Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
D C
  ISTRICT OF  OLUMBIA 
 
M F C
E DICAID  RAUD  ONTROL 
 
U :  2015 O R
NI  T    NSITE  EVIEW 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
Suzanne Murrin  
Deputy Inspector General  
for Evaluation and Inspections  
 
September 2015 
OEI-07-14-00660   
   
EXECUTIVE SUMMARY:  DISTRICT OF COLUMBIA MEDICAID FRAUD 
CONTROL UNIT:  2015 ONSITE REVIEW 
OEI-07-14-00660 
 
WHY WE DID THIS STUDY 
The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit 
(MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units 
performance in accordance with the requirements of the grant.  As part of this oversight, 
OIG conducts periodic reviews of all Units and prepares public reports based on these 
reviews. The reviews assess the Units performance in accordance with the 12 MFCU 
performance standards its compliance with applicable Federal requirements.  
 
HOW WE DID THIS STUDY  
We conducted an onsite review of the District of Columbia (D.C.) Unit in January 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 for 
fiscal years (FYs) 2012 through 2014; (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 Unit management; (6) an onsite review of a 
sample of files for cases that were open at any time in FYs 2012 through 2014; and (7) an 
onsite observation of Unit operations. 
 
WHAT WE FOUND 
Our review of the D.C. Unit identified several findings that may undermine Unit 
efficiency and effectiveness. We identified delays in case progress that may have been 
explained by Unit management practices that we observed, including a lack of 
documented supervisory reviews intended to ensure cases progress at a reasonable pace 
as well as a lengthy clearance process for documents.  We also found that the Unit did not 
use its case management system to allow efficient access to case information, and that it 
investigated seven cases that were outside of the Units authority.  Until July 2015, the 
Units MOU with D.C.s Medicaid agency was out of date.  Formal communication 
between the Unit and the Medicaid agency was infrequent, and the Unit did not report all 
relevant information to Federal partners within required timeframes.    
 
WHAT WE RECOMMEND   
We recommend that the Unit implement effective management practices that ensure 
cases progress at a reasonable pace, and that supervisory reviews  of Unit case files are 
conducted and documented.  The Unit should use its case management system in a way 
that allows for efficient access to case information, and the Unit should repay Federal 
matching funds spent on the cases that were not eligible for Federal funding.  The Unit 
should communicate regularly with the D.C. Medicaid agency.  Finally, we recommend 
that the Unit report all relevant information to the OIG and the National Practitioner Data 
Bank within the required timeframe.  The Unit concurred with all six recommendations.   
   
   
TABLE OF CONTENTS 
Objective......................................................................................................1 

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

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

Findings........................................................................................................7 

From FY 2012 through FY 2014, the Unit reported 

14 convictions, 33 civil judgments and settlements, and 

recoveries of $15 million .................................................................7 

Unit management practices may explain the delays we found in 

20 percent of cases...........................................................................8 

The Unit did not use its case management system to allow  

efficient access to case information .................................................9 

The Unit investigated seven cases that were not eligible under 

Federal regulations for Federal matching funds ............................10 
 
Until July 2015, the Units MOU with the D.C. Medicaid  

agency was out and did not reflect current Federal legal 

requirements; further formal communication was infrequent .......11 
 
The Unit did not report all sentenced individuals to OIG or 

information to the NPDB within required timeframes  ..................12 

The Unit maintained proper fiscal control of its resources ............13 

Other observation: The Unit did not have a process for 

reporting collections information ...................................................13 

Other observation: Policies and procedures were not widely 

circulated to staff ............................................................................13 

Conclusion and Recommendations ............................................................15 

Unit Comments and Office of Inspector General Response ..........17 

Appendixes ................................................................................................19 

A: 2012 Performance Standards ...................................................19 

B: Unit Referrals by Referral Source for FYs 2012 Through 

2014................................................................................................23 

C: Detailed Methodology..............................................................24 

D: Point Estimates and 95-Percent Confidence Intervals Based 

on Reviews of Case Files...............................................................27 

E: Unit Comments.........................................................................28 

Acknowledgments......................................................................................31
 
   
OBJECTIVE 
To conduct an onsite review of the District of Columbia (D.C.) 
Medicaid Fraud Control Unit (MFCU or Unit). 
BACKGROUND 
The mission of State MFCUs, as established by Federal statute, is to 
investigate and prosecute Medicaid provider fraud and patient abuse 
and neglect under State law.1  Pursuant to Title XIX of the SSA, each 
State must maintain a certified Unit unless the Secretary of Health 
and Human Services determines that operation of a Unit would not 
be cost-effective because minimal Medicaid fraud exists in that State 
and that the State has other adequate safeguards to protect Medicaid 
beneficiaries from abuse and neglect.2  Currently, 49 States and D.C. 
(States) have created such Units.3 In fiscal year (FY) 2014, 
combined Federal and State grant expenditures for the Units totaled 
$235 million.4, 5   That year, the 50 Units employed 1,958 individuals.6    
To carry out its duties and responsibilities in an effective and 
efficient manner, each Unit must employ an interdisciplinary staff 
that consists of at least an investigator, an auditor, and an attorney.7   
Unit staff review complaints provided by the State Medicaid agency 
and other sources and determine their potential for criminal 
prosecution and/or civil action.  In FY 2014, the 50 Units 
collectively obtained 1,318 convictions and 874 civil settlements and 
______________________________________________________ 
1 Social Security Act (SSA)  1903(q).  

2 SSA  1902(a)(61).  Regulations at  42 CFR   1007.11(b)(1) add that the  Units 
 
responsibilities may include reviewing complaints of misappropriation of patients 

private funds in  residential health care facilities. 

3 North Dakota and the territories of  American Samoa, Guam, the Northern 

Mariana Islands, Puerto Rico, and the U.S. Virgin Islands have  not established  
Units. 

4 All FY references in this report are based on the Federal FY (October 1  through 
 
September 30). 
 
5  Office of  Inspector General (OIG),  MFCU  Statistical Data for Fiscal Year 2014. 

Accessed at http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm on May 1,  2015. 

