Department of Health and Human Services 
Office of Inspector General 
 
District of Columbia Medicaid 
Fraud Control Unit: 2022 
Onsite Review 
 
Ann Maxwell 
Deputy Inspector General 
for Evaluation and Inspections 
September 2023, OEI-06-22-00420  Department of Health and Human Services 
 
Office of Inspector General 
Report in Brief 
September 2023, OEI-06-22-00420 
Unit Case Outcomes  District of Columbia Medicaid Fraud Control 
Federal fiscal years (FYs)  
Unit: 2022 Onsite Review  
20192021: 
  29 indictments 
What OIG Found 
  16 convictions 
  25 civil settlements and  We made two findings based on our review of areas of concern identified 
during our ongoing administration and oversight activities: the Units law 
judgments 
  $21.5 million in recoveries   enforcement authority and fraud referrals from MCOs.  We found that 
the Units limited law enforcement authority and the lack of adequate 
Unit Snapshot  policies and procedures to address its limited authorities posed 
challenges during our review period of FYs 20192021.  A few months 
The District of Columbia 
after our onsite review, the District of Columbia OIG succeeded in 
Medicaid Fraud Control Unit 
obtaining a legislative amendment from the District of Columbia Council.  
(MFCU or Unit) is located within 
The legislation, which was enacted in January 2023 as the Inspector 
the District of Columbia Office of 
General Enhancement Amendment Act of 2022, provides Unit 
Inspector General (OIG).  At the 
investigators with enhanced law enforcement authorities.  Despite the 
time of our onsite review in 
challenges associated with its limited law enforcement authority, we 
September 2022, the Unit had a 
observed that the Unit maintained strong working relationships with 
total of 21 staff.   
Federal and District partners, including HHS OIG, the Federal Bureau of 
Why OIG Did This Review  Investigation, the U.S. Attorneys Office, and the Districts Department of 
The U.S. Department of Health  Health Care Finances Division of Program Integrity.  Further, we found 
and Human Services (HHS) OIG  that the Unit received few fraud referrals from MCOs during our review 
administers the MFCU grant  period but has begun to take steps to increase these referrals.  
awards, annually recertifies each 
We also made two findings related to other aspects of the Units 
Unit, and oversees the Units 
operations.  We found that, for cases open longer than 90 days,             
performance in accordance with 
41 percent lacked documentation of periodic supervisory reviews 
the requirements of the grant.  
consistent with Unit policy.  We also found that the Unit did not always 
As part of this oversight, OIG 
report convictions or adverse actions to Federal partners within the 
conducts periodic reviews of 
appropriate timeframes.  These operational issues have persisted since 
Units and issues public reports of 
our previous onsite review in 2015; however, we found that the Unit has 
its findings.  
improved in both areas since that time.  
 
The primary purpose of this 
What OIG Recommends  
review was to examine two areas 
of concern that we identified  To address the findings, we recommend that the Unit (1) develop policies 
during our ongoing  and procedures to implement the District of Columbia OIGs expanded 
administration and oversight of  law enforcement authority and ensure that Unit investigators receive 
the District of Columbia MFCU:  training on the new authorities; (2) build upon its efforts with the 
(1) the Units law enforcement  Districts Medicaid agency to increase fraud referrals from the MCOs;    
authority and (2) fraud referrals  (3) ensure that supervisory reviews of case files are conducted and 
from managed care  documented in accordance with Unit policy; and (4) ensure that all 
organizations (MCOs).  As part of  convictions and adverse actions are reported to Federal partners within 
this review, we also examined  the appropriate timeframes.  The Unit concurred with all four 
the Units performance and  recommendations. 
operations.   
   
TABLE OF CONTENTS 
 
 
BACKGROUND ................................................................................................................................................ 1 
CASE OUTCOMES .......................................................................................................................................... 7 
The Unit reported 29 indictments, 16 convictions, and 25 civil settlements and judgments for FYs 
20192021. .................................................................................................................................................................................. 7 
The Unit reported combined civil and criminal recoveries of $21.5 million for  FYs 20192021. .............. 7 
FINDINGS ......................................................................................................................................................... 8 
The Units limited law enforcement authority and lack of adequate policies and procedures posed 
challenges during our review period; the Unit succeeded in obtaining a legislative amendment to 
expand its authorities .............................................................................................................................................................. 8 
The Unit received few fraud referrals from MCOs but has taken steps to increase these referrals ........ 11 
Forty-one percent of the Units case files lacked documentation of periodic supervisory reviews 
consistent with Unit policy .................................................................................................................................................. 12 
The Unit did not always report convictions or adverse actions to Federal partners within the 
appropriate timeframes ........................................................................................................................................................ 13 
RECOMMENDATIONS ................................................................................................................................ 15 
Develop policies and procedures to implement the District of Columbia OIGs expanded law 
enforcement authority and ensure that Unit investigators receive training on the new authorities ...... 15 
Build upon its efforts with the Districts Medicaid agency to increase fraud referrals from the MCOs . 16 
Ensure that supervisory reviews of case files are conducted and documented in accordance with Unit 
policy............................................................................................................................................................................................ 16 
Ensure that all convictions and adverse actions are reported to Federal partners within the 
appropriate timeframes ........................................................................................................................................................ 16 
UNIT COMMENTS AND OIG RESPONSE ................................................................................................ 17 
PERFORMANCE ASSESSMENT ................................................................................................................. 19 
APPENDICES  ............................................................................................................................................... 25 
Appendix A: Unit Referrals by Source for FYs 20192021 ....................................................................................... 25 
Appendix B: Detailed Methodology ................................................................................................................................. 26 
Appendix C: Point Estimates and 95-Percent Confidence Intervals of Case File Reviews ........................... 28 
Appendix D: Unit Comments .............................................................................................................................................. 29 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 34 
   
Acknowledgments .................................................................................................................................................................. 34 
Contact ........................................................................................................................................................................................ 34 
ABOUT THE OFFICE OF INSPECTOR GENERAL .................................................................................... 35 
 
 
   
BACKGROUND 
OBJECTIVES 
1.  To examine two areas of concern identified during our ongoing 
administration and oversight activities of the District of Columbia Medicaid 
Fraud Control Unit (MFCU or Unit): limitations on the MFCUs law 
enforcement authority and the adequacy of managed care fraud referrals. 
2.  To examine the Units performance and operations. 
 
Medicaid Fraud Control Units  
MFCUs investigate (1) Medicaid provider fraud and (2) patient abuse or neglect, and 
prosecute those cases under State law or refer them to other prosecuting offices.1, 2, 3  
Under the Social Security Act (SSA), a MFCU must be a single, identifiable entity of 
State government, separate and distinct from the State Medicaid agency, and 
employ one or more investigators, attorneys, and auditors.4  Each State must operate 
a MFCU or receive a waiver.5  Currently, 50 States, the District of Columbia, Puerto 
Rico, and the U.S. Virgin Islands operate MFCUs.6  
MFCUs are funded jointly by Federal and State Governments.  Each Unit receives a 
Federal grant award equivalent to 90 percent of total expenditures for new Units and 
75 percent for all other Units.7  In Federal fiscal year (FY) 2022, combined Federal and 
State expenditures for the MFCUs totaled approximately $343 million, of which 
approximately $257 million represented Federal funds.8   
_____________________________________________________________________________________________________________________________ 
1 SSA  1903(q)(3)-(4).  Regulations at 42 CFR  1007.11(b)(1) clarify that a Units responsibilities include 
the review of complaints of misappropriation of patients private funds in health care facilities. 
2 As of December 27, 2020, MFCUs may also receive Federal financial participation to investigate and 
prosecute abuse or neglect of Medicaid beneficiaries in a noninstitutional or other setting.  Consolidated 
Appropriations Act, 2021, Public Law 116-260, Division CC, Section 207. 
3 References to State in this report refer to the States, the District of Columbia, and the U.S. territories. 
4 SSA  1903(q). 
5 SSA  1902(a)(61). 
6 The territories of American Samoa, Guam, and the Northern Mariana Islands have not established Units. 
7 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.  Thereafter, the Federal Government contributes         
75 percent, and the State contributes 25 percent. 
8 OIG analysis of MFCUs reporting of expenditures for FY 2022.  Unless stated otherwise, all FYs are from 
October 1 through September 30. 
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OEI-06-22-00420   Background | 1    
OIG Grant Administration and Oversight of MFCUs 
The U.S. Department of Health and Human Services (HHS) Office of Inspector General 
(OIG) administers the grant award to each Unit and provides oversight of Units.9, 10  As 
part of its oversight, OIG conducts desk reviews of each Unit during the annual 
recertification process.  OIG also conducts periodic inspections and reviews.  Finally, 
OIG provides ongoing training and technical support to the Units. 
In its annual recertification review, OIG examines the Units reapplication materials, 
case statistics, and questionnaire responses from Unit stakeholders.  Through the 
recertification review, OIG assesses a Units performance, as measured by the Units 
adherence to published performance standards;11 the Units compliance with 
applicable laws, regulations, and OIG policy transmittals;12 and the Units case 
outcomes. 
OIG further assesses Unit performance by conducting inspections and reviews on 
selected Units, which includes evaluating Units effectiveness in investigating cases of 
possible fraud and patient abuse and neglect.13  These inspections and reviews result 
in public reports of findings and recommendations for improvement.  In these 
reports, OIG may also provide observations regarding Unit operations and practices, 
including beneficial practices that may be useful to share with other Units.  OIG also 
provides training and technical assistance to Units, as appropriate, during inspections 
and reviews. 
District of Columbia MFCU 
The District of Columbia MFCU is located within the District of Columbia OIG.  At the 
time of our onsite review in September 2022, the Unit had 21 employees11 
investigators (including the MFCU director, a Special Agent in Charge, and an 
Assistant Special Agent in Charge), 3 attorneys (including the deputy director),  
4 auditors, and 3 other staff (including analysts).  During our review period of  
FYs 20192021, the Unit spent approximately $9.6 million (with a District share of 
approximately $2.4 million).   
 
