal investigative information with the State 
Medicaid agency, which may affect the States civil recoveries.25  The 
States civil actions often rely on information originally gathered to 
support a potential criminal investigation.  For example, the State 
Medicaid agency refers a case to the Unit for criminal investigation.  
During its investigation, the Unit determines that the case cannot be 
______________________________________________________ 
24 Performance Standard 5(c) states that investigation and prosecution delays should be 
limited to situations imposed by resource constraints or other exigencies.  In addition, 
Performance Standard 7(b) states that case files should contain all relevant facts and 
information. 
25 Pursuant to 18 Pa. C.S.A.  9106(c)(4) (1979), the Unit cannot share criminal 
investigative information with noncriminal justice agencies (e.g., State Medicaid agency).  
Criminal investigative information is information collected during an inquiry into an 
allegation of criminal wrongdoing. 
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prosecuted criminally; however, the case does have potential for civil 
recovery.  In another State, the Unit would likely refer the case back to the 
State Medicaid agency to pursue civilly.  However, because Pennsylvania 
law prohibits the Unit from sharing information gathered during its 
criminal investigation with the State Medicaid agency, the case is not 
referred and potential civil recoveries are not obtained.  Further, unlike 
many other MFCUs, the Unit does not have authority to pursue civil fraud 
recoveries.26  Therefore, it cannot pursue these matters civilly within the 
Unit. 
The Unit is seeking legislative changes that would allow it to share 
information with the State Medicaid agency.  Specifically, the Unit 
director said that the Unit has provided support for the enactment of a 
false claims statute in Pennsylvania.  According to the Unit director, a 
false claims statute would allow sharing of information discovered during 
an investigation with the State Medicaid agency or other agency that could 
pursue false claims actions. 
The Unit does not have authority to pursue patient abuse 
cases 
Under Pennsylvania law, the Unit may investigate and prosecute patient 
neglect cases, but it does not have the authority to investigate or prosecute 
patient abuse cases.  According to Federal regulations, Units are required 
to review complaints of patient abuse or neglect that occur in health care 
facilities funded by the State Medicaid program.27  If the initial review of 
such a complaint indicates substantial potential for criminal prosecution, 
the Unit may investigate the complaint or refer it to an appropriate 
criminal investigative or prosecutorial authority.28  Pennsylvanias 
Neglect of Care-Dependent Persons Act gives the Unit authority to 
investigate cases related to neglect of a care-dependent person if 
physical bodily injury has occurred.29  The Unit director said that this is 
the sole statute authorizing the Unit to prosecute patient neglect cases, and 
______________________________________________________ 
26 Pursuant to 62 P.S.  1407(b)(4), the Unit has authority to pursue criminal Medicaid 
fraud cases.  Pursuant to 62 P.S.  1407(c)(1), the Pennsylvania State Medicaid agency 
has the authority to pursue civil fraud recoveries. 
27 42 CFR  1007.11(b)(1). 
28 42 CFR  1007.11(b)(2). 
29 18 Pa. C.S.A.  2713.  This statute generally defines neglect as causing bodily injury 
by failing to provide treatment, care, goods, or services necessary for the well-being of a 
care-dependent person for whom an individual is responsible to provide care. 
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it does not authorize the Unit to pursue cases of abuse.30  However, there 
are other entities in the State that are specifically authorized to investigate 
and prosecute patient abuse caseslocal law enforcement is responsible 
for investigating these cases and local District Attorneys are responsible 
for prosecuting them.  Therefore, the Unit may refer patient abuse cases to 
these entities for investigation and prosecution. 
   
