U.S. Department of Health and Human Services 
Office of Inspector General 
New Hampshire 
Medicaid Fraud 
Control Unit:   
2017 Onsite Review 
Add
OEI-00-00-00000 
OEI-0M9o-n1t7h- 0200210Y0   
Septe mber 2018  Suzanne Murrin 
oig.hhs.gov  Deputy Inspector General 
oig.hhs.gov   for Evaluation and Inspections  Report in Brief  U.S. Department of Health and Human Services 
September 2018 
Office  of Inspector General 
OEI-09-17-00200 
New Hampshire Medicaid Fraud Control 
MFCU Case Outcomes 
Unit: 2017 Onsite Review  The MFCU had low criminal and 
civil case outcomes during 
FYs 20142016, in comparison 
What OIG Found 
both to its past performance 
The case outcomes of the New Hampshire Medicaid Fraud Control Unit 
history and as compared to 
(MFCU)i.e., the MFCUs convictions of fraud, patient abuse, or neglect; its 
similarly sized MFCUs from other 
criminal recoveries; its civil judgments and settlements; and its civil recoveries
States.  The MFCUs case 
were low during Federal fiscal years (FYs) 20142016.  We found a variety of 
outcomes for FYs 20142016 
factors that contributed to the low case outcomes.  These factors included: 
consisted of:     

a lack of incoming referrals from the Medicaid Program Integrity Unit 
no fraud convictions;
and other key sources;

four convictions of

turnover in staffing and leadership; and
patient abuse or neglect;

investigative delays and a lack of documented supervisory reviews of 
$13,923 in criminal
case files
recoveries;

25 civil judgments and
What OIG Recommends 
settlements; and
We recommend that the MFCU work with its State partners and managed care 

organizations and that it take steps to address the operational factors that  $2.6 million in civil
contributed to its low case outcomes.  Specifically, we recommend that the  recoveries.
MFCU: 
Why OIG Did This Review 

develop and implement a plan to increase referrals from the Medicaid
The primary purpose of this onsite 
Program Integrity Unit and managed care organizations;
review was to identify and address 

develop and implement a plan to reduce turnover in staff and leadership; factors that contributed to the 
 implement policies and procedures to ensure that significant MFCUs low case outcomes during 
investigative delays are explained in the case files and that periodic FYs 20142016.     
supervisory reviews are documented; and
The Office of Inspector General 

revise its fiscal control policies governing vehicle costs. (OIG) administers MFCU grant 
awards, annually recertifies each 
The MFCU concurred with all four recommendations. 
MFCU, and oversees MFCU 
performance in accordance with 
the requirements of the grant.     
As part of this oversight, OIG 
conducts periodic onsite reviews of 
MFCUs and prepares public 
reports.  This onsite review 
supplements OIGs annual 
recertification of this MFCU.   
Full report can be found at oig.hhs.gov/oei/reports/oei-09-17-00200.asp TABLE OF CONTENTS 
BACKGROUND  1 
Methodology  4 
FINDINGS 
The MFCUs case outcomes were low during FYs 20142016  6 
The MFCU received few fraud referrals from the Medicaid Program Integrity Unit and other  7 
key sources; the MFCU initiated greater referral outreach in FY 2016 
The MFCU experienced significant turnover among staff and leadership  9 
A few cases had investigative delays; almost half of the case files lacked documented   10 
supervisory review 
The MFCU generally maintained proper fiscal controls, but lacked some policy guidance  11 
CONCLUSION AND RECOMMENDATIONS 
Develop and implement a plan to increase timely referrals from the State Medicaid agency  12 
and managed care organizations  
Develop and implement a plan to reduce staff and leadership turnover  12 
Implement policies and procedures to ensure that significant investigative delays are explained  12 
in the case files and that periodic supervisory reviews are documented  
Revise its fiscal control policies governing vehicle costs  13 
MFCU COMMENTS AND OIG RESPONSE  14 
APPENDICES 
A:  MFCU Performance Standards  15 
B:  New Hampshire MFCU Referrals Received, by Source, FYs 20142016  21  
C:  Detailed Methodology  22 
D:  MFCU Comments  26 
ACKNOWLEDGMENTS  29  BACKGROUND 
Objective 
To examine performance and operational issues that the Office of 
Inspector General identified during its recertification and onsite review of 
the New Hampshire Medicaid Fraud Control Unit. 
Medicaid Fraud  The function of Medicaid Fraud Control Units (MFCU or Units) is to 
investigate Medicaid provider fraud and patient abuse or neglect, and to 
Control Units 
prosecute those cases under State law or refer them to other prosecuting 
offices.1  Under the Social Security Act (SSA), a MFCU is a single, identifiable 
entity of State government, and the MFCU must be separate and distinct 
from the State Medicaid agency and employ one or more investigators, 
attorneys, and auditors.2  Each State must operate a MFCU or receive a 
waiver.3  Currently, 49 States and the District of Columbia operate MFCUs.4  
Each MFCU receives a Federal grant award, equivalent to 75 percent of total 
allowable expenditures.5  In Federal fiscal year (FY) 2017, the 50 Units 
collectively reported 1,528 convictions; 961 civil judgments or settlements; 
and about $1.8 billion in recoveries.6   
OIG Grant  The Office of Inspector General (OIG) administers the grant award to each 
MFCU and provides oversight of MFCUs.7, 8  As part of its oversight, OIG 
Administration and 
Oversight of the 
 
1 Social Security Act  1903(q)(3).  Regulations at 42 CFR  1007.11(b)(1) add that the Units 
MFCUs  
responsibilities may include reviewing complaints of misappropriation of patients private 
funds in residential health care facilities. 
2 SSA  1903(q). 
3 SSA  1902(a)(61). 
4 State refers to the States, the District of Columbia, and the U.S. territories.  The State of 
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. 
5 SSA  1903(a)(6).  For a Units first 3 years of operation, the Federal government contributes 
90 percent of funding and the State contributes 10 percent. 
6 OIG, MFCU Statistical Data for Fiscal Year 2017, accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2017-
statistical-chart.pdf on May 2, 2018. 
7 As part of grant administration, OIG receives and examines financial information from Units, 
such as budgets and quarterly and final Federal Financial Reports that detail MFCU income 
and expenditures. 
