[Federal Register Volume 59, Number 185 (Monday, September 26, 1994)]
[Unknown Section]
[Page 0]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 94-23692]
[[Page Unknown]]
[Federal Register: September 26, 1994]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Inspector General
Performance Standards for State Medicaid Fraud Control Units
AGENCY: Office of Inspector General, HHS.
ACTION: Notice.
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SUMMARY: In accordance with section 1902(a)(61) of the Social Security
Act and the authority delegated to the Inspector General, this notice
sets forth standards for assessing the performance of the State
Medicaid Fraud Control Units. These standards will be used in the
certification and recertification of each Unit and to determine if a
Unit is effectively and efficiently carrying out its duties and
responsibilities.
EFFECTIVE DATE: These performance standards are effective on September
26, 1994.
FOR FURTHER INFORMATION CONTACT:
Paul F. Conroy, Office of Investigations, (202) 619-3210
Joel Schaer, Legislation, Regulations and Public Affairs Staff, (202)
619-0089
SUPPLEMENTARY INFORMATION:
I. Background
Since the enactment of the Medicare and Medicaid Anti-Fraud and
Abuse Amendments of 1977, authorizing the establishment and funding for
Medicaid Fraud Control Units (MFCUs), 42 States have created such fraud
control units to investigate and prosecute Medicaid provider fraud and
patient abuse and neglect in Medicaid funded facilities.
A MFCU must be a single, identifiable entity of the State
government composed of (i) one or more attorneys experienced in
investigating or prosecuting civil fraud or criminal cases who are
capable of giving informed advice on applicable law and procedures and
providing effective prosecution or liaison with other prosecutors; (ii)
one or more experienced auditors capable of supervising the review of
financial records and advising or assisting in the investigation of
alleged fraud; and (iii) a senior investigator with substantial
experience in commercial or financial investigations who is capable of
supervising and directing the investigative activities of the unit.
While the preference of the enabling legislation has been for the unit
to investigate and prosecute its own cases on a Statewide basis, the
legislative history recognizes that not all States are lawfully able to
establish the MFCU to do so.
The State Medicaid agency is required to enter into an agreement
with the MFCU to refer all suspected cases of provider fraud to the
unit, and to comply with the unit's requests for provider records or
computerized data that is kept by the Medicaid agency. To ensure that
Medicaid overpayments identified by a MFCU in the course of its
investigations are recovered, each MFCU is required either to undertake
civil recovery actions or have procedures to refer overpayments for
collection to other appropriate State agencies.
The HHS Office of Inspector General (OIG) is delegated the
authority to certify and recertify the MFCUs to ensure that the units
fully comply with the governing statute and with Federal regulations
set forth in 42 CFR part 1007. As part of its recertification process,
the OIG reviews the State fraud units' applications for recertification
and may conduct on-site visits to the units to observe their
operations. The OIG also collects and analyzes statistical data on the
number and type of cases under investigation, the number of convictions
obtained, and the amount of recoveries.
II. Use Of Performance Standards
Section 13625 of the Omnibus Budget Reconciliation Act of 1993,
Public Law 103-66, amended section 1902 of the Social Security Act by
adding a new paragraph (a)(61) that establishes a Medicaid State plan
requirement that, effective January 1, 1995, a State must operate a
MFCU in accordance with standards to be established by the Secretary.
The OIG intends to use these performance standards in the
certification and recertification of a Unit, as well as for assessing
the effectiveness of a Unit during on-site reviews.
III. Standards For Assessing The MFCUS
In cooperation with the Units themselves, represented by a working
group from the National Association of Medicaid Fraud Control Units,
the OIG has developed twelve performance standards to be used in
evaluating a Unit's performance. Each of the current Unit directors has
concurred with the standards and accompanying requirements or
indicators set forth below.
Performance Standards
1. A Unit will be in conformance with all applicable statutes,
regulations and policy directives.
In meeting this standard, the Unit must meet, but is not limited
to, the following requirements--
A. The Unit professional staff must consist of permanent employees
working full-time on Medicaid fraud and patient abuse matters.
B. The Unit must be separate and distinct from the single State
Medicaid agency.
C. The Unit must have prosecutorial authority or an approved formal
procedure for referring cases to a prosecutor.
D. The Unit must submit annual reports, with appropriate
certifications, on a timely basis.
E. The Unit must submit quarterly reports on a timely basis.
F. The Unit must comply with the Americans with Disabilities Act,
the Equal Employment Opportunity requirements, the Drug Free Workplace
requirements, Federal lobbying restrictions, and other such rules that
are made conditions of the grant.
2. A Unit should maintain staff levels in accordance with staffing
allocations approved in its budget.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit employ the number of staff that were included in
the Unit's budget as approved by the OIG?
B. Does the Unit employ the number of attorneys, auditors, and
investigators that were approved in the Unit's budget?