_____________________________________________________________________________________________________________________________ 
9 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. 
10 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. 
11 MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012).  The performance 
standards were developed by OIG in conjunction with the MFCUs and were originally published at         
59 Fed. Reg. 49080 (Sept. 26, 1994). 
12 OIG occasionally issues policy transmittals to provide guidance and instruction to MFCUs.  Policy 
transmittals are located at https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp.  
13 42 CFR  1007.17(c )(4)-(5). 
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Referrals 
During FYs 20192021, the Unit reported receiving referrals of Medicaid provider 
fraud from the State Medicaid agency, known as the Department of Health Care 
Finance (DHCF), among other sources.  The Unit received referrals of patient abuse or 
neglect primarily from the Districts Department of Disability Services and the 
Department of Health.  See Appendix A for a list of Unit referrals by source for  
FYs 20192021.   
When the Unit receives a referral of fraud or patient abuse or neglect, the Units 
Special Agent in Charge reviews the information to determine whether (1) immediate 
action is required; (2) the referral has merit; (3) the referral falls within the Units 
jurisdiction; and (4) appropriate action should be recommended to the director and 
deputy director, who make the final decision on whether to open the referral as a 
case.  When a referral is declined, the Unit may refer the matter to another District or 
Federal entity.   
Investigations 
Once the Unit opens a case, Unit management assigns the matter to a team 
consisting of an investigator; an attorney; and, if needed, an auditor and/or a program 
analyst.  The team works together to form a plan for the investigation and 
prosecution of the case, which it may modify as the case proceeds.  Unit investigators 
typically specialize in either fraud cases or patient abuse and neglect cases.  
Investigators participate in periodic supervisory reviews of their caseloads with the 
Special Agent in Charge.  Upon completion of an investigation, criminal cases are 
presented either to the U.S. Attorney Offices Criminal Division or to its Superior Court 
division.  Assistant U.S. Attorneys and MFCU attorneys, designated as Special Assistant 
U.S. Attorneys (SAUSAs) in the Superior Court division, determine whether there is 
sufficient evidence to accept cases for criminal prosecution.  Civil cases are presented 
to the District of Columbia Attorney Generals Office or to the Civil Division of the U.S. 
Attorneys Office. 
Law enforcement jurisdiction.  During our review period, the law enforcement 
authority of the District of Columbia OIG was governed by the Office of the Inspector 
General Law Enforcement Powers Amendment Act of 1998.14  The Act authorized 
District of Columbia OIG criminal investigators, which includes the MFCU 
investigators, to (1) carry firearms within the District of Columbia, or at a District 
government facility located outside of the District, while performing official duties;  
(2) make arrests without a warrant upon probable cause for felony violations that 
occur in their presence, provided that the arrest is made while performing official 
duties within the District or at a District government facility outside of the District; and 
(3) serve as an affiant for or execute search warrants if the warrant is issued upon 
probable cause under the authority of the District of Columbia or the United States.   
_____________________________________________________________________________________________________________________________ 
14 District of Columbia Law No. 12-190 (1999).  
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Prosecutions 
The District of Columbia OIG, where the MFCU is located, has limited prosecutorial 
authority.15  In the District of Columbia, the U.S. Attorneys Office has responsibility 
both for the prosecution of Federal criminal violations and for criminal violations of 
District of Columbia law.  The MFCU therefore refers criminal fraud cases either to the 
Criminal Division in the U.S. Attorneys Office, which prosecutes Federal crimes, or to 
the Superior Court Division, which has responsibility for local criminal violations.  
According to the MFCU, most of its criminal fraud cases are prosecuted by the 
Criminal Division of the U.S. Attorneys Office.  The MFCU has two attorneys 
designated as SAUSAsone of the SAUSAs handles fraud prosecutions and the other 
SAUSA handles patient abuse and neglect prosecutions.  The designation of these 
attorneys as SAUSAs allows the Unit to prosecute fraud cases through the Superior 
Court Division of the U.S. Attorneys Office (when the Criminal Division cannot accept 
a case).  It also allows the Unit to prosecute patient abuse or neglect cases through 
the Superior Court Division.   
For civil cases, the MFCU may refer cases to the Civil Division of the U.S. Attorneys 
Office or to the Attorney Generals Office for prosecution.16  If a case is declined for 
criminal prosecution in the Criminal Division of the U.S. Attorneys Office, the case 
may be referred for legal consideration to the U.S. Attorneys Office Superior Court 
Division or the District of Columbia Office of Attorney Generals Civil Division, or for 
administrative action by DHCF.  
District of Columbia Medicaid Program 
DHCF administers the District of Columbia Medicaid program, which includes 
Medicaid fee-for-service and managed care programs.17  As of September 2022, the 
program served more than 270,000 enrollees and total program expenditures were 
approximately $3.9 billion.18, 19  During our review period, the District of Columbia had 
_____________________________________________________________________________________________________________________________ 
15 District of Columbia Code  4804. 
16 The Unit refers cases to the Districts Attorney Generals Office for prosecution under the Districts False 
Claims Act or other applicable civil statutes.  
17 DHCF, Medicaid Managed Care Performance Report (January 2021December 2021).  Accessed at 
https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/DHCF-CY2021-Medicaid-
Managed-Care-Report.pdf on March 13, 2023. 
18 The Centers for Medicare & Medicaid Services (CMS), State Medicaid and CHIP Applications, Eligibility 
Determinations, and Enrollment Data, September 2022.  Accessed at 
https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-
highlights/index.html on March 13, 2023. 
19 OIG, MFCU Statistical Data for FY 2022.  Accessed at https://oig.hhs.gov/fraud/medicaid-fraud-control-
units-mfcu/expenditures_statistics/fy2022-statistical-chart.pdf on July 13, 2023.  
 