8 The SSA authorizes the Secretary of Health and Human Services to award grants     
(SSA  1903(a)(6)) and to certify and annually recertify the Units (SSA  1903(q)).  The 
Secretary delegated these authorities to OIG in 1979. 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   1  reviews and recertifies each MFCU annually.  The recertification review 
consists of examining the following: the MFCUs annual report; 
questionnaire responses from the MFCUs director and stakeholders; and 
annual case statistics (collectively referred to as recertification data).  
Through the recertification review, OIG assesses a MFCUs performance, as 
measured by the MFCUs adherence to published performance standards;9 
the MFCUs compliance with applicable laws, regulations, and OIG policy 
transmittals;10 and the MFCUs case outcomesi.e., its convictions of fraud, 
patient abuse, or patient neglect; its criminal recoveries; its civil judgments 
and settlements; and its civil recoveries.  (See Appendix A for MFCU 
performance standards, including performance indicators for each 
standard.)  OIG further assesses MFCU performance by periodically 
conducting onsite reviews, that may identify findings and make 
recommendations for improvement.  During an onsite review, OIG may also 
make observations regarding MFCU operations and practices, including 
identifying beneficial practices that may be useful to share with other 
MFCUs.  In addition, OIG provides training and technical assistance to 
MFCUs while OIG is onsite and also on an ongoing basis.  
New Hampshire  The New Hampshire MFCUs office is located in Concord, the State capital.  
MFCU   The MFCU is an entity within the States Attorney Generals Office.  At the 
time of our May 2017 review, the MFCU had eight staff positions: a director 
(who was also an attorney), another attorney, an investigator, a financial 
analyst (who served as the MFCUs auditor), a paralegal, and a legal 
secretary.11  The director served as the immediate supervisor for the other 
staff members.12  For FYs 20142016, the MFCU spent nearly $2.3 million, 
with a State share of about $569,000.13 
Referrals.  The MFCU may receive fraud referrals from the State Medicaid 
agency14 and Medicaid managed care organizations (MCOs), as well as from 
other sources such as private citizens, local prosecutors, OIG, and other law 
9 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  The 
performance standards were developed by OIG in collaboration with the MFCUs and were 
originally published at 59 Fed. Reg. 49080 (Sept. 26, 1994). 
10 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  
Policy transmittals may be found at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-
mfcu/index.asp.  
11 At the time of our onsite review, two of the eight staff positions were vacant.  The MFCU 
had vacancies for both the attorney and investigator positions.    
12 Unless otherwise specified, the term MFCU director refers to the director at the time of 
the onsite review in May 2017.  This director started in the position in May 2016. 
13 OIG, Expenditures and Statistics, Medicaid Fraud Control UnitsMFCU Statistical Data.  
Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp on June 
21, 2018.  
14 The New Hampshire Department of Health and Human Services serves as the State 
Medicaid agency.  
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   2  enforcement agencies.  The MFCU may receive referrals of patient abuse or 
neglect from Adult Protective Services, health care providers, the Long-Term 
Care Ombudsman, and law enforcement agencies.  Appendix B identifies 
the MFCUs referrals, by source, during FYs 20142016.  When the MFCU 
receives a referral, the MFCU director reviews it to determine whether to 
open a full investigation.  If the director decides not to open a case, the 
MFCU can send the referral to another agency for investigation or 
administrative action. 
Investigations and Prosecutions.  After the MFCU opens a case, 
an investigator and/or financial analyst conducts an investigation in 
consultation with one of the attorneys.  If the director determines that the 
case warrants prosecution, it is submitted to higher level officials in the State 
Attorney Generals Office for review, and the officials decide whether the 
MFCU should prosecute the case.15    
New Hampshire  In FY 2017, New Hampshires Medicaid expenditures were approximately 
$2.2 billion.16  Since 2013, New Hampshire has been transitioning its 
Medicaid 
Medicaid program from fee-for-service to one based on managed care.  As 
Program 
of August 2016, approximately 96 percent of New Hampshires roughly 
186,000 Medicaid beneficiaries received their services through two MCOs.17   
Each MCO operates its own Special Investigation Unit that engages in a 
variety of program integrity activities, such as conducting audits of claims 
data to identify and address fraud, waste, and abuse.  State contracts with 
the MCOs require that the Special Investigation Units refer any suspected 
provider fraud to the State Medicaid agencys Program Integrity Unit.18 
The Program Integrity Unit is responsible for monitoring the States 
Medicaid program for instances of fraud, waste, and abuse, and for 
recommending policy and procedure changes.19  It has staff to review 
15 New Hampshire has civil and criminal authorities to address false claims.  The State enacted a 
civil False Claims Act in 2005.  In general, the New Hampshire False Claims Act contains 
provisions that establish civil liabilities and authorize associated penalties for individuals who 
knowingly present, or cause to be presented, a false or fraudulent claim.  In addition to this 
authority, there is a Prohibited Acts criminal statute to address false claims.   
See NH Rev Stat  167:61-b167:61-e and NH Rev Stat  167:61-a.     
16 OIG, Medicaid Fraud Control Unit 2017 Statistical Chart, accessed at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/expenditures_statistics/fy2017-
statistical-chart.pdf on May 29, 2018. 
17 CMS, Center for Program Integrity, New Hampshire Focused Program Integrity Review 
(May 2017), pp. 1-2.  Accessed at https://www.cms.gov/Medicare-Medicaid-
Coordination/Fraud-Prevention/FraudAbuseforProfs/Downloads/NHfy16.pdf on  
November 20, 2017. 
18 The Program Integrity Unit is part of the New Hampshire Department of Health and 
Human Services, Office of Improvement & Integrity. 
19 New Hampshire Department of Health and Human Services, Program Integrity Unit. 
Accessed at https://www.dhhs.nh.gov/oii/pi.htm on March 14, 2018.   
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  3  algorithm outputs from an electronic fraud detection system and to 
generate fraud referrals based on that analysis of the Medicaid data. 
The Program Integrity Unit also conducts preliminary investigations of 
referrals that it receives from other sources.  These referral sources include, 
but are not limited to, the public, MCOs, and other State agencies.  If there 
is a reason to believeon the basis of the Program Integrity Units 
preliminary investigation of the referralsthat an incident of fraud has 
occurred, the Program Integrity Unit is required to refer the case to the 
MFCU.20, 21 
Previous OIG Onsite  In 2012, OIG issued a report regarding its onsite review of the MFCU.  The 
Review  report contained four recommendations stemming from the MFCUs  
nonadherence to certain performance standards.  OIG recommended that 
the MFCU (1) ensure that it maintains an adequate workload through 
referrals from the State Medicaid agency; (2) ensure that case files contain 
documented supervisory reviews; (3) seek to expand staffing to reflect the 
number of staff approved in its budget; and (4) establish annual training 
plans for each professional discipline.  From the MFCUs reporting of 
subsequent actions it had taken, OIG considered each of these 
recommendations as having been implemented. 