______________________________________________________ 
30 The Pennsylvania Attorney General has authority to prosecute criminal cases set forth 
in 71 P.S.  732-205.  According to the Unit, the Pennsylvania courts have concluded that 
the Attorney General does not possess any inherent additional powers not contained in 
the above statute with the exception of a certain specialty statute.  This specialty statute, 
18 Pa.C.S.A.  2713, gives the Unit the authority to prosecute neglect cases.  As such, the 
Unit has authority to pursue neglect cases but not abuse cases. 
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CONCLUSION AND RECOMMENDATION 
For FYs 2012 through 2014, the Pennsylvania Unit reported 130 criminal 
convictions, 37 civil judgments and settlements, and combined criminal 
and civil recoveries of $80 million. 
We found that the Pennsylvania Unit was generally in compliance with 
applicable laws, regulations, and policy transmittals, with one notable 
exception.  Specifically, prior to February 2016 the Unit did not employ a 
Chief Investigator to supervise and direct investigative activities.  With 
respect to the Performance Standards, we found that the Unit did not 
adhere to the performance standard stating that periodic supervisory 
reviews be documented in its case files.  We also found that the Unit 
maintained proper fiscal control of its resources. 
We observed that legal barriers limit the Units ability to refer cases for 
civil recovery and pursue patient abuse cases.  The Unit is seeking 
legislative changes that would expand its authorities.  OIG encourages and 
supports the Units efforts to expand its authorities to the full extent 
envisioned under the MFCU grant program. 
We recommend that the Pennsylvania Unit: 
Implement policies and procedures to ensure it documents 
periodic supervisory reviews and explains investigative delays 
in the case files 
The Unit should revise its policies and procedures manual to require that 
periodic supervisory reviews be documented in case files, consistent with 
Performance Standard 7(a).  Further, the Unit should implement policies 
and procedures to ensure that explanations of investigative delays are 
included in case files.  Documented supervisory reviews could be one 
mechanism for including explanations of investigative delays. 
   
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UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
The Pennsylvania Unit concurred with our recommendation.  The Unit 
stated that it has created and implemented a policy and procedure for 
documenting the Units quarterly supervisory reviews.   
In addition to its comments on the recommendation, the Unit provided 
comments regarding one of our findings and our other observation.  
Regarding the finding that the Unit lacked a Chief Investigator prior to 
February 2016, the Unit stated that it had updated its policies and 
procedures manual to indicate that the Chief Investigator position is 
required by 42 CFR 1007.13.  The Unit stated that it agreed with OIGs 
observations and reiterated that expanding its authority would require 
legislative action by the Pennsylvania State legislature.  The Units 
comments provided further details regarding its legislative proposal to 
expand the Units authorities to the full extent envisioned under the 
MFCU grant program. 
The full text of the Units comments is provided in Appendix E. 
   