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three managed care organizations (MCOs).20  In 2021, the MCOs provided health care 
services to approximately 81 percent of the Districts Medicaid enrollees.21  
Medicaid Program Integrity 
The Division of Program Integrity within DHCF is responsible for the Districts 
Medicaid program integrity efforts and conducts preliminary investigations on all 
potential fraud referrals, including those received from the Districts three MCOs, as 
well as referrals that are self-generated from analysis of Medicaid claims data.22  Upon 
completing a preliminary investigation, DHCF refers cases of suspected provider fraud 
to the MFCU.  According to the memorandum of understanding (MOU) between 
DHCF and the MFCU, after receiving the referral from DHCF, the MFCU has 20 days to 
decide and inform the program integrity unit as to whether the MFCU will open a full 
investigation or decline the referral.  
Previous OIG Reports and Oversight 
OIG conducted a previous onsite review of the District of Columbia MFCU in 2015.23  
In that review, which covered FYs 20122014, OIG found that (1) there were 
investigative delays in 20 percent of cases, which was explained in part by a lengthy 
document clearance process (e.g., subpoena approval), and 68 percent of case files 
lacked documentation of supervisory reviews; (2) Unit staff lacked knowledge on how 
to use its case management system to efficiently access case information; (3) the Unit 
investigated seven cases that were not eligible under Federal regulations for Federal 
matching funds; (4) until July 2015, the Units MOU with DHCF was out of date and 
did not reflect Federal legal requirements, and formal communication between the 
agencies was infrequent; and (5) the Unit did not report all convictions to OIG or 
adverse actions to the National Practitioner Data Bank (NPDB) within the required 
timeframes.  OIG also observed that the Unit did not have a process for reporting 
collections information and that policies and procedures were not widely circulated to 
staff.   
_____________________________________________________________________________________________________________________________ 
20 DHCF, Medicaid Managed Care Performance Report (January 2021-December 2021), p. 2.  Accessed at 
https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/DHCF-CY2021-Medicaid-
Managed-Care-Report.pdf on July 13, 2023.  During our review period, most Medicaid managed care 
enrollees in the District of Columbia were enrolled in one of three MCOs: AmeriHealth Caritas, CareFirst 
BlueCross BlueShield Community Health Plan, and MedStar Family Choice.  A smaller number were 
enrolled in Health Services for Children with Special Needs.   
21 CMS, 2019, 2020, and 2021 Medicaid Managed Care Enrollment Summary.  Accessed at 
https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html on September 20, 
2023.  The percentage of people enrolled in Medicaid managed care in the District of Columbia increased 
from 73 percent in 2019 and 2020 to 81 percent in 2021.  In 2021, 231,323 of the 285,297 people 
enrolled in Medicaid in the District were enrolled in comprehensive managed care, compared to 193,692 
of the 265,501 enrollees in 2020 and 194,136 of the 267,329 enrollees in 2019.   
22 DHCF, About the Division of Program Integrity (DPI).  Accessed at https://dhcf.dc.gov/page/about-
division-program-integrity-dpi on March 21, 2023.  
23 OIG, District of Columbia Medicaid Fraud Control Unit: 2015 Onsite Review, OEI-07-14-00660, 
September 2015.  
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OIG recommended that the Unit (1) ensure that periodic supervisory reviews are 
documented in Unit case files; (2) ensure that delays in case progress are limited to 
situations imposed by resource constraints or other exigencies, and documents are 
cleared timely; (3) ensure that use of its case management system allows for efficient 
access to case information; (4) 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; (5) communicate regularly with DHCF; and (6) ensure that 
all relevant information is reported to OIG and the NPDB within the required 
timeframes.  On the basis of information received from the Unit, OIG considered the 
recommendations implemented as of February 2018.   
Methodology 
We conducted an onsite review of the District of Columbia MFCU in September 2022.  
The review team consisted of OIG evaluators, OIG agents, OIG attorneys, and the 
director of another State MFCU.  Our review covered the 3-year period of  
FYs 20192021; however, we considered legislative activity by the District of Columbia 
Council that occurred after FY 2021.  The primary purpose of this review was to 
examine two areas of concern that we identified during our ongoing administration 
and oversight of the Unit: limitations on the law enforcement authority of the MFCU, 
and the adequacy of fraud referrals from MCOs.  As part of this onsite review, we also 
examined the Units operations and adherence to the 12 MFCU performance 
standards and applicable Federal laws, regulations, and policy transmittals.  In 
examining the Units operations and performance, we applied the published MFCU 
performance standards, but we did not assess adherence to every performance 
indicator for every standard.   
We based the inspection on an analysis of data and information from seven sources: 
(1) a review of Unit documentation; (2) a review of financial documentation;  
(3) structured interviews with key stakeholders; (4) structured interviews with Unit 
management and selected staff; (5) a review of a random sample of case files that 
were open at any point during the review period; (6) a review of convictions 
submitted to OIG for program exclusion and adverse actions submitted to the 
National Practitioner Data Bank (NPDB) during the review period; and (7) observation 
of Unit operations.  See Appendix B for a detailed methodology. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency 
(CIGIE).  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 are other OIG evaluations, including internal and 
external peer review.   
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CASE OUTCOMES 
The Unit reported 29 indictments, 16 convictions, and 25 civil settlements and 
judgments for FYs 20192021.  
Of the 16 convictions reported by the Unit, 14 involved provider fraud and 2 involved 
patient abuse or neglect.  
 
The Unit reported combined civil and criminal recoveries of $21.5 million for  
FYs 20192021. 
 
Source: OIG Analysis of Unit statistical data, FYs 20192021.   
Note: Global civil recoveries derive from civil settlements or judgments in global cases, which are cases that involve 
the U.S. Department of Justice and a group of State MFCUs and are facilitated by the National Association of Medicaid 
Fraud Control Units.   
 