Methodology  We conducted the onsite review in May 2017.  The review team consisted of 
OIG evaluators, auditors, law enforcement agents, and a director from 
another State MFCU.  The primary purpose of the review was to follow up 
on issues that OIG had identified through its ongoing administration and 
oversight activities.  We focused the review on five general areas: (1) case 
outcomes; (2) referrals; (3) staff and leadership turnover; (4) MFCU 
operations; and (5) fiscal controls.   
Our review covered the 3-year period of FYs 20142016.  We based our 
inspection on an analysis of data from six sources: (1) MFCU documentation; 
(2) financial documentation; (3) structured interviews with key stakeholders;
(4) structured interviews with the MFCUs managers and staff; (5) a review of
case files that were open at some point during the review period; and
(6) observation of MFCU operations.  (See Appendix C for a detailed
methodology.)
20 The memorandum of understanding between the Medicaid agency and the MFCU states 
that all cases of suspected provider fraud or abuse should be referred to the MFCU.  
Memorandum of Understanding between New Hampshire Office of the Attorney General and 
New Hampshire Department of Health and Human Services, March 16, 2017, p. 2, Term 4.     
21 If the Program Integrity Unit receives a complaint of Medicaid fraud or identifies 
questionable practices it is required to conduct a preliminary investigation to determine 
whether sufficient evidence exists to warrant a full investigation.  See 42 CFR  455.14. In 
addition, the agency must refer all cases of suspected provider fraud to the MFCU.  See 
42 CFR  455.21.     
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  4  Standards  This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General on 
Integrity and Efficiency.  These inspections differ from other OIG evaluations 
in that they support OIGs direct administration of the MFCU grant program, 
but they are subject to the same internal quality controls as other OIG 
evaluations, including internal peer review.  
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  5  FINDINGS 
The MFCUs  During FYs 20142016, the New Hampshire MFCUs case outcomes were low 
compared to previous years, and its number of fraud convictions was lower 
case outcomes 
than for any other similarly sized MFCU.22  The low case outcomes held true 
were low during 
for both criminal and civil cases.  Exhibit 1 displays the MFCUs case 
FYs 20142016  outcomes during FYs 20142016 and FYs 20112013, and the range of 
outcomes among similarly sized MFCUs during FYs 20142016.  For 
example, the New Hampshire MFCU had no fraud convictions during  
FYs 20142016, whereas it had four fraud convictions during the previous 
3-year period.  In the 3-year period of FYs 20142016, the number of fraud
convictions among similarly sized MFCUs ranged from 9 to 98.
Exhibit 1: The New Hampshire MFCUs case outcomes were low 
compared to previous years and similarly sized MFCUs.*   
New Hampshire  Similarly Sized 
MFCU  MFCUs 
Previous 
Type of  3-year period FYs 20142016 
Case  Outcome  FYs 20142016  (FYs 20112013)  (range) 
Fraud convictions  0  4  9 to 98 
Patient abuse or 
neglect  4  9  0 to 62 
Criminal 
convictions 
Criminal  $224,000 to 
$13,923  $1.1 million 
recoveries  $15.2 million 
Civil settlements 
25  43  19 to 49 
and  judgments 
Civil 
$1.5 million to 
Civil recoveries  $2.6 million  $14.9 million 
$44.4 million 
*Source:  OIG MFCU Statistical Data Charts, FYs 2014-2016.
22 Although comparison across similarly sized MFCUs provides context for the case outcomes 
of a particular MFCU, many factors other than a MFCUs staff size can affect case outcomes.  
See Appendix C for a detailed description of our analysis, including the selection of similarly 
sized MFCUs and limitations associated with the comparative analysis.   
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   6  The MFCU  The New Hampshire MFCU received a total of six fraud referrals from the 
Program Integrity Unit during FYs 20142016, which was the second lowest 
received few 
number among similarly sized MFCUs.23, 24  The MFCU had received the 
fraud referrals 
same total number of fraud referrals from the Program Integrity Unit during 
from the  the previous 3-year period.  This pattern of a low number of fraud referrals 
Medicaid  from the Program Integrity Unit to the New Hampshire MFCU was also 
noted in OIGs 2012 onsite review report.   
Program 
The continued pattern of few fraud referrals from the States Program 
Integrity Unit 
Integrity Unit to the MFCU is concerning because the Program Integrity Unit 
and other key 
monitors the States Medicaid program for fraud.  The Program Integrity 
sources; the  Unit also has staff to analyze Medicaid data for fraud and to conduct 
MFCU initiated  preliminary investigations of referrals that it receives from a variety of 
sources.  Therefore, it should be a significant source of quality referrals for 
greater referral 
the MFCU.  Appendix B illustrates the MFCUs referrals, by source, during 
outreach in  
FYs 20142016.  Performance Standard 4 states that a MFCU should take 
FY 2016  steps to ensure that it receives an adequate volume and quality of referrals 
from its State Medicaid agency and other sources.     
We found that one factor limiting the number of fraud referrals that the 
MFCU received during FYs 20142016 was that the Program Integrity Unit 
did not review and send MCO-generated referrals to the MFCU in a timely 
manner.25  Officials from the Program Integrity Unit identified six fraud 
referrals that they received from the MCOs during FYs 20142016, but did 
not send to the MFCU during that period.26  The officials acknowledged that 
the Program Integrity Unit should have reviewed those referrals from MCOs 
andafter appropriate preliminary investigationsent them to the MFCU 
during FYs 20142016.  Those officials said that the six referrals had not 
been reviewed or forwarded in a timely manner because the Program 
Integrity Unit had key staff vacancies at the time.  The Program Integrity 
Unit eventually forwarded the six referrals to the MFCU in FY 2017, which 
23 By comparison, the number of fraud referrals that similarly sized MFCUs received from 
their respective Program Integrity Units during FYs 20142016 ranged from 4 to 165 per 
MFCU.   