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APPENDIX A 
2012 Performance Standards31  
1.  A UNIT CONFORMS WITH ALL APPLICABLE STATUTES, REGULATIONS, AND POLICY DIRECTIVES, 
INCLUDING: 
A.  Section 1903(q) of the Social Security Act,  containing the basic requirements for operation of a MFCU; 
B.  Regulations for operation of a MFCU contained in 42 CFR part 1007; 
C.  Grant administration requirements at 45 CFR part 92 and Federal cost principles at 2 CFR part 225; 
D.  OIG policy transmittals as maintained on the OIG Web site; and  
E.  Terms and conditions of the notice of the grant award. 
2.  A UNIT MAINTAINS REASONABLE STAFF LEVELS AND OFFICE LOCATIONS IN RELATION TO THE 
STATES MEDICAID PROGRAM EXPENDITURES AND IN ACCORDANCE WITH STAFFING 
ALLOCATIONS APPROVED IN ITS BUDGET.   
A.  The Unit employs the number of staff that is included in the Units budget estimate as approved by OIG. 
B.  The Unit employs a total number of professional staff that is commensurate with the States total Medicaid 
program expenditures and that enables the Unit to effectively investigate and prosecute (or refer for 
prosecution) an appropriate volume of case referrals and workload for both Medicaid fraud and patient abuse 
and neglect. 
C.  The Unit employs an appropriate mix and number of attorneys, auditors, investigators, and other 
professional staff that is both commensurate with the States total Medicaid program expenditures and that 
allows the Unit to effectively investigate and prosecute (or refer for prosecution) an appropriate volume of case 
referrals and workload for both Medicaid fraud and patient abuse and neglect. 
D.  The Unit employs a number of support staff in relation to its overall size that allows the Unit to operate 
effectively. 
E.  To the extent that a Unit maintains multiple office locations, such locations are distributed throughout the 
State, and are adequately staffed, commensurate with the volume of case referrals and workload for each 
location. 
3.  A UNIT ESTABLISHES WRITTEN POLICIES AND PROCEDURES FOR ITS OPERATIONS AND 
ENSURES THAT STAFF ARE FAMILIAR WITH, AND ADHERE TO, POLICIES AND PROCEDURES.   
A.  The Unit has written guidelines or manuals that contain current policies and procedures, consistent with 
these performance standards, for the investigation and (for those Units with prosecutorial authority) prosecution 
of Medicaid fraud and patient abuse and neglect.  
B.  The Unit adheres to current policies and procedures in its operations. 
C.  Procedures include a process for referring cases, when appropriate, to Federal and State agencies.  
Referrals to State agencies, including the State Medicaid agency, should identify whether further investigation 
or other administrative action is warranted, such as the collection of overpayments or suspension of payments. 
D.  Written guidelines and manuals are readily available to all Unit staff, either online or in hard copy. 
E.  Policies and procedures address training standards for Unit employees. 
4.  A UNIT TAKES STEPS TO MAINTAIN AN ADEQUATE VOLUME AND QUALITY OF REFERRALS FROM 
THE STATE MEDICAID AGENCY AND OTHER SOURCES.   
A.  The Unit takes steps, such as the development of operational protocols, to ensure that the State Medicaid 
agency, managed care organizations, and other agencies refer to the Unit all suspected provider fraud cases.  
Consistent with 42 CFR 1007.9(g), the Unit provides timely written notice to the State Medicaid agency when 
referred cases are accepted or declined for investigation. 
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. 
______________________________________________________ 
31 77 Fed. Reg. 32646, June 1, 2012. 
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C.  The Unit provides timely information to the State Medicaid or other agency when the Medicaid or other 
agency requests information on the status of MFCU investigations, including when the Medicaid agency 
requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii). 
D.  For those States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and 
neglect cases, the Unit takes steps, such as the development of operational protocols, to ensure that pertinent 
agencies refer such cases to the Unit, consistent with patient confidentiality and consent.  Pertinent agencies 
vary by State but may include licensing and certification agencies, the State Long Term Care Ombudsman, and 
adult protective services offices.  
E.  The Unit provides timely information, when requested, to those agencies identified in (D) above regarding 
the status of referrals. 
F.  The Unit takes steps, through public outreach or other means, to encourage the public to refer cases to the 
Unit. 
5.  A UNIT TAKES STEPS TO MAINTAIN A CONTINUOUS CASE FLOW AND TO COMPLETE CASES IN 
AN APPROPRIATE TIMEFRAME BASED ON THE COMPLEXITY OF THE CASES. 
A.  Each stage of an investigation and prosecution is completed in an appropriate timeframe. 
B.  Supervisors approve the opening and closing of all investigations and review the progress of cases and take 
action as necessary to ensure that each stage of an investigation and prosecution is completed in an 
appropriate timeframe. 
C.  Delays to investigations and prosecutions are limited to situations imposed by resource constraints or other 
exigencies.   
6.  A UNITS CASE MIX, AS PRACTICABLE, COVERS ALL SIGNIFICANT PROVIDER TYPES AND 