 
District of Columbia Medicaid Fraud Control Unit: 2022 Onsite Review   
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FINDINGS 
Our review examined two areas of concern identified during our ongoing 
administration and oversight activities of the District of Columbia MFCU: (1) the Units 
law enforcement authority and (2) fraud referrals from MCOs.  We also conducted a 
general assessment of whether the Unit complied with legal requirements and 
adhered to the 12 MFCU performance standards.  We found that the Unit addressed 
our primary concern regarding its law enforcement authority by succeeding in 
obtaining a legislative amendment to expand its authorities.  However, we made 
findings regarding the Units lack of adequate policies and procedures to address its 
limited authorities during our review period; the low number of managed care fraud 
referrals; and two operational issues concerning supervisory reviews and reporting to 
Federal partners that have persisted since our previous onsite review in 2015.    
The Units limited law enforcement authority and lack of adequate 
policies and procedures posed challenges during our review period; 
the Unit succeeded in obtaining a legislative amendment to expand 
its authorities 
During our review period of FYs 20192021, the statutory authority of the District of 
Columbia OIG limited the Units law enforcement powers to the District of Columbia 
or District of Columbia facilities in other jurisdictions, and the Unit lacked similar 
authority to conduct operations in Maryland, Virginia, or other jurisdictions where 
District of Columbia Unit investigators may have needed to operate.24  Unit 
investigators were also limited in the types of law enforcement activities they could 
conduct within the District.25  The District of Columbia OIG succeeded in obtaining an 
amendment to the District of Columbia Code in January 2023, expanding the law 
enforcement authority of Unit investigators, and thus addressing our primary concern 
giving rise to this review.   
As part of its oversight, HHS OIG evaluates whether Units effectively carr[y] out the 
functions and requirements for the program as established by statute, which includes 
taking into consideration Units effectiveness in... investigating cases of possible 
fraud.26  We found that the District of Columbia Units limited law enforcement 
authority for its investigators posed challenges to conducting investigations during 
our review period.  Due to the close proximity of the District of Columbia to the 
_____________________________________________________________________________________________________________________________ 
24 The District of Columbia OIG includes an Investigations Unit, in addition to the MFCU, which also 
employs investigators subject to the same statutory jurisdiction.  We did not evaluate the impact of the 
law enforcement limitations on the Investigations Unit.  
25 District of Columbia Law No. 12-190 (1999).  
26 SSA  1902(a)(61).  See 42 CFR  1007.17(c)(4). 
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surrounding States of Maryland and Virginia and the small size of the District, the 
Units cases frequently involved investigative operations outside of District 
boundaries.  As a result, Unit investigators had to rely on other law enforcement 
partners, such as the Federal Bureau of Investigation (FBI) or the Metropolitan Police 
Department, to collect evidence and to complete investigations.  For example, the 
Unit relied on the Metropolitan Police Department or Federal law enforcement 
partners to make arrests of suspects because the Unit did not have authority to do so 
in many cases.27  Further, the Unit was unable to execute search warrants outside of 
the District of Columbia and relied on Federal partners, such as HHS OIGs Office of 
Investigations (OI), to perform that function.   
According to Unit management, the limited law enforcement authority affected 
investigator morale, as investigators were at times not able to be equal partners.  In 
addition, staff and management reported that cases could have progressed more 
quickly if they did not have to rely on other agencies to perform these elements of 
their work.  For example, management explained that relying on partner agencies 
could result in investigative delays if Unit cases did not receive adequate resources or 
priority from those agencies.  
Unit management and staff acknowledged that the limited law enforcement authority 
presented challenges to conducting investigations; however, we found at the time of 
our review that the Unit had taken steps to overcome these challenges and was able 
to operate effectively despite the limitations.  In interviews, Unit management and 
staff reported that the Unit built partnerships with Federal and District law 
enforcement agencies to assist the Unit with investigative tasks, as described above.  
At the time of our review, the Units Federal law enforcement partners, such as HHS 
OIG and the FBI, reported collaborative working relationships with Unit investigators.  
Unit investigators also reported adapting investigative practices to ensure that 
investigations could progress despite the limitations.  For example, investigators 
reported that when an investigation required Unit investigators to conduct interviews 
in another jurisdiction, they typically asked the subject(s) to enter the District to do 
the interview or would conduct it over the telephone.  
_____________________________________________________________________________________________________________________________ 
27 The Unit could only make arrests without a warrant upon probable cause for felony violations that 
occurred in a Unit investigators presence, provided that the arrest was made while the investigator was 
performing official duties within the District or at a District government facility outside the District. 
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Despite the Unit taking steps to address the 
Performance Standard 3(a): The 
challenges associated with its law 
Unit has written guidelines or 
enforcement authority, we found that the Unit 
manuals that contain current 
did not have adequate policies and 
policies and procedures, 
procedures to address its limited authorities 
consistent with these performance 
during our review period.  The Units official 
policies and procedures manual, last updated  standards, for the investigation 
in November 2014, contained investigative  and (for those Units with 
procedures, but those procedures did not  prosecutorial authority) 
address the limitations surrounding the Units  prosecution of Medicaid fraud and 
law enforcement authority.  Unit management  patient abuse and neglect. 
and staff reported that an interim version of 
the manual was developed in 2018 and that management was in the process of 
updating the manual at the time of our review.28  Further, Unit management and staff 
reported that policies surrounding the Units law enforcement jurisdiction were 
communicated to staff informally (e.g., verbally, in PowerPoint presentations, by 
email) by the District of Columbia OIG and Unit management and were not always 
widely distributed.29  The Unit also had interim District of Columbia OIG-wide policies 
surrounding use of force and firearm use that addressed certain aspects of the 
limitations, such as the circumstances under which investigators can carry firearms 
during their official duties.30  However, we found that there were no comprehensive 
written guidelines regarding the Units law enforcement authorities, which caused 
confusion among Unit staff and law enforcement partners.  For example, some staff 
reported instances of not knowing what law enforcement activities the Unit could 
conduct because policies were made verbally and not distributed widely to staff.   
A few months after our onsite review of the Unit, the District of Columbia OIG 
succeeded in obtaining a legislative amendment intended to address the law 
enforcement limitations.31  The legislation, which was signed by the mayor of the 
District of Columbia and enacted in January 2023 as the Inspector General 
Enhancement Amendment Act of 2022, provides District of Columbia OIG 
investigators, including the Unit, with enhanced law enforcement authorities.  
Specifically, the legislation gives investigators expanded authorities, such as the ability 
to (1) make an arrest without a warrant if there is probable cause of a committed 
felony; (2) apply for and execute arrest warrants; (3) directly enter into agreements 
with Federal partners; and (4) carry less lethal weapons.  The new authority specifies 
that District of Columbia OIG criminal investigators may perform their duties within 
_____________________________________________________________________________________________________________________________ 
28 The Unit did not provide the interim MFCU policies and procedures manual when requested.  As such, 
we did not assess the contents of the interim manual.  
29 The Unit did not provide these materials when requested.  As such, we did not assess the contents of 
these documents.  
30 These interim policies, updated in January 2019, also included annual training requirements for firearm 
use and the use of force.   
31 Council of the District of Columbia, B24-0129  Inspector General Enhancement Act of 2021.  Accessed 
at https://lims.dccouncil.gov/Legislation/B24-0129 on March 13, 2023.  
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OEI-06-22-00420   Findings | 10    
the District or, subject to Federal, State, and local laws, outside of the District.32  
Although the expanded authorities in the legislation may address the limitations on 
the Units law enforcement authorities as described in this report, the need for 
adequate policies and procedures surrounding the Units law enforcement authority 
remains.  
The Unit received few fraud referrals from MCOs but has taken steps 
to increase these referrals 
Performance Standard 4(a) states that the 
Performance Standard 4(a): The 
Unit should take steps to ensure that MCOs 
Unit takes steps, such as the 
refer all suspected provider fraud cases to 
development of operational 
the Unit.  During FYs 20192021, the District 
protocols, to ensure that the State 
of Columbia MFCU received a total of       
Medicaid agency, managed care 
208 fraud referrals, but only 3 originated 
from the Districts MCOs.  Given that            organizations, and other agencies 
81 percent of the Districts Medicaid  refer to the Unit all suspected 
population were enrolled in managed care in  provider fraud cases.   
2021, a total of 3 fraud referrals likely 
underrepresents potential Medicaid provider fraud arising in the District of Columbia 
Medicaid managed care program.33  The MCOs in the District of Columbia provide 
services for most of the Districts Medicaid enrollees; the MCOs efforts to refer 
potential instances of fraud in the managed care program to the DHCFs program 
integrity unit, and ultimately to the MFCU, are critical to ensuring Medicaid program 
integrity.  
We found that several factors contributed to the low number of fraud referrals from 
the Districts MCOs.  Unit management reported that the Units communication with 
the MCOs was limited under the prior DHCF program integrity director, which 
reduced the MCO referrals to the Unit.  However, management reported that 
communication with the MCOs increased after the new DHCF program integrity 
director assumed his role in November 2021.  Further, Unit and DHCF program 
integrity management reported that the MCO Special Investigative Units (SIUs) in the 
District of Columbia did not typically conduct fraud investigations and that SIU staff 
would benefit from additional training on health care fraud.  A 2023 Centers for 
Medicare & Medicaid Services (CMS) report focused on the Districts Medicaid 
managed care program also encouraged DHCF to provide training and feedback to 
_____________________________________________________________________________________________________________________________ 
32 District of Columbia Law 24-289.  Inspector General Enhancement Amendment Act of 2022. 
33 CMS, 2019, 2020, and 2021 Medicaid Managed Care Enrollment Summary.  Accessed at 
https://www.medicaid.gov/medicaid/managed-care/enrollment-report/index.html on September 20, 
2023.  The percentage of people enrolled in Medicaid managed care in the District of Columbia increased 
from 73 percent in 2019 and 2020 to 81 percent in 2021.  In 2021, 231,323 of the 285,297 people 