6 Ibid. 

7  SSA  1903(q)(6); 42  CFR 1007.1. 

District of Columbia Medicaid Fraud Control Unit:  2015 Onsite Review  (OEI-07-14-00660)   1 
   
   
judgments.8  That year, the Units reported recoveries of 
approximately $2 billion.9  
Units are required to have either statewide authority to prosecute 
cases or formal procedures to refer suspected criminal violations to 
an agency with such authority.10  In 44 States, the Units are located 
within offices of State Attorneys General; in D.C. and the remaining 
5 States, the Units are located in other State agencies.11, 12 The D.C. 
Unit is located in the D.C. Office of Inspector General.  Generally, 
Units located outside of an Attorney Generals Office must refer 
cases to other offices with prosecutorial authority. 
Each Unit must be a single, identifiable entity of State government, 
distinct from the single State Medicaid agency, and each Unit must 
develop a formal agreement (i.e., a memorandum of understanding 
(MOU)) that describes the Units relationship with that agency.13   
Oversight of the MFCU Program  
The Secretary of Health and Human Services delegated to the Office 
of Inspector General (OIG) the authority both to annually certify the 
Units, and to administer grant awards to reimburse States for a 
percentage of their costs of operating certified Units.14   All Units are 
currently funded by the Federal Government on a 75-percent 
matching basis, with the States contributing the remaining 25 
percent.15   To receive Federal reimbursement, each Unit must submit 
an initial application to OIG.16  OIG reviews the application and 
notifies the Unit if the application is approved and the Unit is 
certified. Approval and certification are for a 1-year period; the Unit 
______________________________________________________ 
8 OIG,  MFCU  Statistical Data  for Fiscal Year 2014. Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm on May 1,  2015. 

9 Ibid. 

10  SSA  1903(q)(1). 
 
11 OIG,  Medicaid Fraud Control Units.  Accessed at http://oig.hhs.gov/fraud/ 

medicaid-fraud-control-units-mfcu/index.asp on February 25, 2015. 

12 Among those States with a Unit, the Unit shares responsibility for protecting the 

integrity of the Medicaid  program with the section of the State Medicaid agency 

that functions  as the program integrity unit.  Some States also employ an Office of 

Medicaid Inspector  General that conducts and coordinates activities to combat 

fraud, waste, and abuse for the State agency. 

13  SSA  1903(q)(2); 42  CFR  1007.9(d). 
  
14 The portion of funds reimbursed to States by the Federal  Government for its
  
share of expenditures for the Federal Medicaid program, including the MFCUs, is 

called Federal Financial Participation.  

15  SSA  1903(a)(6)(B). 
  
16 42  CFR  1007.15(a). 
 
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must be recertified each year thereafter.17 In addition to conducting 
annual recertification, OIG performs  periodic onsite reviews of the 
Units.  
Pursuant to Title XIX of the SSA, States must operate Units that 
effectively carry out their statutory functions and meet program 
requirements.18  OIG developed and issued 12 performance standards 
to further define the criteria it applies in assessing whether a Unit is 
effectively carrying out statutory functions and meeting program  
requirements. Examples of standards include maintaining an 
adequate caseload through referrals from various sources, 
maintaining an annual training plan for all professional disciplines, 
and establishing policy and procedure manuals to reflect the Units 
operations.19 See Appendix A for a description of each of the 
12 performance standards. 
D.C. Unit 
The D.C. Unit expended $2,708,824 in combined State and Federal 
funds in FY 2014.20  At the time of our review, the Units 23 employees 
were located in a single office.  The Unit employs 4 attorneys, 
9 investigators, 3 auditors, 2 program analysts, and a staff assistant.  
The Units management is composed of a director, a deputy director, 
and two supervisory investigators. Five months after the completion of 
our onsite review, the Unit director was removed from her position and 
the Unit deputy director was appointed Acting Director.21    
Referrals.   The Unit tracks and reviews referrals as they are received.  
The Unit receives referrals from a variety of sources including, but not 
limited to, the D.C. Medicaid agency (Department of Health Care 
Finance), the D.C. Department on Disability Services, providers, and 
the Units hotline.  A Unit staff member records referrals in the Units  
case management system.  Unit staff, including at least one attorney, 
review referrals to determine whether the allegation is within the Units  
______________________________________________________ 
17 42 CFR   1007.15(b) and  (c). 

18 SSA  1902(a)(61). 

19 The performance standards referred to in this report were published on 
 
June  1, 2012, and were in effect for the majority of our review period.  

77 Fed. Reg. 32645  (June 1,  2012).  Previous performance standards, established 

in 1994, are found at 59 Fed.  Reg.  49080 (Sept. 26, 1994).  Accessed at 

http://www.gpo.gov/fdsys/pkg/FR-1994-09-26/html/94-23692.htm on 

August 29, 2014.  
   