INCLUDES A BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.   
A.  The Unit seeks to have a mix of cases from all significant provider types in the State. 
B.  For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
D.  As part of its case mix, the Unit maintains a balance of fraud and patient abuse and neglect cases for those 
States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and neglect cases. 
C.  The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors.  Special Unit initiatives may focus on specific provider types. 
E.  As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7.  A UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER AND DEVELOPS A CASE 
MANAGEMENT SYSTEM THAT ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.   
A.  Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B.  Case files include all relevant facts and information and justify the opening and closing of the cases. 
C.  Significant documents, such as charging documents and settlement agreements, are included in the file.  
D.  Interview summaries are written promptly, as defined by the Units policies and procedures. 
E.  The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
F.  The Unit has an information management system that allows for the monitoring and reporting of case 
information, including the following:  
1.  The number of cases opened and closed and the reason that cases are closed. 
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 
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4.  The number of referrals received by the Unit and the number of referrals by the Unit to other agencies. 
5.  The number of cases criminally prosecuted by the Unit or referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending prosecutions. 
6.  The number of criminal convictions and the number of civil judgments. 
7.  The dollar amount of overpayments identified. 
8.  The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil judgments or prefiling settlements. 
8.  A UNIT COOPERATES WITH OIG AND OTHER FEDERAL AGENCIES IN THE INVESTIGATION AND 
PROSECUTION OF MEDICAID AND OTHER HEALTH CARE FRAUD.   
A.  The Unit communicates on a regular basis with OIG and other Federal agencies investigating or prosecuting 
health care fraud in the State. 
B.  The Unit cooperates and, as appropriate, coordinates with OIGs Office of Investigations and other Federal 
agencies on cases being pursued jointly, cases involving the same suspects or allegations, and cases that have 
been referred to the Unit by OIG or another Federal agency.  
C.  The Unit makes available, to the extent authorized by law and upon request by Federal investigators and 
prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the 
Medicaid program. 
D.  For cases that require the granting of extended jurisdiction to investigate Medicare or other Federal health 
care fraud, the Unit seeks permission from OIG or other relevant agencies under procedures as set by those 
agencies.  
E.  For cases that have civil fraud potential, the Unit investigates and prosecutes such cases under State 
authority or refers such cases to OIG or the U.S. Department of Justice. 
F.  The Unit transmits to OIG, for purposes of program exclusions under section 1128 of the Social Security Act, 
all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
G.  The Unit reports qualifying cases to the Healthcare Integrity & Protection Databank, the National Practitioner 
Data Bank, or successor data bases. 
9.  A UNIT MAKES STATUTORY OR PROGRAMMATIC RECOMMENDATIONS, WHEN WARRANTED, TO 
THE STATE GOVERNMENT.   
A.  The Unit, when warranted and appropriate, makes statutory recommendations to the State legislature to 
improve the operation of the Unit, including amendments to the enforcement provisions of the State code. 
B.  The Unit, when warranted and appropriate, makes other regulatory or administrative recommendations 
regarding program integrity issues to the State Medicaid agency and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State legislature and the State Medicaid or other 
agencies in response to recommendations.  
10.  A UNIT PERIODICALLY REVIEWS ITS MEMORANDUM OF UNDERSTANDING (MOU) WITH THE 
STATE MEDICAID AGENCY TO ENSURE THAT IT REFLECTS CURRENT PRACTICE, POLICY, AND 
LEGAL REQUIREMENTS.   
A.  The MFCU documents that it has reviewed the MOU at least every 5 years, and has renegotiated the MOU 
as necessary, to ensure that it reflects current practice, policy, and legal requirements. 
B.  The MOU meets current Federal legal requirements as contained in law or regulation, including 42 CFR  
455.21, Cooperation with State Medicaid fraud control units, and 42 CFR  455.23, Suspension of payments 
in cases of fraud. 
C.  The MOU is consistent with current Federal and State policy, including any policies issued by OIG or the 
Centers for Medicare & Medicaid Services (CMS). 
D.  Consistent with Performance Standard 4, the MOU establishes a process to ensure the receipt of an 
adequate volume and quality of referrals to the Unit from the State Medicaid agency. 
E.  The MOU incorporates by reference the CMS Performance Standard for Referrals of Suspected Fraud from 
a State Agency to a Medicaid Fraud Control Unit. 
11.  A UNIT EXERCISES PROPER FISCAL CONTROL OVER UNIT RESOURCES.   
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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.  
   