enrolled in Medicaid in the District were enrolled in comprehensive managed care, compared to 193,692 
of the 265,501 enrollees in 2020 and 194,136 of the 267,329 enrollees in 2019.   
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the Districts MCOs regarding the quantity and quality of MCO referrals.34  An official 
in one of the Districts MCOs attributed the low number of referrals to delays caused 
by the shutdowns during the COVID-19 pandemic.  While the pandemic likely 
impacted referrals, we found that CMS identified concerns regarding the low number 
of MCO referrals prior to the pandemic, during a 2017 program integrity review of the 
District.35   
We identified a strong and effective working relationship between the Unit and the 
current leadership at the DHCF program integrity unit.  During interviews, the Unit 
and DHCF both reported that they had begun taking steps to increase referrals from 
the MCOs.  Specifically, the two agencies shared that they had started working 
collaboratively to address the low number of referrals, including by developing 
trainings for the MCOs on identifying fraud and conducting investigations.  Unit 
management also reported attending monthly meetings hosted by DHCF with all 
District agency stakeholders, including the MCOs, and noted that they had recently 
seen an increase in attendance and engagement from MCO staff.  Unit management 
also explained that they had begun working on strengthening the relationships with 
the MCOs since the appointment of the new DHCF program integrity director.   
Forty-one percent of the Units case files lacked documentation of 
periodic supervisory reviews consistent with Unit policy  
Performance Standard 7(a) states that supervisory reviews should be conducted 
periodically, consistent with Unit policies and procedures, and noted in the case file.  
During our review period, the Unit policy required a supervisory review of case files 
every 90 days.  Consistent with findings from OIGs 2015 onsite review, we found that 
for cases that were open longer than 90 days, 41 percent of the Units case files did 
not contain documentation of quarterly supervisory reviews.36  Of these case files,  
36 percent did not contain documentation of supervisory reviews every 90 days (i.e., 
the supervisory reviews were conducted less frequently) and 5 percent did not contain 
documentation of any supervisory review.  See Appendix C for the point estimates 
and confidence intervals for the case file reviews.  
_____________________________________________________________________________________________________________________________ 
34 CMS, District of Columbia Focused Program Integrity Review Final Report, August 2023.  Accessed 
at https://www.cms.gov/files/document/washington-dc-fy22-focused-pi-review-report.pdf on August 16, 
2023. 
35 CMS, District of Columbia Focused Program Integrity Review Final Report, August 2017.  Accessed 
at https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/DCfy17.pdf on February 24, 2023. 
36 The previous OIG report found that 68 percent of the Units case files lacked documentation of 
periodic supervisory reviews.     
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At the time of our site visit, Unit management reported conducting periodic 
supervisory reviews on a bimonthly basis (i.e., in even-numbered months).37  To 
ensure regular reviews of case files, Unit staff reported, the Units Special Agent in 
Charge now sends email appointments for the reviews every 2 months.  Unit 
management also explained that investigators discuss their cases during team 
meetings and other informal conversations, often more frequently than in their 
scheduled supervisory reviews.  Periodic supervisory review of cases during the 
investigation and prosecution phases can help ensure timely completion of cases, and 
documenting those reviews in the case files can help ensure that cases are properly 
managed. 
The Unit did not always report convictions or adverse actions to 
Federal partners within the appropriate timeframes  
According to Federal requirements and Performance Standard 8(f), the Unit should 
transmit to OIGwithin 30 days of sentencing, or as soon as practicable if the Unit 
encounters delays in receiving the necessary information from the courtreports of 
all MFCU convictions for the purpose of permitting OIG to exclude the convicted 
parties from Federal health care programs.38  We found that 13 of the Units  
15 convictions were reported within 30 days or as soon as practicable after the 
information was received from the court.39  However, two convictions were reported 
late, more than 90 days after sentencing.  We found that the Units submission of 
convictions to OIG had improved since OIGs 2015 onsite review, which found that the 
Unit did not report any of its convictions to OIG within the required timeframe.40  Late 
reporting of convictions to OIG delays the initiation of the program exclusion process, 
which may result in improper payments to providers by the Medicaid program or 
other Federal health care programs as well as possible harm to Medicaid enrollees.  
Federal regulations, consistent with Performance Standard 8(g), also require that the 
Unit report any adverse actions of health care providers to the NPDB within  
30 calendar days of the final adverse action date.41  The Unit did not report 5 of its  
15 adverse actions to the NPDB within the appropriate timeframe.  Of the five adverse 
actions submitted late, one was submitted within 31 to 60 days after the action, one 
_____________________________________________________________________________________________________________________________ 
37 We found that the Units policies and procedures manual had not been updated to reflect the change 
in the frequency of the supervisory reviews.  We examined the Units case files to determine whether 
supervisory reviews were conducted every 90 days, consistent with the manual. 
38 42 CFR  1007.11(g), effective May 21, 2019.  Performance Standard 8(f) also states that Units should 
transmit to OIG, for purposes of program exclusions, all pertinent information on MFCU convictions 
within 30 days of sentencing, including charging documents, plea agreements, and sentencing orders.  
39 We did not include late reporting of convictions where the MFCU encountered significant delays in 
receiving necessary sentencing information from the court. 
40 OIG, District of Columbia Medicaid Fraud Control Unit: 2015 Onsite Review, OEI-07-14-00660, 
September 2015. 
41 45 CFR  60.5.  Examples of final adverse actions include, but are not limited to, convictions, civil 
judgments (but not civil settlements), and program exclusions (SSA  1128E(g)(1)). 
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was submitted between 61 to 90 days after the action, and three were submitted 
more than 90 days after the action.  We found that the Units submission of adverse 
actions to the NPDB had improved since OIGs 2015 onsite review, which found that 
the Unit did not report any of its adverse actions timely.42  The NPDB is intended to 
restrict physicians, dentists, and other health care practitioners from moving State to 
State without disclosure or discovery of previous medical malpractice and adverse 
actions.43  If a Unit fails to report adverse actions to the NPDB, other health care 
organizations may unknowingly hire individuals who have adverse actions made 
against them. 
_____________________________________________________________________________________________________________________________ 
42 OIG, District of Columbia Medicaid Fraud Control Unit: 2015 Onsite Review, OEI-07-14-00660, 
September 2015. 
43 NPDB, About Us.  Accessed at https://www.npdb.hrsa.gov/topNavigation/aboutUs.jsp on February 19, 
2023. 
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RECOMMENDATIONS 
From the information we reviewed, we found that the Units limited law enforcement 
authority posed challenges to conducting investigations during our review period, 
and the Unit did not have adequate policies and procedures regarding its limited 
authorities.  We found that, at the time of our onsite review, the Unit had taken steps 
to overcome its limited law enforcement authority, including partnering with Federal 
and local law enforcement and modifying its investigative practices.  Following our 
onsite review, the District of Columbia OIG succeeded in obtaining an amendment to 
the District of Columbia Code in January 2023, providing Unit investigators with 
enhanced law enforcement authorities.  In our review, we also found that the Unit 
received few fraud referrals from MCOs during FYs 20192021 but has reportedly 
begun taking steps, in collaboration with DHCF, to increase these referrals.  
Additionally, we found that, for cases open longer than 90 days, 41 percent lacked 
documentation of periodic supervisory reviews consistent with Unit policy.  Lastly, we 
found that the Unit did not always report convictions or adverse actions to Federal 
partners within the appropriate timeframes.   
To address the findings identified in this report, we made the following 
recommendations to the District of Columbia MFCU.  
We recommend that the District of Columbia MFCU: 
Develop policies and procedures to implement the District of 
Columbia OIGs expanded law enforcement authority and ensure that 
Unit investigators receive training on the new authorities 
The Unit should work with District of Columbia OIG officials to develop and 
implement written policies and procedures that address the expanded law 
enforcement authorities in the Inspector General Enhancement Amendment Act of 
2022.  The Unit, to the extent it has not done so, should also consider including 
policies that address operating as law enforcement officers in jurisdictions outside of 
the District of Columbia.  The Unit should ensure that law enforcement partner 
agencies understand the policies and procedures surrounding its law enforcement 
authorities.  The Unit should also ensure that policies remain up to date and that Unit 
staff have access to the policies and procedures.   
Additionally, the Unit should ensure that all Unit investigators receive training on the 
new authorities to confirm that all policies and procedures are implemented 
appropriately in practice.  The Unit should also provide guidance and/or training to 
Federal and District law enforcement partners on its new authorities, as applicable.    
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Build upon its efforts with the Districts Medicaid agency to increase 
fraud referrals from the MCOs 
To ensure that the Unit receives an adequate number of managed care fraud referrals, 
the Unit should continue to collaborate with the District Medicaid agency program 
integrity unit to conduct outreach and training with the Districts MCOs.  As part of 
these efforts, the Unit should provide periodic feedback to the MCOs on the quality of 
their referrals, including the types of referrals the Unit would like to receive and 
helpful information to include in a quality referral.  The Unit should consider 
memorializing its ongoing and planned efforts in an MOU or other document with the 
District Medicaid agency program integrity unit and the Districts MCOs.  The Unit 
should also continually assess whether its efforts are helping increase referrals of 
potential fraud and if there are other ways to enhance its relationships with the MCOs. 
Ensure that supervisory reviews of case files are conducted and 
documented in accordance with Unit policy 
The Unit should ensure that supervisors conduct and document reviews of case files 
consistent with Unit policy.  The Unit should also ensure that current processes for 
conducting and documenting supervisory reviews are included in its policies and 
procedures manual.  
Ensure that all convictions and adverse actions are reported to 
Federal partners within the appropriate timeframes 
The Unit should ensure that it consistently reports all convictions to OIG within  
30 days of sentencing, or as soon as practicable if there are delays in receiving the 
necessary information from the court.  The Unit should also ensure that it reports all 
adverse actions to the NPDB within 30 days of the action.  The Units processes for 
reporting convictions and adverse actions to Federal partners should be included in 
its policies and procedures manual.  The Unit could provide training to staff on 
reporting convictions and adverse actions to Federal partners and could implement 
automated reminders to alert staff about when to report the convictions and adverse 
actions.  
 