24 The MFCU received one additional fraud referral from another part of the Medicaid agency 
during FYs 20142016.     
25 Each of the MCOs contracts with the State and each of the MCOs policies and procedures 
require that the Special Investigations Units refer any suspected provider fraud to the 
Program Integrity Unit.     
26 In addition to the six MCO-generated referrals that Program Integrity Unit officials 
reported having received during FYs 20142016 and having relayed to the MFCU in FY 2017, 
there was one additional MCO referral that the Program Integrity Unit reported having 
received in FY 2014 and having reviewed and sent to the MFCU that same year.  However, 
the MFCU reported that it had not received any MCO fraud referrals during that period, 
either from the Program Integrity Unit or directly from the MCOs.  It is possible that for this 
one referral, the MFCU might have received the information but did not deem it to constitute 
an actual referral.     
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  7  was the year of the OIG onsite review.  The time that had elapsed between 
when the Program Integrity Unit received each of the six referrals and when 
it sent them to the MFCU ranged from 6 months to 29 months.  See 
Exhibit 2.  According to the MFCU director, the delays for each of these 
referrals compromised the viability of any potential investigations or 
prosecutions. 
The low volume of MCO-generated referrals over a 3-year period is 
concerning for a State where about 96 percent of the Medicaid population 
is served by MCOs.  Performance Standard 6(B) states that for a State that 
relies substantially on managed care entities for the provision of Medicaid 
services, the MFCUs case mix should consist of a commensurate number of 
MCO cases.  In a 2017 report, CMS highlighted this issue in observing that 
the number of fraud referrals that each of New Hampshires MCOs had sent 
to the Program Integrity Unit was low compared to the size of the plans.27  
A low number of MCO fraud referrals in a State that is predominantly served 
by MCOs makes it difficult for the MFCU to carry out its mission effectively.  
Exhibit 2: The MFCU experienced significant delays in receiving MCO 
referrals from the Program Integrity Unit.*    
PIU Sent to NH MFCU 
Received (measured in months) 
Referral 1 6
Referral 2 11
Referral 3 12
Referral 4 17
Referral 5 17
Referral 6 29
*Source:  Program Integrity Units response to OIG data request, September 2017.
In FY 2016, the MFCU initiated outreach efforts in an attempt to 
increase incoming referrals  
In May 2016, the MFCU director initiated efforts to increase the number of 
fraud referrals from the MCOs.  The MFCU held meetings with Special 
Investigations Unit staff from the two MCOs.  During these meetings, MFCU 
27 CMS (Center for Program Integrity), New Hampshire Focused Program Integrity Review 
(May 2017), p. 4, accessed at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/NHfy16.pdf on November 29, 2017.  The CMS 
analysis of referrals used data from FYs 20132015. 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  8  leadership provided education on fraud trends, the importance of referring 
any suspected fraud, and the kinds of information needed in a quality 
referral of fraud.28    
The MFCU also expanded its outreach to increase the number of referrals of 
patient abuse or neglect.  The MFCU provided outreach and education 
addressing how and when to make referrals to the MFCU.  The information 
was provided to nursing homes, local law enforcement agencies, a police 
academy, and other long-term care facilities and State agencies.   
As part of the effort to increase referrals of patient abuse or neglect, the 
MFCU director established a process that would notify the MFCU whenever 
the States Adult Protective Services agency referred an allegation of patient 
abuse or neglect to local law enforcement.  This process may have 
contributed to a significant increase in referrals of patient abuse or neglect 
to the MFCU.29  The MFCU received no referrals from Adult Protective 
Services in FYs 20142015, but received 27 from that agency in FY 2016 and 
46 in FY 2017.30      
The MFCU also created two documents to facilitate its outreach.  One was 
a pamphlet that described the MFCU and its role in combating Medicaid 
fraud, drug diversion, and patient abuse and neglect.  The pamphlet 
included contact information for the MFCU and other State oversight and 
law enforcement agencies.  The other document was a jurisdiction chart 
that illustrated the types of allegations that the MFCU has authority to 
investigate under the MFCU grant.  These efforts may have contributed to 
an increase in the number of fraud referrals sent to the MFCU in FY 2017.  
For example, during FYs 20142016, the MFCU received no fraud referrals 
from the States certification and survey agency.  However, the MFCU 
received 22 fraud referrals from that agency in FY 2017. 
The MFCU  Although the staffing level remained generally constant (at eight 
employees), the MFCU experienced significant staff turnover during 
experienced 
FYs 20142016.  At the time of our onsite review, the staff member with the 
significant 
longest tenure had served with the MFCU for approximately 3 years.  Of the 
turnover among  eight individuals who left the MFCU, five transitioned elsewhere within the 
State Attorney Generals Office.  Staff turnover may have also contributed to 
staff and 
low case outcomes.  One MFCU staff member commented that staff 
leadership 
turnover killed production.   
28 In the last few months of the FY 20142016 period, the MFCU director initiated outreach 
efforts to increase referrals of fraud.  However, in FY 2017, the MFCU reported receiving no 
referrals from MCOs, either directly or through the Program Integrity Unit.     
29 By examining patient-abuse referrals sent to law local enforcement, the MFCU may have 
been able to assume responsibility for some cases falling under its jurisdiction.     
30 The total of number of patient abuse or neglect referrals received from all sources 
increased from a total of 37 during FYs 20142015 to 58 in FY 2016.  
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   9  The MFCU leadership also had significant turnover.  The MFCU had two 
different directors during the 3-year period of FYs 20142016.  The first of 
these departed in February 2016.  The subsequent director, who was serving 
as director at the time of our onsite review, left the MFCU after serving 
about 15 months (from May 2016 to August 2017).  Another individual 
began as director of the MFCU in September 2017.   
A few cases had  We identified significant investigative delays associated with a few of the 
case files that we reviewed and a lack of documented periodic supervisory 
investigative 
reviews for almost half of the case files.  Among the 95 case files we 
delays; almost half 
reviewed, 13 cases appeared to have experienced significant investigative 
of the case files  delays.31  Performance Standard 5(B) states that MFCU supervisors should 
lacked  take action as necessary to ensure that investigations and prosecutions are 
completed in an appropriate timeframe.  However, case files associated with 
documented 
13 investigations lacked documentation of any investigative activities for at 
supervisory review 
least 1 year, and 5 of those 13 case files lacked documentation of any 
investigative activities for longer than 2 years.   