20 OIG, MFCU Statistical Data  for Fiscal Year 2014. Accessed at 
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/expenditures_statistics/fy2014-statistical-chart.htm on May 1,  2015. 
21 All references to Unit director in this report are to the individual who  was the 
Unit director  during our onsite review in January 2015.      
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jurisdiction. Unit referrals by referral source, for FYs 2012 through 
2014, may be found in Appendix B. 
Investigations.   If the Units director or deputy director believes a 
referral falls within the Units jurisdiction, he or she assigns an 
interdisciplinary team to investigate the matter.   The team consists of  
an attorney and an investigator, with an auditor and/or program analyst 
as needed. If this investigation yields sufficient evidence to move 
forward with legal action, Unit attorneys work with attorneys in the 
United States  Attorneys Office (USAO) to pursue criminal 
prosecution. 
Prosecutions. The Unit relied on the USAO for prosecution of its 
criminal cases during the period we reviewed; the USAO serves as 
both the local and the Federal prosecutor for D.C. Although the Unit 
has authority to prosecute misdemeanor criminal fraud cases, the 
Units deputy director reported that it has not exercised that authority 
for any of its cases. All of the Unit attorneys are sworn Special 
Assistant United States Attorneys (SAUSAs), and therefore able to 
represent the D.C. Office of Inspector General in D.C. Superior Court 
and Federal District Court on matters originated by the Unit.  As 
SAUSAs, the Unit attorneys are co-counsel with the assigned Assistant 
United States  Attorney (AUSA) during all phases of litigation on 
criminal and civil Unit cases.   
The Unit relies on the D.C. Office of the Attorney General for 
execution of global civil settlements and judgments.  This was the D.C. 
Office of the Attorney Generals only role with respect to the Units 
operations. 
Unit Reporting to Federal Entities 
Reporting to OIG. OIG excludes any person or entity from  
participation in Federal health care programs who is convicted of a 
criminal offense related to the delivery of an item or service under 
Medicaid or to the neglect or abuse of patients in residential health care 
facilities.  No payment may be made by Medicaid, Medicare, or other 
Federal health care programs for an item or service provided, ordered, 
or prescribed by an excluded individual or entity.22 Convictions 
resulting from Unit investigations must be reported to OIG for program  
exclusion within 30 days from the date of sentencing.23    
______________________________________________________ 
22 SSA    1128(a); 42 CFR  1001.1901. 
23 Performance Standard  8(f).  
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Reporting to National Practitioner Data Bank. Separate from the 
reporting of convictions to OIG for exclusion purposes, Federal 
regulations require that all State and Federal government agencies 
report any final adverse actions to the National Practitioner Data Bank 
(NPDB).24   Adverse actions include actions resulting from  
investigations or prosecutions of healthcare providers and suppliers.  
Examples of final adverse actions include, but are not limited to, 
convictions, civil judgments (but not civil settlements), and program  
exclusions. Final adverse actions must be reported to the NPDB 
within 30 days following the action.25 In addition to Federal 
regulations, Performance Standard 8(g) states that Units should report 
all qualifying cases to the Healthcare Integrity & Protection 
Databank, the NPDB, or successor data bases.   
Previous Review  
A 2009 OIG onsite review of the Unit found that the Units MOU 
with the D.C. Medicaid agency was not signed by the D.C. Medicaid 
agency director and therefore was never executed.  Subsequent to 
that onsite review, the Unit director provided OIG with a copy of the 
revised MOU that had been finalized, signed, and executed by the 
D.C. Medicaid agency. 
The 2009 review also resulted in a suggestion for improving the 
Units official case files; the case files did not contain an index 
identifying the information contained within the file.  In 2013, the 
Unit implemented an electronic case file management system that 
contained a case log identifying information contained within the 
file.  We address the implementation of this case file management 
system in this report. 
METHODOLOGY 
We conducted the onsite review in January 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 for FYs 2012 through 2014; 
(2) a review of financial documentation for FYs 2012 through 2014; 
______________________________________________________ 
24 45 CFR   60.5.  The NPDB  was established by the Department of Health and  
Human Services as a national health care fraud and abuse data collection  
program... for the reporting  of certain final adverse actions... against health care 
providers, suppliers, or practitioners.  SSA  1128E(a); 45  CFR  61.1(2012).  
This information used to  be  housed in a separate databank called the Healthcare 
Integrity and Protection  Databank  (HIPDB).  The HIPDB and the NPDB were  
merged into one databank in  May 2013.  78  Fed. Reg. 20473  (April 5,  2013). 
25 45 CFR   60.5. 
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(3) structured interviews with key stakeholders; (4) a survey of Unit 
staff; (5) structured interviews with Unit management; (6) an onsite 
review of a sample of files for cases that were open at any time in 
FYs 2012 through 2014; and (7) onsite observation of Unit 
operations. Appendix C provides a detailed methodology.   
Standards 
These reviews are conducted in accordance with the Quality Standards 
for Inspection and Evaluation issued by the Council of the Inspectors 
General on Integrity and Efficiency. 
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FINDINGS 
Our review of the D.C. Unit identified several findings that may 
undermine Unit efficiency and effectiveness.  We identified delays 
in case progress that may have been explained by Unit management 
practices that we observed, including a lack of documented 
supervisory reviews and a lengthy clearance process for documents.  
We also found that the Unit did not use its case management system  
to allow efficient access to case information, and that it investigated 
several cases that were outside of the Units authority.  Until July 
2015, the Units MOU with the D.C. Medicaid agency was out of 
date. Regular meetings between the Unit and the Medicaid agency 
were not always held, and the Unit did not report all relevant 
information to Federal partners within required timeframes.    
From FYs 2012 through FY  2014, the Unit reported 
14 convictions, 33 civil judgments and
settlements, and recoveries of $15 million 
For FYs 2012 through 2014, the Unit reported 14 criminal 
convictions and 33 civil judgments and settlements.  Of the Units 
14 convictions over the 3-year period, 9 convictions involved 
allegations of fraud and 5 involved allegations of patient abuse or 
neglect. All but one of the 33 civil settlements and judgments 
involved global cases, totaling $10.6 million.26  The remaining 
civil judgment of $771,271 was part of a False Claims Act judgment 
against a D.C. health care provider, which resulted from an 
investigation by multiple Federal and State partners.   
The Unit reported no nonglobal civil settlements and judgments in 
FYs 2012 and 2014 and no criminal recoveries in FY 2012.  The 
Unit reported $7,572 in criminal recoveries in FY 2014.  See Table 1 
for yearly convictions, civil judgments and settlements, recoveries, 
and expenditures. 
   
______________________________________________________ 
26 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 on  behalf of the States. 
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Table 1:  D.C. MFCU Outcomes, FYs 20122014  
Outcomes   FY 2012   FY 2013   FY 2014   Total  
Criminal Convictions   4   7   3   14  
Civil Settlements and 
8   13   11   32  
Judgments--Global  
Civil Settlements and 
0   1   0   1  
Judgments--Nonglobal  
Criminal Recoveries  $0  $3,933,198   $7,572   $3,940,770 
Civil RecoveriesGlobal   $3,799,116   $3,097,014   $3,748,169   $10,644,299 
Civil RecoveriesNonglobal   $0  $771,271  $0  $771,271 
     Total Recoveries*  $3,799,116   $7,801,483   $3,755,741   $15,356,340 
     Total Expenditures   $2,725,291   $2,473,055   $2,708,824   $7,907,169  
Source:  OIG analysis of Unit-submitted documentation, FYs 20122014, 2015. 
Unit management practices may explain the 

delays we found in 20 percent of cases 

Sixty-eight percent of cases lacked documentation of 
periodic supervisory reviews intended to ensure cases 
progress at a reasonable pace  
Sixty-eight percent of the Units case files lacked documentation of 
periodic supervisory reviews.27  OIG performance standards state 
that supervisors should review progress of cases, ensuring that each 
stage of an investigation is completed in an appropriate timeframe.  
A document should be included in the case file that shows that the 
reviews took place.28  Further, the  Units policy stated that quarterly 
case reviews are intended to ensure cases are progressing at a 
reasonable pace, to share ideas and strategies, to discuss problems or 
issues, and provide necessary assistance. 
Twenty percent of cases were not progressing at a 

reasonable pace 
 
Through an indepth review of case documentation, OIG found that 
20 percent of cases did not progress at a reasonable pace, and that 
the lack of progress could not be attributed to resource constraints or  
other exigencies.29, 30  The Unit director confirmed that the cases were 
______________________________________________________ 
27 Appendix  D contains the point estimate and 95-percent confidence interval for 

the 68-percent  statistic. 
 
28 Performance Standards 5(b)  and 7(a). 
 
29 According to  Performance Standard 5(c), delays during the investigative phase 

should  be limited to situations imposed  by resource constraints or other exigencies. 
 