 
 
 
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UNIT COMMENTS AND OIG RESPONSE 
The District of Columbia MFCU concurred with all four of our recommendations.  
First, the Unit concurred with our recommendation to develop policies and 
procedures to implement the District of Columbia OIGs expanded law enforcement 
authority and ensure that Unit investigators receive training on the new authorities.  
The Unit reported that the District of Columbia OIG has convened a team tasked with 
amending its internal policies and procedures to reflect the updated law enforcement 
authorities for its Investigations Unit and the MFCU.  In developing the policies and 
procedures, the Unit reported, the District of Columbia OIG plans to consult with the 
Metropolitan Police Department and will use a peer review process to assess its law 
enforcement activities, policies, and procedures against applicable CIGIE Quality 
Standards for Investigations.   
Second, the Unit concurred with our recommendation to build upon its efforts with 
the Districts Medicaid agency to increase fraud referrals from the MCOs.  The Unit 
reported that, through its partnership with DHCFs Division of Program Integrity, it will 
continue strengthening its efforts to receive referrals from the MCOs.   
Third, the Unit concurred with our recommendation to ensure that supervisory 
reviews of case files are conducted and documented in accordance with Unit policy.  
The Unit reported that it has implemented a bimonthly case review process with its 
Special Agent in Charge to ensure that each case receives adequate supervisory 
review.   
Fourth, the Unit concurred with our recommendation to ensure that all convictions 
and adverse actions are reported to Federal partners within the appropriate 
timeframes.  The Unit explained that the instances in which it did not meet the 
reporting requirements were due to administrative delays.  The Unit reported that it 
will continue its processes to ensure that adverse actions are reported within the 
appropriate timeframes.   
In addition to the Units concurrence with the recommendations, the Unit provided 
comments that disputed the technical accuracy or completeness of several statements 
contained in the first finding of the report.  We have, where appropriate, added 
additional context or explanation in this final version of the report. 
In regard to the Units comment about its lack of authority to operate outside of the 
District, we note that it was correct during our review period that the District of 
Columbia OIG, including the MFCU, lacked authority to conduct law enforcement 
actions in Maryland and Virginia.  This posed a particular challenge with respect to the 
large number of health care fraud cases involving persons or businesses which 
operate both in the District and in neighboring States.  The District of Columbia 
Council, as a part of the 2022 legislation, addressed this gap by providing additional 
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authority, subject to federal, state, and local laws, outside of the District.44  This 
included, but is not limited to, the ability to carry firearms, make arrests, and to apply 
for and execute arrest and search warrants under the authority of the District or of the 
United States upon probable cause. 
In response to the Units comment that HHS OIG declined to offer written support for 
proposed legislation regarding the authority of the District of Columbia OIG in 2022, 
we note that HHS OIG has a practice, consistent with our nonpartisan status, of not 
advocating for specific legislation pending before a State legislature.   
For the full text of the Units comments, see Appendix D.  
_____________________________________________________________________________________________________________________________ 
44 District of Columbia Code  1-301.115a(f-1). 
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PERFORMANCE ASSESSMENT 
We assessed the District of Columbia MFCUs adherence to the 12 MFCU performance standards, 
including its compliance with applicable laws, regulations, and policy transmittals.  From this review, we 
found that the Unit generally operated in accordance with applicable laws, regulations, and policy 
transmittals in FYs 20192021.  We made four findings that warrant further attention, which are 
presented here and in the body of the report.  We also made observations about Unit operations and 
practices.  The complete MFCU performance standards, including the performance indicators, were 
published at 77 Fed. Reg. 32645 (June 1, 2012), and appear on OIGs website at 
https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/.  
Performance Standard 1: Compliance with Requirements 
A Unit conforms with all applicable statutes, regulations, and policy directives. 
Observation: From the information we reviewed, the District of Columbia MFCU generally 
complied with applicable laws, regulations, and policy transmittals. 
From the information reviewed, we found that the Unit was generally in compliance with applicable 
requirements.  However, we identified one area of concern related to the Units reporting of convictions 
and adverse actions to Federal partners, as described in the finding on page 13.   
As part of our review, we also assessed the Units compliance with applicable laws as it related to its 
limited law enforcement authority.  We found that, at the time of our review, the Unit had taken steps 
to address its limited law enforcement authority and appeared to be operating in compliance with all 
applicable laws.  
Performance Standard 2: Staffing 
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.  
Observation: The Unit was nearly fully staffed at the time of our review but had vacancies during 
the review period.  
Performance Standard 2(a) states that a Unit should employ the number of staff that is included in the 
Units budget estimate as approved by OIG.  During our review period, the Unit was approved by OIG 
for 23 staff.  At the time of our review, the Unit employed 21 staff.  However, we observed that the Unit 
had several vacancies during our review periodthe Unit employed 19 staff during FYs 20192020 and 
16 staff in FY 2021.45  Among the vacancies were investigator positions and an auditor position.  During 
_____________________________________________________________________________________________________________________________ 
45 The review period of FYs 20192021 coincided with the onset of the COVID-19 pandemic, which may 
have affected the Units ability to hire staff. 
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our onsite review, Unit management reported that they had recently hired several new staff, including 
an investigative analyst and a data analyst, and that they planned to hire additional staff in FY 2023.   
Performance Standard 3: Policies and Procedures 
A Unit establishes written policies and procedures for its operations and ensures that staff are 
familiar with, and adhere to, policies and procedures. 
Finding: The Units limited law enforcement authority and lack of adequate policies and 
procedures posed challenges during our review period; the Unit succeeded in obtaining a 
legislative amendment to expand its authorities. 
See page 8.  
Observation: The Unit maintained a policies and procedures manual, but parts of the manual did 
not describe the Units current practices.  
Performance Standard 3(a) states that the Unit should have written guidelines or manuals that contain 
current policies and procedures.  The Unit maintained a policies and procedures manual, which was 
available to staff electronically.  However, we observed that the Units policies and procedures manual 
was last updated in 2014 and did not always reflect current practice.  For example, the Units policies 
and procedures manual had not been updated to reflect a change in the frequency of conducting and 
documenting periodic supervisory reviews (see the finding on page 12).  Further, we observed that the 
Units referral intake process had changed during our review period; however, no updates had been 
made to the policies and procedures manual to reflect such change.  During our onsite review, Unit 
management reported that they were in the process of updating the policies and procedures manual.   
Performance Standard 4: Maintaining Adequate Referrals 
A Unit takes steps to maintain an adequate volume and quality of referrals from the State Medicaid 
agency and other sources. 
Finding: The Unit received few fraud referrals from MCOs but has taken steps to increase these 
referrals. 
See page 11.  
Performance Standard 5: Maintaining Continuous Case Flow 
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. 
Observation: Nearly all case files contained documentation of supervisory approval for case 
openings and, as appropriate, supervisory approval for case closings. 
According to Performance Standard 5(b), supervisors should approve the opening and closing of all 
investigations.  Our review found that nearly all of the case files contained documentation of 
supervisory approval of case openings and closings.  An estimated 96 percent of case files had 
supervisory approval to open the case for investigation, and an estimated 97 percent of the Units 
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closed cases contained supervisory approval to close the case.  See Appendix C for point estimates and 
confidence intervals for our case file review.  
Performance Standard 6: Case Mix 
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.  
Observation: During our review period, the Unit increased its number of patient abuse and 
neglect cases, and its caseload covered a broad mix of provider types. 
In our review of the Units case information, we observed that the number of investigations related to 
patient abuse or neglect increased significantly, during and after our review period, from 7 percent of 
cases in FY 2019 to 42 percent in FY 2022.  The Unit director reported taking steps to increase the 
number of patient abuse or neglect cases in the Units case mix after he was appointed in December 
2019.  Specifically, the Unit conducted outreach to sources of patient abuse or neglect referrals; hired 
an investigator to specialize in cases of patient abuse and neglect; and worked with the U.S. Attorneys 
Office to have one of the Units attorneys trained as a SAUSA to prosecute patient abuse and neglect 
cases in District of Columbia Superior Court Division (see also Performance Standard 10).  As a result of 
these efforts, the Unit was able to open more of its patient abuse and neglect referrals as cases over the 
course of our review period.   
During our review period, the Units cases covered 31 different provider types, including pharmaceutical 
manufacturers, nursing homes, dentists, and nurses.   
Performance Standard 7: Maintaining Case Information 
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. 
Finding: Forty-one percent of the Units case files lacked documentation of periodic supervisory 
reviews consistent with Unit policy.  
See page 12.   
Observation: The Unit generally maintained case files in an effective manner, but the Units case 
management system and some practices did not allow for efficient access to case information.  
Performance Standard 7 states that a Unit maintains case files in an effective manner and develops a 
case management system that allows efficient access to case information.  At the time of our review, the 
Unit used an electronic case management system to record and track all case information.  We 
determined that overall, the Unit maintained case files in an effective manner; however, we identified 
some limitations with the Units case management system.  During our case file review, we observed 
that the case management system was difficult to navigate and, as a result, it was time-consuming to 
locate investigative documents.  In interviews, several Unit staff also reported that the case 
management system was not user-friendly and was not designed with investigations in mind.  However, 
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Unit management reported that the Unit planned to transition to a new case management system in 
2023.   
Performance Standard 7 also requires that case files include all relevant facts and information and justify 
the opening and closing of the cases.  We observed some opportunities for improvement with regard 
to maintaining investigative documentation.  For example, some case files lacked certain investigative 
documents, such as opening memorandums and interview reports.  Further, we observed that many 
case files lacked documentation that the Unit communicated its closing decision to the referring 
agency.  Notifying the referring agency when the Unit has closed a case helps ensure that the referring 
agency can pursue other administrative actions, as appropriate.  On the basis of these observations, we 
provided the Unit with technical assistance to further enhance its case file organization.   
Performance Standard 8: Cooperation with Federal Authorities on 
Fraud Cases 
A Unit cooperates with OIG and other Federal agencies in the investigation and prosecution of 
Medicaid and other health care fraud. 
Finding: The Unit did not always report convictions or adverse actions to Federal partners within 
the appropriate timeframes. 
See page 13.  
Observation: The Unit maintained a strong collaborative partnership with Federal law 
enforcement partners, including OI and the U.S. Attorneys Office. 
We found that during our review period, the Unit and OI jointly investigated a total of 31 cases.  An OI 
investigative supervisor who worked with the Unit described the communication and collaboration 
between OI and the Unit as exceptional.  OI management and the Units Special Agent in Charge 
reported the working relationships between Unit and OI investigators as particularly strong.  
We also observed positive working relationships between the Unit and the U.S. Attorneys Office in the 
District of Columbia.  We interviewed an official in the Criminal Division of the U.S. Attorneys Office, 
who reported that Unit investigators provided a high level of expertise and effort on cases worked with 
the U.S. Attorneys Office.  The official also reported having a particularly positive working relationship 
with the Units Special Agent in Charge and Assistant Special Agent in Charge.  Further, an official in the 
Superior Court Division of the U.S. Attorneys Office reported good relationships with two of the Units 
attorneys, who are cross-designated as SAUSAs in the Major Crimes Division.   
 