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   15 
     
   
APPENDIX B 
Pennsylvania State Medicaid Fraud Control Unit Referrals by 
Referral Source for FYs 2012 Through 2014 
  FY 2012  FY 2013  FY 2014 
Abuse &  Patient  Abuse &  Patient  Abuse &  Patient 
Referral Source  Fraud  Fraud  Fraud 
Neglect  Funds  Neglect  Funds  Neglect  Funds 
Medicaid agency   
PI/SURS32  93  1  1  131  0  0  133  1  0 
Medicaid agency  
3  3  0  3  2  0  0  4  0 
other 
Managed care 
17  0  0  22  0  0  21  0  0 
organizations 
State survey and 
1  0  0  0  0  0  0  0  0 
certification agency 
Other State 
2  1  0  5  7  0  1  5  0 
agencies 
Licensing board  0  0  0  0  0  0  0  0  0 
Law enforcement  3  0  0  14  3  0  7  1  0 
Office of Inspector 
1  1  0  3  1  0  1  1  0 
General 
Prosecutors  0  0  0  0  0  0  0  0  0 
Providers  23  0  0  26  0  0  10  0  0 
Provider 
0  0  0  0  0  0  0  0  0 
associations 
Private health 
0  0  0  0  0  0  0  0  0 
insurer 
Long-term-care 
0  0  0  0  0  0  0  0  0 
ombudsman 
Adult protective 
0  0  0  0  0  0  0  0  0 
services 
Private citizens  8  2  1  7  2  0  9  3  1 
MFCU hotline  0  0  0  0  0  0  0  0  0 
Self-generated  0  0  0  0  0  0  0  0  0 
Other  19  0  0  28  0  0  27  1  0 
   Total  170  8  2  239  15  0  209  16  1 
   Annual Total  180  254  226 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
______________________________________________________ 
32 The abbreviation PI stands for program integrity; the abbreviation SURS stands for 
Surveillance and Utilization Review Subsystem. 
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APPENDIX C 
Investigations Opened and Closed By Provider Category for 
FYs 2012 Through 2014 
Table C-1:  Fraud Investigations  
Provider Category  FY 2012  FY 2013  FY 2014 
Facilities  Opened  Closed  Opened  Closed  Opened  Closed 
     Hospitals  1  0  0  0  0  0 
     Nursing facilities  4  8  6  7  5  5 
     Other long-term-care  
0  0  0  0  2  1 
     Facilities 
     Substance abuse treatment            
0  1  1  0  0  0 
     centers  
     Other   2  2  1  1  6  2 
   Subtotal  7  11  8  8  13  8 
Practitioners  Opened  Closed  Opened  Closed  Opened  Closed 
     Doctors of medicine or  
6  5  11  6  14  11 
     osteopathy 
     Dentists  2  5  4  5  3  6 
     Podiatrists  0  0  1  1  0  0 
     Optometrists/opticians  1  0  0  1  2  1 
     Counselors/psychologists  30  19  37  40  34  34 
     Chiropractors  0  0  0  0  0  0 
     Other   1  1  3  1  2  3 
   Subtotal  40  30  56  54  55  55 
Medical Support  Opened  Closed  Opened  Closed  Opened  Closed 
     Pharmacies  2  1  3  2  2  3 
     Pharmaceutical  
16  15  21  11  22  19 
     Manufacturers 
     Suppliers of durable medical 
1  0  1  1  0  0 
     equipment and/or supplies 
     Laboratories  0  0  0  0  1  0 
     Transportation services  2  3  0  2  0  0 
     Home health care agencies  4  2  5  2  8  4 
     Home health care aides  95  60  140  128  108  138 
     Nurses, physician assistants,  
     nurse practitioners, certified   0  0  0  0  0  0 
     nurse aides 
     Radiologists  0  0  0  0  0  0 
     Medical supportother   3  3  4  1  0  4 
   Subtotal  123  84  174  147  141  168 
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Table C-1 (Continued):  Fraud Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
Program Related  Opened  Closed  Opened  Closed  Opened  Closed 
     Managed care organizations  0  0  0  0  0  0 
     Medicaid program  
0  0  0  0  0  0 
     administration 
     Billing company  0  0     0  0  0 
     Other  0  0  0  0  0  0 
   Subtotal  0  0  0  0  0  0 
   Total Provider Categories  170  125  238  209  209  231 
Source:  OIG analysis of Unit-submitted documentation, 2015. 
 