30 Appendix  D contains the point estimate and 95-percent confidence interval for 

the 20-percent  statistic. 
 
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not progressing towards closure timely, explaining that one or more 
of the following problems occurred in each of the cases:  
reassignment to other attorneys or investigators;  failure to  
investigate timely; delay of 3 months in approval of a request for 
information from the D.C. Medicaid agency; and lack of  reports of 
investigation or interviews in the case file.  OIG determined that in 
60 percent of the cases with delays in progression, reviews were 
conducted by a supervisor; however, no input or direction was given 
to the investigator on how to proceed with these cases.  
A lengthy document clearance process impeded case 
progress 
In response to our staff survey, 25 percent of staff reported that the 
document clearance process affected the Units ability to complete 
investigations timely.  Specifically, Unit staff reported delays in 
obtaining approval of documents (e.g., closing memos, subpoenas, 
arrest warrants) from the Unit director.  An investigator reported that 
he had used a template to write a subpoena and submitted it for 
approval 10 weeks prior to OIGs onsite review.  At the time of the 
onsite review, the subpoena still had not been approved.  Similarly, 
staff reported closing memos that remained in the clearance process 
for a year, and reported losing momentum in case progress due to the 
lengthy closure process. The Unit director reported that the 
clearance process was necessary to improve the quality of 
documents. 
The Unit did not use its case management system 
to allow efficient access to case information 
OIGs review of case files demonstrated a lack of knowledge among 
Unit staff on how to use the Units electronic case management  
system.  Case documentation was incomplete (e.g., some  
investigators listed a witness interview completed in the case  
management system; however, there was no report of the interview 
in the case file) and the Unit was unable to report accurate 
case-related statistics to OIG for the purposes of oversight.   
According to Performance Standard 7, the Unit should maintain case 
files in an effective manner and develop a case management system  
that allows efficient access to case information.   
The Unit confirmed having difficulties reporting case-related 
statistics to OIG as far back as 2008, and had implemented a new 
case management system in 2013.  However, the Units problems  
reporting accurate case-related statistics to OIG persisted at the time 
of our review. The Unit director reported that all case-related  
District of Columbia Medicaid Fraud Control Unit:  2015 Onsite Review  (OEI-07-14-00660)                                   9 
     
   
statistics reported to OIG since 2013 were inaccurate, because those 
statistics were calculated on the basis of the dates cases were 
received rather than the dates cases were opened.  The Unit 
discovered this inaccuracy during our onsite review in January 2015. 
The Unit investigated seven cases that were not
eligible under Federal regulations for Federal 
matching funds 
Seven cases were not eligible for Federal matching funds because of 
either (1) the location of the alleged incident, or (2) the type of fraud 
investigated. In six of these seven cases, the Unit reviewed 
complaints of abuse and neglect (i.e., patient funds) that occurred 
outside of health care facilities or board and care facilities; therefore, 
these cases are ineligible for Federal matching funds.31  In the 
seventh case, the Unit investigated the case of a recipient who 
fraudulently cashed a paycheck belonging to someone else.  This 
case was unrelated to Medicaid and therefore ineligible for Federal 
matching funds. 
The Units involvement with these seven cases may be attributed to 
confusion about its authority with regard to complaints of patient 
abuse or neglect. In explaining why the Unit investigated cases not 
eligible for Federal matching funds, the Unit director informed OIG 
that she believed that the Units investigative authority allowed for 
investigations whenever a person receives Medicaid-funded services.   
______________________________________________________ 
31  SSA  1903(q)(4)(A)(ii) & 42  CFR  1007.19(d). 
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Until July 2015, the Units MOU with the D.C. 
Medicaid agency was out of date and did not 
reflect current Federal legal requirements; further, 
formal communication was infrequent  
The Units MOU with the D.C. Medicaid agency was last updated in 
December 2008 and did not address Federal payment suspension 
regulations that went into effect in March 2011.32 Specifically, the 
MOU did not include a provision describing the referral process 
between the Unit and the D.C. Medicaid agency for providers that 
are subject to a payment suspension on the basis of a credible 
allegation of fraud.  According to Performance Standard 10, the Unit 
must review its MOU with the State Medicaid agency at least every 
5 years, and ensure that the MOU meets current Federal legal 
requirements.  
The MOU between the Unit and the D.C. Medicaid agency stipulates 
that the entities meet on a quarterly basis to discuss which 
preliminary investigations completed by the D.C. Medicaid agency 
warrant full investigations, and to discuss the terms of the MOU.33   
The D.C. Medicaid agency reported that these quarterly meetings did 
not always occur as scheduled.  A February 2014 Centers for 
Medicare & Medicaid Services review of the D.C. Medicaid agency 
also found that the quarterly meetings had not taken place, and 
identified ineffective interagency communication between the Unit 
and the D.C. Medicaid agency.34 The Unit deputy director reported 
that he would like to establish communication with the new D.C. 
Medicaid director. D.C. Medicaid agency officials reported that they 
would like to get the meetings back on track.  
______________________________________________________ 
32 The Patient Protection and Affordable Care Act, P.L. No. 111-148  6402(h)(2)  
(March  23, 2010), as amended by the Health Care Reconciliation Act  of  2010,  
P.L. No. 111-152 (March 30, 2010) requires State Medicaid programs, as a 
condition of receiving Federal Financial Participation, to suspend payments to  
providers for whom there is a credible allegation of fraud,  unless good cause exists  
to not suspend  payments.  One way to establish  good cause is for the MFCU to 
inform the State Medicaid agency that the suspension would compromise or 
jeopardize its investigation of the provider.  CMS and  OIG implemented this 
provision in  revisions to 42 CFR   455.23  and 1007.9(e) effective March  25, 
2011 (76 Fed. Reg. 5862). 
33 MOU between Department of Health Care Finance and the MFCU,  
Section VII(A)(3), December 31, 2008. 
34 CMS, Medicaid Integrity  Program District of  Columbia  Comprehensive 
Program Integrity Review Final Report, p. 9, February 2014.  Accessed at  
http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/DCfy12.pdf  
on  March 19, 2015.  
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A revised MOU between the Unit and D.C. Medicaid agency was 
finalized on July 2, 2015. This MOU includes a provision describing 
the referral process between the Unit and the D.C. Medicaid agency 
for providers that are subject to a payment suspension on the basis of 
a credible allegation of fraud. The MOU also reiterates that the Unit 
and D.C. Medicaid agency agree to meet no less than quarterly to 
discuss matters pertaining to the terms of the MOU. 
The Unit did not report all convictions to OIG or 
adverse actions to the NPDB within required 
timeframes 
The Unit did not report convictions to OIG within the 
required timeframe 
The Unit obtained 14 convictions in the review period but, according 
to its own data, did not report any of those sentenced individuals to 
OIG for program exclusion within the required timeframe.  OIG 
received reports of 9 of the 14 convictions within 30 days.  These 
cases were likely reported to OIG by another agency that jointly 
investigated or prosecuted the case.  According to Performance 
Standard 8(f), when an individual is sentenced, the Unit should 
report the conviction to OIG within 30 days of sentencing for the 
purposes of program exclusion.  Reports ranged from 1 day late to 
299 days late; on average, the convictions were reported 88 days 
late. Late reporting of convictions to OIG could delay the initiation 
of the program exclusion process, resulting in improper payments to 
providers. 
The Unit did not report convictions to the NPDB within the 
required timeframe 
The Unit did not report information for any of its 14 convictions to 
the NPDB within the required timeframe.  According to Federal 
regulation, final adverse actions, such as criminal convictions, must 
be reported to the NPDB within 30 days following the action.35   
The Unit reported information to the NPDB between 48 days late 
and 954 days late; on average, the adverse actions were reported 
583 days late. The Unit reported all adverse actions to the NPDB 
after the start of the review.  Late reports of adverse actions to the 
NPDB may prevent it from fulfilling its intended purpose, the 
restriction of health care providers ability to move from State to 
______________________________________________________ 
35 45 CFR   60.5. 
District of Columbia Medicaid Fraud Control Unit:  2015 Onsite Review  (OEI-07-14-00660)                                   12 
     