 
 
 
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Performance Standard 9: Program Recommendations 
A Unit makes statutory or programmatic recommendations, when warranted, to the State 
government. 
Observation: The Unit made recommendations to the District of Columbia government during 
our review period.   
Performance Standard 9(a) states that Units, when warranted and appropriate, make statutory 
recommendations to the State legislature to improve the operation of the Unit, including amendments 
to the enforcement provisions of the State code.  During our review period, the Unit pursued a 
legislative amendmentthe Inspector General Enhancement Act of 2021with the District of Columbia 
Council to address its law enforcement limitations.  The bill, which was enacted in January 2023 as the 
Inspector General Enhancement Amendment Act of 2022, gives the District of Columbia OIG 
investigators (including Unit investigators) enhanced law enforcement authorities, as described on 
pages 10 and 11.   
Performance Standard 10: Agreement with Medicaid Agency 
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. 
Observation: The Units MOU with the State Medicaid agency reflected current practice, policy, 
and legal requirements.  
The District of Columbia OIG and DHCF had a current MOU, amended on July 21, 2021.  The MOU 
reflected all policy and legal requirements as well as the current practices between the parties, including 
addressing referrals of both suspected fraud and credible allegations of fraud to the MFCU.  
Performance Standard 11: Fiscal Control 
A Unit exercises proper fiscal control over its resources.  
Observation: From our limited review, we identified no deficiencies in the Units fiscal control of 
its resources.  
From the Units responses to a detailed fiscal controls questionnaire and from follow-up with fiscal staff 
and Unit officials, we identified no significant issues related to the Units budget process, accounting 
system, cash management, procurement, electronic data security, property, or personnel.    
Performance Standard 12: Training 
A Unit conducts training that aids in the mission of the Unit.  
Observation: The U.S. Attorneys Office trained the MFCU attorneys as SAUSAs, allowing the Unit 
to prosecute cases in the Superior Court Division of the U.S. Attorneys Office. 
Starting in 2020, the District of Columbia MFCU collaborated with the U.S. Attorneys Office to train and 
appoint two of the Units attorneys as SAUSAs.  The purpose of the SAUSA program, as explained by 
Unit management, was to allow the Unit to prosecute cases that may otherwise be declined for 
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prosecution by the U.S. Attorneys Office due to resource limitations.46  The training program to become 
a SAUSA includes a 3-week course which combines academic classes, trial skills, and hands-on 
experience.  The MFCU attorneys also completed a 3-month misdemeanor rotation to gain additional 
experience.  SAUSAs handle their own cases and have the same responsibilities as does a regular 
Assistant U.S. Attorney.  The Unit currently has two SAUSAsone who primarily prosecutes cases of 
Medicaid fraud, and one who prosecutes cases of patient abuse or neglect and misappropriation of 
funds.   
In interviews, the Unit and the U.S. Attorneys Office both cited the success of the SAUSA program.  An 
official in the U.S. Attorneys Office Superior Court Division reported that this arrangement with the 
MFCU has been successful for both agencies and has provided invaluable experience for Unit 
prosecutors.  The Unit attorneys also described the program as a positive experience that has given 
them access to additional resources, such as trainings.  The Unit director reported that the Unit plans to 
add one more SAUSA in 2023.  
Observation: The Unit maintained a training plan and provided staff with weekly trainings on 
topics relevant to the Units mission.   
The Unit had a training plan for its investigators, attorneys, and auditors pursuant to Performance 
Standard 12(a), which states that a Unit maintains a training plan that includes an annual minimum 
number of training hours and is at least as stringent as required for professional certification.  During 
our review period, the Units annual training plan required 40 hours of training every year for each 
professional discipline.  We observed that Unit staff in the professional disciplines generally met or 
exceeded the minimum number of training hours required by the Units training plan.  In addition to the 
required annual training, the Unit held weekly in-service training sessions for staff on topics related to 
the mission and function of the Unit.  The short training sessions, organized by the Units Special Agent 
in Charge, included topics such as the subpoena process, writing skills, and presenting cases for 
prosecution.  
_____________________________________________________________________________________________________________________________ 
46 The Unit has limited prosecutorial authority, as described on page 4 in the Background.  As such, the 
Unit must refer cases of Medicaid fraud and patient abuse or neglect to other agencies, such as the U.S. 
Attorneys Office, for prosecution.   
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OEI-06-22-00420  Performance Assessment | 24    
 