Table C-2:  Patient Abuse and Neglect Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nursing facilities  3  1  6  6  6  6 
     Other long-term-care facilities  5  4  9  8  10  11 
Nurses, physician assistants, 
nurse practitioners, certified  0  0  0  0  0  0 
nurse aides 
     Home health aides  0  0  0  0  0  0 
     Other  0  0  0  0  0  0 
   Total  8  5  15  14  16  17 
Source: OIG analysis of Unit-submitted documentation, 2015. 
 
Table C-3:  Patient Funds Investigations 
Provider Category  FY 2012  FY 2013  FY 2014 
  Opened  Closed  Opened  Closed  Opened  Closed 
     Nondirect care  2  1  1  0  1  2 
Nurses, physician assistants, 
nurse practitioners, certified  0  0  0  0  0  0 
nurse aides 
     Home health aides  0  0  0  0  0  0 
     Other  0  0  0  0  0  0 
   Total  2  1  1  0  1  2 
Source: OIG analysis of Unit-submitted documentation, 2015. 
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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 Pennsylvania MFCU. 
Data Collection  
Review of Unit Documentation.  We collected information for FYs 2012 
through 2014 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 information from several sources, including the Units 
quarterly statistical reports; its annual reports; its recertification 
questionnaire; its policies and procedures manual; and its MOU with the 
State Medicaid agency.  We requested any additional data or clarification 
from the Unit as necessary. 
Review of Unit Financial Documentation.  To evaluate internal control of 
fiscal resources, we reviewed policies and procedures related to the Units 
budgeting, accounting systems, cash management, procurement, property, 
and staffing.  We reviewed records in the Payment Management System 
(PMS)33 and revenue accounts to determine the accuracy of the Federal 
Financial Reports (FFRs) for FYs 2012 through 2014.  We also obtained 
the Units claimed grant expenditures from its FFRs and the supporting 
schedules.  From the supporting schedules, we requested and reviewed 
supporting documentation for the selected items.  We noted any instances 
of noncompliance with applicable regulations.   
We reviewed three purposive samples to assess the Units internal control 
of fiscal resources.  All three samples were limited to the review period of 
FYs 2012 through FY 2014.  The three samples included the following: 
1.  To assess the Units expenditures, we selected a purposive sample 
of 124 non-payroll transactions and manual accounting 
adjustments.  We selected routine and nonroutine transactions 
representing a variety of budget categories and payment amounts. 
______________________________________________________ 
33 The PMS is a grant payment system operated and maintained by the Department of 
Health and Human Services, Program Support Center, Division of Payment Management.  
The PMS provides disbursement, grant monitoring, reporting, and case management 
services to awarding agencies and grant recipients, such as MFCUs. 
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2.  To assess the Units inventory, we selected and verified a 
purposive sample of 17 items from the current inventory list of 254 
items.  To ensure a variety in our inventory sample, we included 
items that were portable, high value, or unusual in nature (e.g., a 
pole camera).     
3.  To assess employees time and efforti.e., their work hours 
spent on various MFCU tasks we selected three purposive 
samples of Unit employees who were paid during the review 
period:  for FY 2012, we sampled 23 of 34 Unit employees; for FY 
2013, we sampled 23 of 35 Unit employees; and for FY 2014, we 
sampled 19 of 35 Unit employees.  We then requested and 
reviewed documentation (e.g., time card records) to support the 
time and effort of each employee in the selected pay period. 
Interviews with Key Stakeholders.  In September and October 2015, we 
interviewed key stakeholders, including officials in the United States 
Attorneys Offices, the State Attorney Generals Office, and other State 
agencies that interacted with the Unit (e.g., the Medicaid Program Integrity 
Unit, Bureau of Facility Licensure and Certification, and State Department 
of Aging).  Additionally, we interviewed two managed care health plans that 
interact with the Unit.  We also interviewed supervisors from OIGs Region 
III Office of Investigations 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 opportunities for improvement.  
We used the information collected from these interviews to develop 
subsequent interview questions for Unit management. 
Survey of Unit Staff.  In September 2015, we conducted an online survey 
of all 38 nonmanagerial Unit staff within each professional discipline 
(e.g., 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 October and November 2015.  
We interviewed the Unit director, Chief Auditor, Special Agent in Charge, 
the supervisory agents, and two Senior Deputy Attorneys General.  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. 
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Onsite Review of Case Files.  We requested that the Unit provide us with a 
list of cases that were open at any point during FYs 2012 through 2014.  
The Unit provided a list of 786 cases that were open during this period.  
For each of these 786 cases, the Unit provided data including the current 
status of the case; whether the case was criminal or civil; and the date on 
which the case was opened.  From this list of cases, we excluded 114 cases 
that were categorized as grand jury and 27 cases that had been closed 
prior to the period of our review and thus should not have been included.  
The remaining number of cases was 645. 
From these 645 cases, we selected a simple random sample of 110 cases 
for review.  From the initial sample of 110 case files, we selected a simple 
random sample of 55 files for a more indepth review of selected issues, 
such as the timeliness of investigations and case development. 
Three cases in our sample of 110 were not reviewed.  These cases were 
grand jury cases, and therefore ineligible to be in the sample.  After 
excluding the three ineligible cases, we reviewed the remaining 107 case 
files, of which 105 were for cases that had been open for longer than 30 
days. 
Because there were 3 ineligible cases in the 110 sampled cases, it is 
possible that there could be other ineligible cases in the population.  
Therefore, we estimate that there were 627 total eligible cases in the 
population based on the eligible sample.34  
Onsite Review of Unit Operations.  During our November 2015 onsite 
visit, we reviewed the Units workspace and operations.  Specifically, we 
visited the Unit headquarters in the State capital.  While onsite, 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. 
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.35 
   