   
State without disclosure or discovery of previous medical 
malpractice and adverse actions.  
The Unit maintained proper fiscal control of its 
resources 
The Unit maintained proper fiscal control of its resources during the 
review period. According to Performance Standard 11, the Unit 
should exercise proper fiscal control over the Units resources.  On 
the basis of the review conducted by OIG auditors, the Units 
financial documentation indicated that the Units requests for 
reimbursement for FYs 2012 through 2014 represented allowable, 
allocable, and reasonable costs.  In addition, the Unit maintained 
adequate internal controls relating to accounting, budgeting, 
personnel, procurement, property, and equipment. 
Other observation:  The Unit did not have a 
process for reporting collections information 
The Unit director reported that there is no process in place for the 
Unit to obtain collections information (i.e., monies actually collected 
from criminal or civil judgments), which are reported to OIG as part 
of the Quarterly Statistical Reports (QSR).  According to the terms 
and conditions of the grant, the Unit must submit QSRs as 
described by OIG.36 The Unit did not report data related to 
collections for any quarter of the 3-year review period in either the 
original or revised QSR submissions.  Among the 50 Units, the D.C. 
Unit was the only Unit not to report any collections data for 
FYs 2012 through 2014. 
Other observation:  Policies and procedures were 
not widely circulated to staff 
The Unit deputy director reported that policies and procedures were 
an evolving process, and had not been widely circulated prior to our 
onsite review. Staff reported being unaware of policies and 
procedures until the start of the review.  According to Performance 
Standard 3, the Unit should ensure that staff are familiar with, and 
adhere to, policies and procedures.  Unit policies and procedures are 
established to ensure a productive Unit and govern, in part, the 
______________________________________________________ 
36 OIG,  Definitions and Instructions for Completion of the State Medicaid Fraud 
Control Unit Quarterly Statistical Report, 2007.  Accessed  at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/forms/Quarterly%20Statistical%20Report%20Instructions.pdf on  
March 12, 2015. 
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investigation and case review process, procedures for written 
documents, chain of command, and training. 
   
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CONCLUSION AND RECOMMENDATIONS 
Our review of the D.C. Unit identified several findings that may 
undermine Unit efficiency and effectiveness.  We identified delays 
in case progress that may have been explained by Unit management 
practices that we observed, including a lack of documented 
supervisory reviews and a lengthy clearance process for documents.  
We also found that the Unit did not use its case management system  
to allow efficient access to case information, and that it investigated 
several cases that were outside of the Units authority.  Until July 
2015, the Units MOU with the D.C. Medicaid agency was out of 
date. Regular meetings between the Unit and the Medicaid agency 
were not always held, and the Unit did not report all relevant 
information to Federal partners within required timeframes.    
We recommend that the District of Columbia Unit: 
Ensure that periodic supervisory reviews are documented 
in Unit case files  
The Unit should ensure that periodic supervisory reviews of case 
files are conducted consistent with the Units case file review policy 
and that these reviews are documented in the case files.   
Ensure that delays in case progress are limited to 
situations imposed by resource constraints or other 
exigencies, and documents are cleared timely  
To demonstrate that extended delays were imposed by resource 
constraints or other exigencies, the Unit could implement a policy to 
document such occurrences in the case files.  To ensure that 
documents are cleared in a timely manner, the Unit could revise its 
document clearance process to minimize delays.  
Ensure that use of its case management system allows  
for efficient access to case information 
The Unit should ensure that the Units staff use of the case 
management system allows for efficient access to case information 
such as interview summaries, case-related statistics, and standardized 
reports. The Unit could provide additional training and guidance in 
how to input and extract case information for the system.  
   
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Repay Federal matching funds spent on the cases that 
were not eligible for Federal funding and implement 
procedures to ensure that cases are within grant authority 
The Unit should work with OIG to identify the staff hours and 
expenditures associated with the seven ineligible cases and repay 
those Federal matching funds.  The Unit should develop and 
implement procedures to ensure that Unit staff investigate cases 
solely within the Units grant authority.   
Communicate regularly with the D.C. Medicaid agency 
The Unit should follow the terms of the MOU by maintaining formal 
communication, including regular meetings, with the D.C. Medicaid 
agency.  
Ensure that all relevant information is reported to OIG and 
NPDB within required timeframes  
The Unit should ensure that it reports individuals and entities to OIG 
for exclusion within 30 days of sentencing, consistent with 
Performance Standard 8(f).  Similarly, the Unit should report all 
adverse actions to the NPDB within 30 days of the action, as 
specified in Federal regulation. 
 