APPENDICES  
Appendix A: Unit Referrals by Source for FYs 20192021 
 
FY 2019  FY 2020  FY 2021  3-Year Total 
Abuse or  Abuse or  Abuse or  Abuse or 
Referral Source  Fraud  Fraud  Fraud  Fraud  Total 
Neglect  Neglect  Neglect  Neglect 
Adult Protective 
0  1  0  0  0  7  0  8  8 
Services 
Anonymous  1  0  0  1  0  0  1  1  2 
HHS OIG  1  0  0  0  1  1  2  1  3 
Law Enforcement 
15  0  11  0  10  5  36  5  41 
Other 
Licensing Board  0  0  0  0  0  0  0  0  0 
Local Prosecutor  0  0  4  0  2  76  6  76  82 
Long-Term Care 
0  0  0  0  0  6  0  6  6 
Ombudsman 
Managed Care 
0  0  0  0  0  0  0  0  0 
Organizations* 
Medicaid Agency 
Program Integrity  11  0  34  0  16  2  61  2  63 
UnitDHCF  
Medicaid Agency 
0  0  0  0  0  1  0  1  1 
Other 
Private Citizens  2  3  1  1  1  2  4  6  10 
Private Health 
0  1  0  0  0  0  0  1  1 
Insurer 
Provider  0  254  0  1,002  0  6  0  1,262  1,262 
Provider 
0  2  0  1  0  0  0  3  3 
Association 
State Agency
17  1,325  11  1,363  25  1,306  53  3,994  4,047 
Other** 
State Survey and 
0  1  0  2  1  0  1  3  4 
Certification 
Other  13  3  20  6  11  157  44  166  210 
Sub-Total  60  1,590  81  2,376  67  1,569  208  5,535  5,743 
Total  1,650  2,457  1,636  5,743 
Source: OIG analysis of Unit Annual Statistical Reports, FYs 20192021. 
*The Units three managed care referrals as referenced in the finding on page 11 are included in the DHCF referral numbers because the Unit 
receives all managed care referrals through DHCF.  The number of managed care referrals was specified in the Units recertification materials.  
**The Unit received these referrals primarily from the Department of Disability Services and the Department of Health.
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OEI-06-22-00420  Appendix A | 25    
Appendix B: Detailed Methodology 
We collected and analyzed data from seven sources as described below to identify 
any opportunities for improvement and instances in which the Unit did not adhere to 
the MFCU performance standards or was not operating in accordance with laws, 
regulations, or policy transmittals.  We also used the data sources to make 
observations about the Units case outcomes as well as the Units operations and 
practices concerning the performance standards.   
Data Collection and Analysis 
Review of Unit Documentation 
Prior to the onsite inspection, we reviewed the recertification analysis for  
FYs 20192021, which involved examining the Units recertification materials, 
including (1) the Units annual reports, (2) the Unit directors recertification 
questionnaires, (3) the Units MOU with DHCF, (4) the DHCF program integrity 
directors questionnaires, and (5) the OI Special Agent in Charge questionnaires.  We 
also reviewed the Units policies and procedures manual and the Units self-reported 
case outcomes and referrals included in its annual statistical reports for  
FYs 20192021.  Additionally, we examined the recommendations from the 2015 OIG 
onsite review report and the Units implementation of the recommendations.    
Review of Unit Financial Documentation 
We conducted a limited review of the Units control over its fiscal resources.  Prior to 
the onsite inspection, we analyzed the Units responses to a questionnaire about 
internal controls and conducted a review of the Units quarterly financial reports.  We 
followed up with District of Columbia OIG officials and the Unit to clarify any issues 
identified in the questionnaire about internal controls.   
Interviews with Key Stakeholders 
In September 2022, we conducted telephone interviews with key stakeholders, 
including officials in DHCF; an MCO; OI; and the U.S. Attorneys Office, including the 
District of Columbia Superior Court Division.  We focused these interviews on the 
Units relationship and interaction with the stakeholders as well as opportunities for 
improvement.  We used the information collected from these interviews to develop 
subsequent interview questions for Unit management and staff.    
Interviews with Unit Management and Selected Staff 
We conducted structured interviews with the Units management and selected staff in 
September 2022.  We interviewed the director; the deputy director; two attorneys; the 
supervisor of the analysts and auditors; and six investigators, including the Special 
Agent in Charge and the Assistant Special Agent in Charge.  In addition, we 
interviewed the supervisor of the Unitthe Principal Deputy Inspector General.  These 
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OEI-06-22-00420   Appendix B | 26    
interviews focused on our two targeted areas (the Units law enforcement authority 
and fraud referrals from the MCOs); Unit operations; and the Units training and 
technical assistance needs.  We also followed up on any issues identified from the key 
stakeholder interviews and our analysis of Unit documentation.   
Onsite Review of Case Files 
We asked the Unit to provide us with a list of cases that were open at any point 
during FYs 20192021 and to include the status of each case; whether the case was 
criminal, nonglobal civil, or global civil; and the dates on which the case was opened 
and closed, if applicable.  The total number of cases that met these parameters was 
263.  We excluded all global civil cases from our review of the Units case files because 
global civil cases are civil false claims actions that typically involve multiple agencies, 
such as the U.S. Department of Justice and a group of State MFCUs.  Thus, we 
excluded 22 global civil cases, leaving 241 case files.  We then selected a simple 
random sample of 78 cases from the population of 241 cases.  This sample allowed us 
to make estimates of the overall percentage of case files with various characteristics 
with an absolute precision of no more than +/- 10 percent at the 95-percent 
confidence level.  We reviewed the 78 case files for adherence to the relevant 
performance standards and compliance with statutes, regulations, and policy 
transmittals.  During the onsite review of the sampled case files, we consulted MFCU 
staff to address any apparent issues with individual case files, such as missing 
documentation.   
Review of Unit Submissions to OIG and the NPDB 
We also reviewed all 15 of the Units convictions that were submitted to OIG for 
program exclusion during our review period, and all 15 of the Units adverse actions 
that were submitted to the NPDB during our review period.  We reviewed whether the 
Unit submitted information on all sentenced individuals and entities to OIG for 
program exclusion and all adverse actions to the NPDB for FYs 20192021.  We also 
assessed the timeliness of the submissions to OIG and the NPDB.   
Onsite Review of Unit Operations 
The Unit is in the process of moving to a new office space and was operating on full 
telework at the time of our review.  As such, we were not able to perform a full onsite 
review of Unit operations, including an inventory review.  The District of Columbia OIG 
retained a suite of office space at its previous location, and we conducted our data 
collection in that location.   
 
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Appendix C: Point Estimates and 95-Percent Confidence Intervals of 
Case File Reviews 
95-Percent 
     
Confidence Interval 
Estimate Description  Sample Size  Point Estimate  Lower  Upper 
Percentage of All Cases That Had Supervisory Approval 
78  96.15%  90.04%  98.76% 
To Open 
Percentage of All Cases Closed at the Time of Our 
78  85.90%  77.59%  91.70% 
Review 
Percentage of All Closed Cases That Had Supervisory 
67  97.01%  90.46%  99.17% 
Approval To Close 
Percentage of Eligible Cases That Contained 
Documentation of Supervisory Reviews Consistent with  66  59.09%  47.72%  69.71% 
Unit Policy 
Percentage of Eligible Cases That Contained 
Documentation of Supervisory Reviews but Not  66  36.36%  26.14%  47.72% 
Consistent with Unit Policy 
Percentage of Eligible Cases That Contained No 
66  4.55%  1.24%  11.62% 
Documentation of Supervisory Review 
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Appendix D: Unit Comments 
 
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OEI-06-22-00420   Appendix D | 30    
 
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OEI-06-22-00420   Appendix D | 31    
 
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OEI-06-22-00420   Appendix D | 32    
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OEI-06-22-00420   Appendix D | 33    
ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Anna Brown served as the project leader for this review.  Others in the Office of 
Evaluation and Inspections who conducted the review include Kristen Calille and 
Kaisee Riddell.  Medicaid Fraud Policy and Oversight Division staff who participated in 
the review included Susan Burbach.  Office of Evaluation and Inspections 
headquarters staff who provided support include Robert Gibbons and Sara Swisher.  
We would also like to acknowledge the contributions of two agents from the Office of 
Investigations and three attorneys from the Office of Counsel to the Inspector 
General.  Randall Clouse, the director of the Virginia MFCU, served as a peer reviewer. 
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector 
General for Evaluation and Inspections in the Dallas regional office, and Petra Nealy 
and Amy Ashcraft, Deputy Regional Inspectors General, as well as in consultation with 
Richard Stern, Director of the Medicaid Fraud Policy and Oversight Division. 
 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
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OEI-06-22-00420   Acknowledgments and Contact | 34    
ABOUT THE OFFICE OF INSPECTOR GENERAL 
Office of Inspector General 
https://oig.hhs.gov 
The mission of the Office of Inspector General (OIG) is to provide objective oversight 
to promote the economy, efficiency, effectiveness, and integrity of the Department of 
Health and Human Services (HHS) programs, as well as the health and welfare of the 
people they serve.  Established by Public Law No. 95-452, as amended, OIG carries out 
its mission through audits, investigations, and evaluations conducted by the following 
operating components: 
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.  The audits examine the performance of HHS programs, funding recipients, 
and contractors in carrying out their respective responsibilities and provide 
independent assessments of HHS programs and operations to reduce waste, abuse, 
and mismanagement. 
The Office of Evaluation and Inspections.  OEIs national evaluations 
provide HHS, Congress, and the public with timely, useful, and reliable information on 
significant issues.  To promote impact, OEI reports also provide practical 
recommendations for improving program operations. 
The Office of Investigations.  OIs criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs and operations 
often lead to criminal convictions, administrative sanctions, and civil monetary 
penalties.  OIs nationwide network of investigators collaborates with the Department 
of Justice and other Federal, State, and local law enforcement authorities.  OI works 
with public health entities to minimize adverse patient impacts following enforcement 
operations.  OI also provides security and protection for the Secretary and other 
senior HHS officials. 
The Office of Counsel to the Inspector General.  OCIG provides legal 
advice to OIG on HHS programs and OIGs internal operations.  The law office also 
imposes exclusions and civil monetary penalties, monitors Corporate Integrity 
Agreements, and represents HHSs interests in False Claims Act cases.  In addition, 
OCIG publishes advisory opinions, compliance program guidance documents, fraud 
alerts, and other resources regarding compliance considerations, the anti-kickback 
statute, and other OIG enforcement authorities 
   
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