The MFCU staff did not have explanations for the delays in 9 of the 13 cases 
that we identified as having delays.  Of these nine cases with unexplained 
delays, seven were assigned to one investigator who left the MFCU before 
our onsite review.  MFCU staff explained that for many of these cases, the 
allegations associated with the cases were too old to effectively investigate 
or prosecute when new MFCU personnel took over the cases. 
We also found that many case files lacked documented supervisory reviews.  
Among the 95 case files that we reviewed, almost half44lacked 
documentation that supervisors conducted periodic reviews of the cases.  
OIGs 2012 report on its prior New Hampshire MFCU onsite review 
contained a similar finding.  Performance Standard 7(A) indicates that MFCU 
supervisors should review case files periodically and that these reviews 
should be noted in the related case files.  MFCU staff did not have 
explanations for the lack of documentation in the case files.  However, prior 
to our onsite review, the then-director of the MFCU strengthened the case 
file review policy for supervisors by requiring reviews every 90 days, rather 
than every 120 days.  At the time of our onsite review, it was too early to 
assess whether this policy change had had any impact on the MFCUs 
review practices.  
31 Although our initial sample of cases consisted of 102 cases, 6 of those cases had been 
closed after preliminary review and MFCU staff could not locate 1 other file. 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  10  The MFCU generally  During FYs 20142016, the MFCU generally maintained adequate internal 
maintained proper  controls related to accounting, budgeting, personnel, procurement, 
property, and equipment.  However, although the MFCU claimed 
fiscal controls, but 
expenditures that represented allowable costs, it did not have policies and 
lacked some policy 
procedures in place to ensure that vehicle costs were allocated in 
guidance  accordance with Federal regulations.32   
32 The MFCU claimed vehicular costs on one occasion that were not directly related to MFCU 
activities.  45 CFR  75.405(a).  A cost is allocable to a particular Federal award or other cost 
objective if the goods or services involved are chargeable or assignable to that Federal award 
or cost objective in accordance with relative benefits received.   
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  11  CONCLUSION AND RECOMMENDATIONS 
A variety of factors contributed to the low case outcomes that the MFCU 
experienced during FYs 20142016.  These factors were (1) a lack of 
incoming referrals from the Medicaid Program Integrity Unit and other 
key sources; (2) turnover in staffing and leadership; and (3) investigative 
delays and a lack of documented supervisory reviews of case files.  
Therefore, we recommend that the MFCU: 
Develop and implement a plan to increase referrals from the 
Medicaid agency and MCOs  
Both this 2017 onsite review and OIGs prior 2012 review found a lack of 
incoming referrals from the Medicaid agency.  The MFCU should further 
engage with the Medicaid agencys Program Integrity Unit, and with the two 
MCOs Special Investigative Units, to develop and implement a plan to 
increase the number of referrals to the MFCU.  The plan should include 
provisions that would ensure the appropriate quantity, quality, and 
timeliness of referrals.  The MFCU should build upon the increased outreach 
that it initiated in 2016 to ensure that its partners have all the information 
that the MFCU can supply to help increase referrals from them.  The MFCU 
should also monitor the flow of referrals from these sources, and should 
take action to alert the Medicaid agency and MCOs if referrals remain low 
or begin to decline over time.   
Develop and implement a plan to reduce staff and leadership 
turnover  
The MFCU should identify the causes of its significant staff and leadership 
turnover and address those causes.  In consultation with OIG and other 
appropriate officials at the State Attorney Generals office, the MFCU should 
develop a written plan to address MFCU employee retention, both at the 
staff and director levels.  Continual staff turnover can disrupt casework 
continuity and result in investigative delays.  Frequent changes in MFCU 
leadership can also make it more difficult to maintain consistent internal 
practices, such as supervisor oversight of casework.  The plan should 
identify methods for recruiting and retaining employees.   
Implement policies and procedures to ensure that significant 
investigative delays are explained in the case files and that 
periodic supervisory reviews are documented 
Both this 2017 onsite review and OIGs prior 2012 review found that MFCU 
cases lacked documented supervisory reviews.  Documented supervisory 
review of cases is important in helping to ensure that cases do not have 
unnecessary investigative delays and in helping to advance cases.  Although 
the MFCU took actions that appeared to have addressed OIGs 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   12  recommendation from 2012, those actions did not have a lasting effect
again, many cases had no documentation that periodic supervisory reviews 
had occurred.  The MFCU should establish a documented process to record 
when and whether periodic supervisory reviews occur.     
Revise its fiscal control policies governing vehicle costs  
The MFCU should revise its fiscal control policies to ensure that the 
allocation of equipment costs, such as vehicle costs, is in accordance with 
Federal regulation. 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   13  MFCU COMMENTS AND OIG RESPONSE 
The MFCU concurred with all four of our recommendations. 
Regarding our recommendation that the MFCU develop and implement a 
plan to increase referrals from the Medicaid agency and MCOs, the MFCU 
stated that it now participates in monthly case review meetings that are 
attended by the Program Integrity Unit and MCOs.  During these meetings, 
the agencies examine pending investigations and referrals.  The MFCU said 
that it will foster close collaboration with the Program Integrity Unit to 
increase the number of referrals.     
Regarding our recommendation that the MFCU develop and implement a 
plan to reduce staff and leadership turnover, the MFCU stated that its future 
recruitment efforts would target individuals with a demonstrated 
commitment to the MFCUs mission.  The MFCU further expressed its intent 
to keep attorneys within the MFCU to the extent possible, so as to allow 
them to develop subject-matter expertise, and to refrain from transferring 
staff to positions external to the MFCU.   
Regarding our recommendation that the MFCU implement policies and 
procedures to ensure that significant investigative delays are explained in 
the case files and that periodic supervisory reviews are documented, the 
MFCU reported revising its case file review process.  The MFCU stated that 
as part of this effort, it would review and redesign the forms used to 
document case file reviews, and that it anticipates completing this effort 
within 4 months.   
Regarding our recommendation that the MFCU revise its fiscal control 
policies governing vehicle costs, the MFCU reported implementing a new 
policy requiring staff to record vehicular miles associated with off-grant 
activities, so that the costs can be deducted from allowable grant 
reimbursement requests.  The MFCU expects the new policy to be added to 
its Policy and Procedure Manual within 45 days.     
The full text of the MFCUs comments is provided in Appendix D.  