   
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UNIT COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The District of Columbia Unit concurred with all six of our 
recommendations.   
Regarding the first recommendation, the Unit stated that it 
streamlined operations, reducing the number of case file reviews that 
supervisors need to complete from 18 to 4 per quarter thereby 
making it easier to ensure that case reviews are completed and 
documented in case files in a timely fashion. 
Regarding the second recommendation, the Unit stated that it is 
re-evaluating its caseload and closing marginal cases to focus on 
truly meritorious cases.  The Unit stated that it has also revised its 
document clearance process and is developing new policies to ensure 
documents are processed timely.  
Regarding the third recommendation, the Unit stated that it is 
working with its case management software vendor to improve the 
quality of case-related statistics and standardized reports.  The Unit 
stated that management has taken a series of steps to ensure the 
timely preparation of interview summaries and submissions into the 
case management system.  The Unit also stated that management is 
also working with its vendor to develop additional training and 
guidance to improve the staffs ability to input and extract case 
information. 
Regarding the fourth recommendation, the Unit stated that it has 
amended its complaint review process to immediately close and refer 
elsewhere allegations occurring outside of Medicaid-funded 
facilities. The Unit stated that it will repay funds in the amount of 
$8,025. 
Regarding the fifth recommendation, the Unit stated that it has 
worked to improve the quality and frequency of communication with 
the D.C. Medicaid agency since the appointment of the new Unit 
director in May 2015. The Unit further states that it intends to fully 
comply with the terms of the newly developed MOU requiring 
formal communication with the Medicaid agency, including regular 
meetings. 
Regarding the sixth recommendation, the Unit stated that it will 
amend its policies and procedures to ensure timely reporting 
sentencings to OIG and adverse actions to NPDB.  The Unit stated 
that it will also amend its case management software to generate 
District of Columbia Medicaid Fraud Control Unit:  2015 Onsite Review  (OEI-07-14-00660)                                   17 
     
   
notices to Unit staff to prepare the documents necessary to transmit 
information to OIG and NPDB.  
The Units comments are provided in Appendix E.   
   
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APPENDIX A 
2012 Performance Standards37   
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. 
______________________________________________________ 
37 77 Fed. Reg. 32645, June  1, 2012. 
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B. The Unit provides periodic feedback to the State Medicaid agency  and other referral sources on the 
adequacy of both the volume and quality  of its referrals. 
C. The Unit provides timely information to the State Medicaid or other agency when the Medicaid or other 
agency requests information on the status of MFCU  investigations, including when the Medicaid agency 
requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii).  
D. For those States in which the Unit has original jurisdiction to investigate or prosecute patient abuse and 
neglect cases, the Unit takes steps, such as the development of operational protocols, to ensure that pertinent 
agencies refer such cases to the Unit, consistent with patient confidentiality and consent.  Pertinent agencies 
vary by State but may include licensing and certification agencies, the State Long Term Care Ombudsman, and 
adult protective services offices.  
E. The Unit provides timely information, when requested, to those agencies identified in (D) above regarding 
the status of referrals. 
F. The Unit takes steps, through public outreach or other means, to encourage the public to refer cases to the 
Unit. 
5. A  UNIT TAKES STEPS TO MAINTAIN  A  CONTINUOUS CASE FLOW  AND TO  COMPLETE CASES IN AN  
APPROPRIATE TIMEFRAME BASED ON  THE COMPLEXITY OF THE CASES.  
A. Each stage of an investigation and prosecution is completed in an appropriate timeframe.  
B. Supervisors approve the opening and closing of all investigations and review the progress of cases and take 
action as necessary to ensure that each stage of an investigation and prosecution is completed in an 
appropriate timeframe.  
C. Delays to investigations and prosecutions are limited to situations imposed by resource constraints or other 
exigencies. 
6. A  UNITS CASE MIX, AS PRACTICABLE, COVERS ALL SIGNIFICANT PROVIDER TYPES AND 
INCLUDES A  BALANCE OF FRAUD AND, WHERE APPROPRIATE, PATIENT ABUSE AND NEGLECT 
CASES.    
A. The Unit seeks to have a mix of cases from all significant provider types in the State. 
B. For those States that rely substantially on managed care entities for the provision of Medicaid services, the 
Unit includes a commensurate number of managed care cases in its mix of cases.  
D. As part of its case mix, the Unit maintains a balance of fraud and patient abuse and neglect cases for those 
States in which the Unit has original jurisdiction to  investigate or prosecute patient abuse and neglect cases.  
C. The Unit seeks to allocate resources among provider types based on levels of Medicaid expenditures or 
other risk factors. Special Unit initiatives may focus on specific provider types. 
E. As part of its case mix, the Unit seeks to maintain, consistent with its legal authorities, a balance of criminal 
and civil fraud cases. 
7. A  UNIT MAINTAINS CASE FILES IN AN EFFECTIVE MANNER  AND DEVELOPS A  CASE  
MANAGEMENT SYSTEM THAT  ALLOWS EFFICIENT ACCESS TO CASE INFORMATION AND OTHER 
PERFORMANCE DATA.    
A. Reviews by supervisors are conducted periodically, consistent with MFCU policies and procedures, and are 
noted in the case file. 
B. Case files include all relevant facts and information and justify the opening and closing of the cases. 
C. Significant documents, such as charging documents and settlement agreements, are included in the file.  
D. Interview summaries are written promptly, as defined by the Units policies and procedures.  
E. The Unit has an information management system that manages and tracks case information from initiation to 
resolution. 
F. The Unit has an information management system that allows for the monitoring and reporting of case 
information, including the following:  
1. The number of cases opened and closed and the reason that cases are closed. 
District of Columbia Medicaid Fraud Control Unit:  2015 Onsite Review  (OEI-07-14-00660)                                   20 
     