C. Does the Unit employ a reasonable size of professional staff in
relation to the State's total Medicaid program expenditures?
D. Are the Unit office locations established on a rational basis
and are such locations appropriately staffed?
3. A Unit should establish policies and procedures for its
operations, and maintain appropriate systems for case management and
case tracking.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit have policy and procedure manuals?
B. Is an adequate, computerized case management and tracking system
in place?
4. A unit should take steps to ensure that it maintains an adequate
workload through referrals from the single State agency and other
sources.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit work with the single State agency to ensure
adequate fraud referrals?
B. Does the Unit work with other agencies to encourage fraud
referrals?
C. Does the Unit generate any of its own fraud cases?
D. Does the Unit ensure that adequate referrals of patient abuse
complaints are received from all sources?
5. A Unit's case mix, when possible, should cover all significant
provider types.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit seek to have a mix of cases among all types of
providers in the State?
B. Does the Unit seek to have a mix of Medicaid fraud and Medicaid
patient abuse cases?
C. Does the Unit seek to have a mix of cases that reflect the
proportion of Medicaid expenditures for particular provider groups?
D. Are there any special Unit initiatives targeting specific
provider types that affect case mix?
E. Does the Unit consider civil and administrative remedies when
appropriate?
6. A Unit should have a continuous case flow, and cases should be
completed in a reasonable time.
In meeting this standard, the following performance indicators will
be considered--
A. Is each stage of an investigation and prosecution completed in
an appropriate time frame?
B. Are supervisors approving the opening and closing of
investigations?
C. Are supervisory reviews conducted periodically and noted in the
case file?
7. A Unit should have a process for monitoring the outcome of
cases.
In meeting this standard, the Unit's monitoring of the following
case factors and outcomes will be considered--
A. The number, age, and type of cases in inventory.
B. The number of referrals to other agencies for prosecution.
C. The number of arrests and indictments.
D. The number of convictions.
E. The amount of overpayments identified.
F. The amount of fines and restitution ordered.
G. The amount of civil recoveries.
H. The numbers of administrative sanctions imposed.
8. A Unit will cooperate with the OIG and other Federal agencies,
whenever appropriate and consistent with its mission, in the
investigation and prosecution of health care fraud.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit communicate effectively with the OIG and other
Federal agencies in investigating or prosecuting health care fraud in
their State?
B. Does the Unit provide OIG regional management, and other Federal
agencies, where appropriate, with timely information concerning
significant actions in all cases being pursued by the Unit?
C. Does the Unit have an effective procedure for referring cases,
when appropriate, to Federal agencies for investigation and other
action?
D. Does the Unit transmit to the OIG, for purposes of program
exclusions under section 1128 of the Social Security Act, reports of
convictions, and copies of Judgment and Sentence or other acceptable
documentation within 30 days or other reasonable time period?
9. A Unit should make statutory or programmatic recommendations,
when necessary, to the State government.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit recommend amendments to the enforcement provisions
of the State's statutes when necessary and appropriate to do so?
B. Does the Unit provide program recommendations to single State
agency when appropriate?
C. Does the Unit monitor actions taken by State legislature or
State Medicaid agency in response to recommendations?
10. A Unit should periodically review its Memorandum of
Understanding (MOU) with the single State Medicaid agency and seek
amendments, as necessary, to ensure it reflects current law and
practice.
In meeting this standard, the following performance indicators will
be considered--
A. Is the MOU more than 5 years old?
B. Does the MOU meet Federal legal requirements?
C. Does the MOU address cross-training with the fraud detection
staff of the State Medicaid agency?
D. Does the MOU address the Unit's responsibility to make program
recommendations to the Medicaid agency and monitor actions taken by the
Medicaid agency concerning those recommendations?
11. The Unit director should exercise proper fiscal control over
the unit resources.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit director receive on a timely basis copies of all
fiscal and administrative reports concerning Unit expenditures from the
State parent agency?
B. Does the Unit maintain an equipment inventory?
C. Does the Unit apply generally accepted accounting principles in
its control of Unit funding?
12. A Unit should maintain an annual training plan for all
professional disciplines.
In meeting this standard, the following performance indicators will
be considered--
A. Does the Unit have a training plan in place and funds available
to fully implement the plan?
B. Does the Unit have a minimum number of hours training
requirement for each professional discipline, and does the staff comply
with the requirement?
C. Are continuing education standards met for professional staff?
D. Does training undertaken by staff aid in the mission of the
Unit?
These standards may be periodically reviewed and discussed with the
Units and other State representatives to ascertain their effectiveness
and applicability. Additional or revised performance standards may be
proposed when deemed appropriate.
Dated: September 16, 1994.
June Gibbs Brown,
Inspector General.
[FR Doc. 94-23692 Filed 9-23-94; 8:45 am]
BILLING CODE 4150-04-P