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  14  APPENDIX A:  MFCU Performance Standards  
33
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 website; and
E) Terms and conditions of the notice of the grant award.
2) A Unit maintains reasonable staff levels and office locations
in relation to the States Medicaid program expenditures
and in accordance with staffing allocations approved in its
budget.
A) The Unit employs the number of staff that is included in the Units
budget estimate as approved by OIG.
B) The Unit employs a total number of professional staff that is
commensurate with the States total Medicaid program expenditures
and that enables the Unit to effectively investigate and prosecute (or
refer for prosecution) an appropriate volume of case referrals and
workload for both Medicaid fraud and patient abuse and neglect.
C) The Unite employs an appropriate mix and number of attorneys,
auditors, investigators, and other professional staff that is both
commensurate with the States total Medicaid program expenditures
and that allows the Unit to effectively investigate and prosecute (or
refer for prosecution) an appropriate volume of case referrals and
workload for both Medicaid fraud and patient abuse and neglect.
D) The Unit employs a number of support staff in relation to its overall
size that allows the Unit to operate effectively.
E) To the extent that a Unit maintains multiple office locations, such
locations are distributed throughout the State, and are adequately
staffed, commensurate with the volume of case referrals and
workload for each location.
3) A Unit establishes written policies and procedures for its
operations and ensures that staff are familiar with, and
adhere to, policies and procedures.
A) The Unit has written guidelines or manuals that contain current
policies and procedures, consistent with these performance
33 77 Fed. Reg. 32645 (June 1, 2012). 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  15  standards, for the investigation and (for those Units with 
prosecutorial authority) prosecution of Medicaid fraud and patient 
abuse and neglect. 
B) The Unit adheres to current policies and procedures in its
operations.
C) Procedures include a process for referring cases, when appropriate,
to Federal and State agencies.  Referrals to State agencies, including
the State Medicaid agency, should identify whether further
investigation or other administrative action is warranted, such as the
collection of overpayments or suspension of payments.
D) Written guidelines and manuals are readily available to all Unit staff,
either online or in hard copy.
E) Policies and procedures address training standards for Unit
employees.
4) A Unit takes steps to maintain an adequate volume and
quality of referrals from the State Medicaid agency and
other sources.
A) The Unit takes steps, such as the development of operational
protocols, to ensure that the State Medicaid agency, managed care
organizations, and other agencies refer to the Unit all suspected
provider fraud cases.  Consistent with 42 CFR 1007.9(g), the Unit
provides timely written notice to the State Medicaid agency when
referred cases are accepted or declined for investigation.
B) The Unit provides periodic feedback to the State Medicaid agency
and other referral sources on the adequacy of both the volume and
quality of its referrals.
C) The Unit provides timely information to the State Medicaid or other
agency when the Medicaid or other agency requests 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.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   16  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
providers types and includes a balance of fraud and, where
appropriate, patient abuse and neglect cases.
A) The Unit seeks to have a mix of cases from all significant provider
types in the State.
B) For those States that rely substantially on managed care entities for
the provision of Medicaid services, the Unit includes a
commensurate number of managed care cases in its mix of cases.
C) The Unit seeks to allocate resources among provider types based on
levels of Medicaid expenditures or other risk factors.  Special Unit
initiatives may focus on specific provider types.
D) As part of its case mix, the Unit maintains a balance of fraud and
patient abuse and neglect cases for those States in which the Unit
has original jurisdiction to investigate or prosecute patient abuse
and neglect cases.
E) As part of its case mix, the Unit seeks to maintain, consistent with its
legal authorities, a balance of criminal and civil fraud cases.
7) A Unit maintains case files in an effective manner and
develops a case management system that allows efficient
access to case information and other performance data.
A) Reviews by supervisors are conducted periodically, consistent with
MFCU policies and procedures, and are noted in the case file.
B) Case files include all relevant facts and information and justify the
opening and closing of the cases.
C) Significant documents, such as charging documents and settlement
agreements, are included in the file.
D) Interview summaries are written promptly, as defined by the Units
policies and procedures.
E) The Unit has an information management system that manages and
tracks case information from initiation to resolution.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   17  F) The Unit has an information management system that allows for the
monitoring and reporting of case information, including the
following:
1) The number of cases opened and closed and the reason
that cases are closed.
2) The length of time taken to determine whether to open a
case referred by the State Medicaid agency or other
referring source.
3) The number, age, and types of cases in the Units
inventory/docket.
4) The number of referrals received by the Unit and the
number of referrals by the Unit to other agencies.
5) The dollar amount of overpayments identified.
6) The number of cases criminally prosecuted by the Unit or
referred to others for prosecution, the number of
individuals or entities charged, and the number of
pending prosecutions.
7) The number of criminal convictions and the number of
civil judgments.
8) The dollar amount of fines, penalties, and restitution
ordered in a criminal case and the dollar amount of
recoveries and the types of relief obtained through civil
judgments or prefiling settlements.
8) A Unit cooperates with OIG and other Federal agencies in
the investigation and prosecution of Medicaid and other
health care fraud.
A) The Unit communicates on a regular basis with OIG and other
Federal agencies investigating or prosecuting health care fraud in
the State.
B) The Unit cooperates and, as appropriate, coordinates with OIGs
Office of Investigations and other Federal agencies on cases being
pursued jointly, case involving the same suspects or allegations, and
cases that have been referred to the Unit by OIG or another Federal
agency.
C) The Unit makes available, to the extent authorized by law and upon
request by Federal investigators and prosecutors, all information in
its possession concerning provider fraud or fraud in the
administration of the Medicaid program.