______________________________________________________ 
34 The eligible sample size in which we make this estimate is 107.  The 95-percent 
confidence interval for this estimate is 597641. 
35 All relevant regulations, statutes, and policy transmittals are available online at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu. 
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   21 
     
   
APPENDIX E 
Unit Comments 
   
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   22 
     
   
   
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   23 
     
   
   
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   24 
     
   
   
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   25 
     
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Brian T. Whitley, Regional 
Inspector General for Evaluation and Inspections in the Kansas City 
regional office, and Jennifer King, Deputy Regional Inspector General; 
and in consultation with Richard Stern, Director of the Medicaid Fraud 
Policy and Oversight Division. 
Rae Hutchison, of the Kansas City regional office, served as the project 
leader for the study.  Other Office of Evaluation and Inspections staff who 
conducted the review include Michael P. Barrett.  Other Medicaid Fraud 
Policy and Oversight Division staff who participated in the review include 
Susan Burbach.  Office of Investigations staff also participated in the 
review.  Office of Audit Services staff who conducted a financial review 
include Marilyn Carrion, Valerie Johnson, and Michael Jones.  Other 
central office staff who contributed to this review include Kevin Farber, 
Lonie Kim, and Joanne Legomsky. 
Pennsylvania State Medicaid Fraud Control Unit:  2015 Onsite Review (OEI-07-15-00360)                                   26 
     
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS) programs, as  well  as the health  and welfare of individuals served by those programs.  
This statutory mission is carried  out through a nationwide network of audits, investigations,  
and inspections conducted by the following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of fraud and misconduct  related to HHS programs, operations, and individuals.  With  
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and  abuse cases involving HHS programs, including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.