   
2. The length of time taken to determine whether to open a case referred by the State Medicaid agency  or other 
referring source.  
3. The number, age, and types of cases in the Units inventory/docket 
4. The number of referrals received by the Unit and the number of referrals by  the Unit to other agencies.  
5. The number of cases criminally prosecuted by the Unit or referred to others for prosecution, the number of 
individuals or entities charged, and the number of pending prosecutions. 
6. The number of criminal convictions and the number of civil judgments. 
7. The dollar amount of overpayments identified. 
8. The dollar amount of fines, penalties, and restitution ordered in a criminal case and the dollar amount of 
recoveries and the types of relief obtained through civil judgments or prefiling settlements. 
8. A  UNIT COOPERATES WITH OIG AND OTHER FEDERAL AGENCIES IN THE INVESTIGATION AND 
PROSECUTION OF MEDICAID  AND OTHER HEALTH CARE FRAUD.    
A. The Unit communicates on a regular basis with OIG and other Federal agencies investigating or prosecuting 
health care fraud in the State.  
B. The Unit cooperates and, as appropriate, coordinates with OIGs Office of Investigations and other Federal 
agencies on cases being pursued jointly, cases involving the same suspects or allegations, and cases that have 
been referred to the Unit by  OIG or another Federal agency.   
C. The Unit makes available, to the extent authorized by law and upon request by  Federal investigators and 
prosecutors, all information in its possession concerning provider fraud or fraud in the administration of the 
Medicaid program. 
D. For cases that require the granting of extended jurisdiction to investigate Medicare or other Federal health 
care fraud, the Unit seeks permission from OIG or other relevant agencies under procedures as set by those 
agencies. 
E. For cases that have civil fraud potential, the Unit investigates and prosecutes such cases under State 
authority  or refers such cases to OIG or the U.S. Department of Justice.  
F. The Unit transmits to OIG, for  purposes of program exclusions under section 1128 of the Social Security Act, 
all pertinent information on MFCU convictions within 30 days of sentencing, including charging documents, plea 
agreements, and sentencing orders. 
G. The Unit reports qualifying cases to the Healthcare Integrity & Protection Databank, the National Practitioner 
Data Bank, or successor data bases. 
9. A  UNIT MAKES STATUTORY OR PROGRAMMATIC RECOMMENDATIONS, WHEN WARRANTED, TO  
THE STATE GOVERNMENT.    
A. The Unit, when warranted and appropriate, makes statutory  recommendations to the State legislature to 
improve the operation of the Unit, including amendments to the enforcement provisions of the State code. 
B. The Unit, when warranted and appropriate, makes other regulatory or administrative recommendations 
regarding program integrity issues to the State Medicaid agency  and to other agencies responsible for Medicaid 
operations or funding.  The Unit monitors actions taken by the State legislature and the State Medicaid or other 
agencies in response to recommendations.  
10. A  UNIT PERIODICALLY REVIEWS ITS MEMORANDUM OF UNDERSTANDING (MOU) WITH THE 
STATE MEDICAID AGENCY TO  ENSURE THAT IT REFLECTS CURRENT PRACTICE, POLICY, AND  
LEGAL REQUIREMENTS.    
A. The MFCU documents that it has reviewed the MOU at least every 5 years, and has renegotiated the MOU  
as necessary, to ensure that it reflects current practice, policy, and legal requirements. 
B. The MOU meets current Federal legal requirements as contained in law or regulation, including 
42 CFR 455.21, Cooperation with State Medicaid fraud control units, and 42 CFR 455.23, Suspension of 
payments in cases of fraud.  
C. The MOU is consistent with current Federal and  State policy, including any policies issued by  OIG or the 
Centers for Medicare & Medicaid Services (CMS). 
D. Consistent with Performance Standard 4, the MOU establishes a process to ensure the receipt of an 
adequate volume and quality of referrals to the Unit from the State Medicaid agency.  
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E. The MOU incorporates by  reference the CMS Performance Standard for Referrals of Suspected Fraud from  
a State Agency to a Medicaid Fraud Control Unit. 
11. A  UNIT EXERCISES PROPER FISCAL CONTROL OVER UNIT RESOURCES.    
A. The Unit promptly submits to OIG its preliminary budget estimates, proposed budget, and Federal financial 
expenditure reports.   
B. The Unit maintains an equipment inventory that is updated regularly to reflect all property under the Units 
control. 
C. The Unit maintains an effective time and attendance system and personnel activity  records.  
D. The Unit applies generally accepted accounting  principles in its control of Unit funding. 
E. The Unit employs a financial system in compliance with the standards for financial management systems 
contained in 45 CFR 92.20.  
12. A  UNIT CONDUCTS TRAINING THAT  AIDS IN THE MISSION OF THE UNIT.    
A. The Unit maintains a training plan for each professional discipline that includes an annual minimum number 
of training hours and that is at least as stringent as required for professional certification.  
B. The Unit ensures that professional staff comply with their training plans and maintain records of their staffs 
compliance.  
C. Professional certifications are maintained for all staff, including those that fulfill continuing education 
requirements.  
D. The Unit participates in MFCU-related training, including training offered by  OIG and other MFCUs, as such 
training is available and as funding permits. 
E. The Unit participates in cross-training with the fraud detection staff of the State Medicaid agency.  As part of 
such training, Unit staff provide training on the elements of successful fraud referrals and receive training on the 
role and responsibilities of the State Medicaid agency.   
 
 
 
 
 
   
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APPENDIX B 
Table B-1:  Unit Referrals by Referral Source for FYs 2012 
Through 2014 
  FY 2012   FY 2013   FY 2014  
Abuse &   Patient  Abuse &   Patient  Abuse &   Patient 
Referral Source   Fraud   Fraud   Fraud  
Neglect   Funds   Neglect   Funds   Neglect   Funds  
D.C. Medicaid 
4  0  0  24  0  0  10  0  0 
agency 
D.C. agency  
1  0  0  0  9  0  0  0  0 
other  
D.C. survey  and 
0  3  2  0  0  0  0  0  0 
certification agency 
Other State 
agencies38   15  110  17  5  38  9  3  58  7 
D.C. Board of 
0  1  0  0  0  0  2  0  0 
Nursing 
Law enforcement   1  2  0  2  0  0  2  0  0 
Office of Inspector 
0  0  0  1  0  0  0  0  0 
General 
Prosecutors  4  0  0  2  1  0  0  0  0 
Providers  1  2  3  0  7  3  2  11  2 
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  2  1  1  0  0 
ombudsman  
Adult protective 
0  0  0  0  0  0  0  0  0 
services  
Private citizens  7  5  0  3  2  1  5  3  0 
MFCU hotline   6  1  1  1  0  0  28  0  0 
Other   8  0  0  29  1  1  27  0  1 
   Total   47  124  23  67  60  15  80  72  10 
   Annual Total  194  142  162 
Source:  OIG analysis of Unit-submitted documentation, FYs 20122014, 2015. 
   