D) For cases that require the granting of extended jurisdiction to
investigate Medicare or other Federal health care fraud, the Unit
seeks permission from OIG or other relevant agencies under
procedures as set by those agencies.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   18  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.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   19  11) A Unit exercise 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.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  20  APPENDIX B:  New Hampshire MFCU Referrals 
Received, by Source, FYs 20142016 
FY 2014  FY 2015  FY 2016  Period Total 
Patient  Patient  Patient  Patient 
Abuse/  Abuse/  Abuse/  Abuse/ 
Source  Fraud  Neglect  Fraud  Neglect  Fraud  Neglect  Fraud  Neglect  Total 
Public/Private 
39  3  36  3  19  3  94  9  103 
Citizens 
Adult Protective 
0  0  0  0  2  27  2  27  29 
Services 
Other Law 
4  1  0  6  3  10  7  17  24 
Enforcement 
Providers  5  6  0  7  1  2  6  15  21 
Other/MFCU 
3  1  2  0  11  4  16  5  21 
Hotline 
Other State 
2  0  0  0  4  6  6  6  12 
Agencies 
Long-Term Care 
0  4  0  2  0  5  0  11  11 
Ombudsman 
Licensing Board  3  1  1  2  0  1  4  4  8 
HHS OIG  0  0  4  0  4  0  8  0  8 
SURS/PIU*  1  0  2  0  3  0  6  0  6 
Prosecutors  0  1  1  0  0  0  1  1  2 
Medicaid 
0  0  1  0  0  0  1  0  1 
Agency-Other 
MCOs  0  0  0  0  0  0  0  0  0 
Total  57  17  47  20  47  58  151  95  246 
74  67  105 
*SURS is an acronym for the States Surveillance and Utilization Review Subsystem and PIU is an acronym for the States Program Integrity Unit.
New Hampshires PIU was formerly referred to as its SURS.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   21  APPENDIX C:  Detailed Methodology 
The onsite review team consisted of OIG evaluators, auditors, and agents, as 
well as a director from another State MFCU.  The primary purpose of the 
review was to follow up on issues identified by OIG through its ongoing 
oversight activities.  We focused the review on five general areas: (1) case 
outcomes, (2) referrals, (3) staff turnover, (4) MFCU operations, and, (5) fiscal 
controls. 
We analyzed qualitative and quantitative data from a variety of sources. 
These included:  
 case outcome data;
 referral data associated with the MFCU;
 other documentation submitted by the MFCU;
 structured interviews with MFCU staff and key stakeholders;
 onsite review of case files;
 onsite observations; and
 documentation related to the MFCUs fiscal controls.
Data Collection   Case outcomes  
Prior to the onsite visit, we examined statistical reports and other 
and Analysis  
documentation submitted by the MFCU to OIG.  This included MFCU case 
outcome data pertaining to FYs 20142016 and the previous 3-year period   
(FYs 20112013).34  We examined five case outcome measures: (1) the 
number of fraud convictions; (2) the number of convictions for patient 
abuse or neglect; (3) the amount of monetary recoveries associated with 
criminal convictions; (4) the number of civil settlements and judgments; and 
(5) the amount of monetary recoveries associated with civil cases.
For each measure, we performed two types of comparative analysis.  We 
compared outcomes for the New Hampshire MFCU during each 
3-fiscal-year period to determine whether outcomes changed during
FYs 20142016.  We also compared New Hampshires outcomes for
FYs 20142016 to those of other similarly sized MFCUs.35  The 8 similarly
sized MFCUs have staff sizes ranging from 6 to 10 employees; the
New Hampshire MFCU has an approved staffing level of 8 employees.36
34 To provide context about the effect of some New Hampshire MFCU initiatives, we included 
some FY 2017 data. 
35 Although comparison across similarly sized MFCUs provides context for the case outcomes 
of a particular MFCU, many factors other than a MFCUs staff size can affect case outcomes. 
36 The figures of 6-10 employees comes from the numbers of employees that MFCUs 
reported having at the end of FY 2016.   
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  22  Referrals of fraud and patient abuse or neglect  
We examined data associated with referrals sent to and received by the 
MFCU from a variety of sources.  This included the number of referrals that 
the MFCU reported receiving during FYs 20142016; the number of referrals 
from the previous 3-FY period; and the number of referrals received by 
similarly sized MFCUs during FYs 20142016.  These data included both 
fraud referrals and those allegations related to patient abuse or neglect.  For 
six referrals of provider fraud that the Program Integrity Unit referenced as 
having received from the States MCOs, we learned when the Program 
Integrity Unit had relayed the referrals to the MFCU (2017) and then 
calculated for each referral the timespan (in months) between when the 
Program Integrity Unit had received the referral and when it passed the 
referral along to the MFCU.  We also examined the processes that the MFCU 
used for monitoring the opening of cases, and we examined the outcomes 
of cases.  We also reviewed the MFCUs memorandum of understanding 
with the State Medicaid agency.   
Other documentation 
We examined the MFCUs policies and procedures and held discussions with 
Unit management to gain an understanding of those policies and 
procedures.  We confirmed with the MFCU director that the information we 
had was current and requested any additional data or clarification that we 
needed.  We also examined data associated with the MFCUs staff, both to 
identify the number of MFCU staff and to determine how long each staff 
member had been at the MFCU during the period of FYs 20142016.  
Interviews with MFCU staff and director 
We conducted interviews with all the MFCU staff, including the 
then-director of the MFCU, at the time of the onsite review.  These 
interviews focused on case outcomeswhy they were low during  
FYs 20142016 and how to improve them.  The interviews were informed by 
our analysis of the MFCUs case-outcomes data, other documentation, and 
stakeholder interviews.  We asked MFCU staff to provide us with any 
additional context that could help us understand the MFCUs operations, 
including issues with retaining staff.  Subsequent to the onsite review, we 
followed up with the MFCU director and the directors successor, to clarify 
certain data that we collected onsite and to gain further information. 
Key stakeholder interviews 
In April and May 2017, we interviewed individual stakeholders from eight 
entities who were familiar with the MFCUs operations.  Staff conducting the 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   23  structured interviews included OIG evaluators and agents, and a director 
from another State MFCU.  Stakeholders whom we interviewed included a 
manager and an attorney from the Medicaid agencys Program Integrity 
Unit; the Criminal Bureau Chief from the New Hampshire Department of 
Justice;37 the States Long-Term Care Ombudsman; a manager from the 
Bureau of Elderly and Adult Services (Adult Protective Services); Special 
Investigations Unit staff from the States two MCOs; two Assistant U.S. 
Attorneys; and another OIG agent who worked closely with the MFCU.   
We focused these interviews on (1) the MFCUs relationship and interactions 
with these entities; (2) any areas in which stakeholders believed the MFCU 
had opportunities for improvement; and (3) practices that may be beneficial 
to the MFCUs operations or to other MFCUs.  As needed, we followed up 
with some of the interviewees after the onsite review. 
Case file reviews 
We asked the MFCU to provide us with a list of cases that were open at any 
point during FYs 20142016.  The MFCU provided us with a list of 224 cases 
that met these parameters.  Forty-three of these cases were global cases, 
which we excluded from consideration for our onsite review of case files.  
