The OIG found West Virginia’s control unit failed to meet the performance standards in the following ways:
1. Case files lacked documentation. The Medicaid Fraud Control Unit performance standards require supervisory approval for the opening and closing of all case files. The OIG found 20 percent of the files at the West Virginia unit lacked documentation of approval to open, and 27 percent of the files lacked documentation of approval to close from 2010 to 2012.
2. Convicted individuals were not referred to the OIG within time limit. The Medicaid Fraud Control Unit performance standards require state units to inform the OIG of any individuals convicted of Medicaid fraud within their state within 30 days of the conviction for the purpose of program exclusion. The OIG found West Virginia’s fraud unit failed to send conviction information to the OIG for 50 percent of convicted individuals within the 30 day time limit from 2010 to 2012.
3. Case management system was inadequate. The Medicaid Fraud Control Unit performance standards require all state fraud units to have a computerized case management and tracking system. The OIG found West Virginia’s case management system lost data on a regular basis and often merged case file information from unrelated cases.
4. Incomplete inventory. The Medicaid Fraud Control Unit performance standards require all state fraud units to maintain a regularly updated inventory that reflects all property under the unit’s control. The OIG found many items, including a paper shredder and an identification card system, which were not reflected on the unit’s inventory report.
5. Investigation and prosecution timeline was not followed. The Medicaid Fraud Control Unit performance standards require each stage of an investigation and prosecution to be completed in an appropriate timeframe. West Virginia’s unit had a policy requiring no more than 60 days to pass between the receipt of a referral and the opening of a case. The OIG found West Virginia’s fraud unit was not following its 60 day policy and 70 percent of cases referred to the unit were not opened after 60 days.
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