______________________________________________________ 
38 The Unit reported that referrals from the D.C. Department on Disability Services 
make up the majority of these referrals. 
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APPENDIX C 
Detailed Methodology 
Data collected from the seven sources below were used to describe 
the caseload and assess the performance of the D.C. Unit.   
Data Collection 
Review of Unit Documentation. Prior to the onsite visit, we analyzed 
information from several sources regarding the Units investigation 
of Medicaid cases, including information about the number of 
referrals the Unit received, the number of investigations the Unit 
opened and closed, the outcomes of those investigations, and the 
Units case mix.  We also collected and analyzed information about 
the number of cases that the Unit referred for prosecution and the 
outcomes of those prosecutions.  We gathered this information from  
several sources, including the Units QSRs, annual reports, 
recertification questionnaire, policy and procedures manuals, and 
MOU with the D.C. Medicaid agency.  Additionally, we confirmed 
with the Unit director that the information we had was current as of 
January 2015. 
Review of Unit Financial Documentation. To evaluate internal 
control of fiscal resources, OIG auditors determined whether the 
Unit (1) claimed expenditures that represented allowable, allocable, 
and reasonable costs in accordance with applicable Federal 
regulations, and (2) maintained adequate internal controls related to 
accounting, budgeting, personnel, procurement, property, and 
equipment for FYs 2012 through 2014.  OIG auditors also 
(1) reviewed quarterly and final financial status reports and 
supporting documentation that the Unit submitted, (2) judgmentally 
selected and reviewed transactions within the direct cost categories, 
and (3) confirmed whether indirect costs were accurately reported 
using the negotiated and approved indirect cost rates during the 
period of our review. Finally, auditors reviewed records in the 
Department of Health and Human Services Payment Management 
System and determined whether there was any unallowable Federal 
reimbursement. 
Interviews with Key Stakeholders. In December 2014 and 
February 2015, we interviewed key stakeholders, including officials in 
the USAO (Civil Division), the D.C. Office of the Attorney General, 
and other agencies that interacted with the Unit (i.e., Federal Bureau of 
Investigation, D.C. Health Care Facilities Licensing, and D.C. 
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Department on Disability Services).  We also interviewed supervisors 
from OIGs Region III offices who work regularly with the Unit.   
During our onsite review, we interviewed officials with the USAO 
(Criminal Division, Fraud and Public Corruption Section) and the D.C. 
Medicaid agencys Program Integrity Unit.  We focused these  
interviews on the Units relationship and interaction with OIG and 
other Federal and State authorities.  We used the information collected 
from these interviews to develop subsequent interview questions for 
Unit management.  
Survey of Unit Staff.  In December 2014, we conducted an online 
survey of all 17 nonmanagerial Unit staff within each professional 
discipline (i.e.,  investigators, auditors, and attorneys) as well as 
support staff.  The response rate was 94 percent.  The survey focused 
on operations of the Unit, opportunities for improvement, and 
practices that contributed to the effectiveness and efficiency of Unit 
operations and/or performance.  The survey also sought information 
about the Units compliance with applicable laws and regulations.   
Onsite Interviews with Unit Management.   We conducted structured 
interviews with the Units management during our onsite review.  We  
interviewed the Units director, the Units deputy director, and the 
Units two supervisory criminal investigators.  We asked these 
individuals to provide information related to (1) the Units 
operations, (2) practices that contributed to the effectiveness and 
efficiency of Unit operations and/or performance, (3) opportunities 
for the Unit to improve its operations and/or performance, and (4) 
clarification regarding information obtained from other data sources. 
Onsite Review of Case Files and Other Documentation. We  
requested that the Unit provide us with a list of cases that were open 
at any point during FYs 2012 through 2014. This list of 648 cases 
included, but was not limited to, the current status of the case; 
whether the case was criminal, civil, or global; and the date on which 
the case was opened. From this list of cases, we excluded 70 cases 
that were categorized as global and 133 that were categorized as 
referrals. 
We removed 44 cases categorized as patient funds from the  
universe of 648 cases to examine separately.  We reviewed all 
44 cases while onsite to determine if these cases were eligible for 
Federal matching funds.  We conducted this review because of 
concerns raised by stakeholders and Unit staff prior to the onsite 
review.  
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We then selected a simple random sample of 100 cases from the 
remaining 401 cases.  This sample of 100 cases included 92 cases 
that were open longer than 90 days.  We reviewed all 100 sampled 
case files. 
During the onsite review, one sampled case file was determined to be 
a global case.  As a result, the number of eligible case files in our 
sample was reduced from 100 to 99.  To project the number of 
eligible case files in the entire population, we used the proportion of 
the eligible case files from our sample.  Our estimates of the 
percentages of all case files with certain characteristics apply to the 
estimated population of 397 files for nonglobal cases that were open 
during the period of our review.  The point estimate and 95-percent 
confidence interval for the projection can be found in Appendix D.   
From the initial sample of 100 case files, we selected a further  
simple random sample of 50 files for an OIG investigator to conduct 
an indepth review of selected issues, such as the timeliness of  
investigations and case development. 
Onsite Review of Unit Operations. During our January 2015 site 
visit, we observed the Units offices and meeting spaces; security of 
data and case files; location of select equipment; and the general 
functioning of the Unit. We also determined whether the Unit 
reported convictions to OIG for program exclusion and whether the 
Unit reported adverse actions to the NPDB.  
Data Analysis  
We analyzed data to identify any opportunities for improvement and 
any instances in which the Unit did not fully meet the performance 
standards or was not operating in accordance with laws, regulations, 
or policy transmittals.39 We based our findings on data analysis, 
statements from Unit staff, and our own judgment. 
   
______________________________________________________ 
39 All relevant  regulations, statutes, and  policy transmittals are available online at  
http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu.  
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APPENDIX D 
Table D-1:  Point Estimates and 95-Percent Confidence 
Intervals Based on Reviews of Case Files 
95-Percent Confidence 
Sample  Point  Interval  
Estimate  
Size*  Estimate  
Lower  Upper  
Percentage of files for cases that were open 
longer than 90 days that did not contain  92**   68.5%***  59.6%  76.2%  
documentation of periodic supervisory review  
Percentage of cases that had delays in case 
49*   20.4%  12.2%  32.1%  
progression  
Percentage of cases with delays in case 
progression that had documentation of  10  60%   32.9%   82%  
periodic supervisory  review  
*The original sample size for the in depth review of 50  case files was reduced by 1 due to a global case being 
 
included. 

**The original sample size of 100 was reduced by 1 due to a global case being included, and further reduced by 
 
7 to exclude those  cases open for less than 90 days. 

***The actual percentage is 68.48 percent.  The number 68.48 rounds to 68.5.  As a whole number, however, this 
 
percentage rounds to 68 percent. 

Source:  OIG analysis of D.C. MFCU case files, 2015. 

 
 
   
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APPENDIX E 
Unit Comments 
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ACKNOWLEDGEMENTS 
This report was prepared under the direction of Brian T.  Whitley, 
Regional Inspector General for Evaluation and Inspections in the 
Kansas City regional office.   
Teresa Dailey served as the project leader for this study.  Other 
Office of Evaluation and Inspections staff who conducted the study 
include Tricia Fields, Conswelia McCourt, and Dennis J. Tharp.  
Office of Investigations staff also participated in the review.  Central 
office staff who contributed include Jordan Clementi, 
Christine Moritz, and Jacquelyn Towns.  Office of Audit Services 
staff who contributed to this study include Marilyn Carrion, Valerie 
Johnson, and Michael Jones. 
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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.