(Global cases are False Claims Act cases that are litigated in Federal court by 
the U.S. Department of Justice and typically involve a group of MFCUs.)  
Of the remaining 181 cases on the list, 78 were related to fraud allegations.  
We examined case files related to all 78 of these cases because we were 
most concerned with the MFCUs low fraud outcomes for FYs 20142016.  
We added one additional case to our list of fraud cases because it was not 
clear whether it was a case of fraud or a case of patient abuse or neglect.   
Of the 102 cases of patient abuse or neglect on the MFCUs list, we 
purposively selected the 23 cases that the MFCU had opened since 
January 2015 to give us a picture of the MFCUs most recent investigations 
of patient abuse or neglect.  With the assistance of OIG agents and the 
director from another State MFCU, we reviewed referrals received by the 
MFCU and the MFCUs processes for monitoring the opening, status, and 
outcomes of cases.38  We also reviewed the MFCUs approach to 
investigating and prosecuting cases there were open at some point during 
FYs 20142016. 
Onsite observations 
While onsite, we examined the MFCUs workspace and operations to 
identify any instances of nonadherence to performance standards and/or 
instances of noncompliance with applicable Federal laws, regulations, and 
37 The Criminal Bureau Chief directly supervises the MFCU director. 
38 To verifyin the absence of documentationwhether the periodic reviews for these files 
had ever been conducted, we followed up with the MFCU staff.   
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   24  OIG policy transmittals.  Among other things, we evaluated the security of 
the MFCUs case files and the functionality of the MFCUs electronic system 
for tracking case files.   
Fiscal review 
OIG auditors reviewed the MFCUs internal fiscal controls and use of fiscal 
resources to identify any internal control issues or other issues involving the 
use of resources.  The review examined the MFCUs response to a 
questionnaire about internal controls over accounting, budgeting, 
personnel, procurement, property, and equipment and the MFCUs financial 
policies and procedures.  OIG staff also held discussions with MFCU staff 
about policies and procedures and questionnaire responses.   
We also examined the MFCUs claimed grant expenditures for  
FYs 20142016.  For these expenditures, we (1) reviewed quarterly and 
annual Federal financial status reports (SF-425 forms) that the MFCU 
submitted to OIG; (2) examined, on a limited test basis, evidence supporting 
selected expenditures within the direct cost categories; and (3) verified, on  
a limited test basis, whether selected indirect costs were adequately 
allocated to the MFCU in accordance with the approved indirect cost rate 
proposal. 
While onsite, we reviewed three purposive samples to assess the MFCUs 
internal control of fiscal resources: 
1. To assess the MFCUs expenditures, we selected 38 transactions
for additional review.  We selected these transactions from the
monthly expenditures for 3 months, one for each fiscal year.  We
purposively included transactions from different Federal cost
categories and included automated as well as manual journal
entries.  We then requested and reviewed documentation
supporting the selected transactions.
2. To assess employees time and effort (i.e., their work hours spent
on various MFCU tasks), we selected a sample of three pay
periods, one from each fiscal year.  We then requested and
reviewed documentation to support the time and effort of MFCU
staff during the selected pay periods.
3. We also reviewed the MFCUs fixed-asset inventory.  The
fixed-asset inventory accounted for 109 items that were present
and 5 items that had been either disposed of or replaced.
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   25  APPENDIX D:  MFCU Comments 
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   26  New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   27  New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)   28  ACKNOWLEDGMENTS 
Michael Henry served as the team leader for this study, and  
Matthew DeFraga served as the lead analyst.  Others in the Office of 
Evaluation and Inspections who conducted the study include  
Anthony Soto McGrath.  Medicaid Fraud Policy and Oversight Division staff 
who participated in the review include Susan Burbach.  Office of Evaluation 
and Inspections staff who provided support include Kevin Farber,  
Christine Moritz, and China Tantameng.  
We would also like to acknowledge the contributions of Office of Audit 
Services staff, including Ravinder Chana and Charles McKenney.  Office of 
Investigations staff and a peer reviewer from another State MFCU also 
participated in this review. 
This report was prepared under the direction of Blaine Collins, Regional 
Inspector General for Evaluation and Inspections in the San Francisco 
regional office, and Abigail Amoroso and Michael Henry, Deputy Regional 
Inspectors General; and in consultation with Richard Stern, Director of the 
Medicaid Fraud Policy and Oversight Division.     
To obtain additional information concerning this report or to obtain copies, 
contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.  
New Hampshire Medicaid Fraud Control Unit: 2017 Onsite Review (OEI-09-17-00200)  29  ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public 
Law 95-452, as amended, is to protect the integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and 
welfare of beneficiaries served by those programs.  This statutory mission is 
carried out through a nationwide network of audits, investigations, and 
inspections conducted by the following operating components: 
Office of Audit  The Office of Audit Services (OAS) provides auditing services for HHS, either 
by conducting audits with its own audit resources or by overseeing audit 
Services 
work done by others.  Audits examine the performance of HHS programs 
and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, 
abuse, and mismanagement and promote economy and efficiency 
throughout HHS. 
Office of Evaluation  The Office of Evaluation and Inspections (OEI) conducts national evaluations 
to provide HHS, Congress, and the public with timely, useful, and reliable 
and Inspections 
information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and 
effectiveness of departmental programs.  To promote impact, OEI reports 
also present practical recommendations for improving program operations.  
Office of  The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, 
Investigations 
operations, and beneficiaries.  With investigators working in all 50 States 
and the District of Columbia, OI utilizes its resources by actively 
coordinating with the Department of Justice and other Federal, State, and 
local law enforcement authorities.  The investigative efforts of OI often lead 
to criminal convictions, administrative sanctions, and/or civil monetary 
penalties. 
Office of Counsel to  The Office of Counsel to the Inspector General (OCIG) provides general 
legal services to OIG, rendering advice and opinions on HHS programs and 
the Inspector 
operations and providing all legal support for OIGs internal operations.  
General 
OCIG represents OIG in all civil and administrative fraud and abuse cases 
involving HHS programs, including False Claims Act, program exclusion, and 
civil monetary penalty cases.  In connection with these cases, OCIG also 
negotiates and monitors corporate integrity agreements.  OCIG renders 
advisory opinions, issues compliance program guidance, publishes fraud 
alerts, and provides other guidance to the health care industry concerning 
the anti-kickback statute and other OIG enforcement authorities.