Performance Standards for Medicaid Fraud Control Units

<RULE> DEPARTMENT OF HEALTH AND HUMAN SERVICES <SUBAGY>Office of Inspector General</SUBAGY> <CFR>42 CFR Part 1007</CFR> <SUBJECT>Performance Standards for Medicaid Fraud Control Units</SUBJECT> <HD SOURCE="HED">AGENCY:</HD> Office of Inspector General (OIG), Department of Health and Human Services (HHS). <HD SOURCE="HED">ACTION:</HD> Notice of final revised performance standards. <SUM> <HD SOURCE="HED">SUMMARY:</HD> This document sets forth OIG guidance regarding standards OIG will apply in assessing the performance of Medicaid Fraud Control Units (MFCUs or Units). Based on its experience in overseeing MFCUs, and after consultation with key stakeholders, OIG is revising the standards. These standards replace and supersede standards published on June 1, 2012. </SUM> <EFFDATE> <HD SOURCE="HED">DATES:</HD> Effective Date: These standards are effective upon publication. </EFFDATE> <FURINF> <HD SOURCE="HED">FOR FURTHER INFORMATION CONTACT:</HD> Susan Burbach, OIG Office of Evaluation and Inspections, 202-731-8516, <E T="03">susan.burbach@oig.hhs.gov.</E> </FURINF> <SUPLINF> <HD SOURCE="HED">SUPPLEMENTARY INFORMATION:</HD> <HD SOURCE="HD1">I. Background</HD> The mission of MFCUs is to investigate and prosecute (or refer for prosecution): (1) fraud committed by Medicaid providers, (2) fraud in the administration of the Medicaid program, and (3) patient abuse or neglect of residents in health care facilities and board and care facilities and of Medicaid enrollees in noninstitutional or other settings. MFCUs receive most of their funding from the Federal Government, and each MFCU operates as “a single, identifiable entity of State government.” Each of the 50 States has a MFCU, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Except for four States, each MFCU is organized as part of the State Attorney General's office. HHS-OIG has been delegated authority under sections 1903(q) and 1903(a)(6) of the Social Security Act (the Act) to certify and annually recertify Units as eligible for Federal financial participation (FFP), and to reimburse States for costs incurred in operating a MFCU. Through the certification and recertification process, OIG ensures that the Units meet the requirements for FFP set forth in section 1903(q) of the Act and in Federal regulations found at 42 CFR part 1007. As part of this process, OIG applies a series of performance standards, as required by section 1902(a)(61) of the Act, in determining the effectiveness of Units in carrying out required MFCU functions. The standards provide helpful guidance to MFCUs in their operations and assist OIG in its recertification process and periodic reviews of MFCUs. If OIG determines there are opportunities for a Unit to improve its adherence to the standards, OIG will work with the Unit to implement changes or may impose and monitor formal recommendations for improvement. The standards reflect practices identified both by OIG and MFCUs that will improve MFCU effectiveness in fulfilling their oversight mission. OIG's goal, both with these standards and with OIG's other oversight activities, is to support each Unit in maximizing its effectiveness in fighting Medicaid fraud and protecting enrollees and other facility residents. We encourage Units to implement these standards in light of each State's organization and practices and to identify additional best practices that will improve their effectiveness. OIG initially published the MFCU performance standards in 1994 (see 59 FR 49080, September 26, 1994) and revised the standards in 2012 (see 77 FR 32645, June 1, 2012). Based on its experience in overseeing MFCUs, OIG has updated the standards. The updated standards were developed in consultation with the National Association of Medicaid Fraud Control Units. OIG welcomes stakeholder feedback on the standards and may consider future revisions in response to feedback. <HD SOURCE="HD1">II. Standards for Assessing MFCU Performance</HD> <HD SOURCE="HD2">Performance Standard 1—Compliance With Requirements</HD> A Unit conforms with applicable statutes, regulations, and policy directives, including: A. Section 1903(q) of the Social Security Act, containing the basic requirements for operation of a MFCU; B. Regulations for operation of a MFCU contained in 42 CFR part 1007; C. Federal administrative requirements, cost principles, and audit requirements referenced in the notice of grant award terms and conditions; D. Applicable State and Federal requirements and standards pertaining to information security as described in Standard 7F; E. OIG policy transmittals as maintained on the OIG website; and F. Terms and conditions of the notice of the grant award as maintained on the OIG website. <HD SOURCE="HD2">Performance Standard 2—Staffing</HD> A Unit maintains reasonable staff levels and office locations in relation to the State's Medicaid program expenditures and has a salary and benefit package that allows the Unit to recruit and retain qualified staff. To determine whether a Unit meets this standard, OIG will consider the following performance indicators: A. The Unit seeks to employ a total number of professional staff that is commensurate with the State's total Medicaid program expenditures and that enables the Unit to effectively investigate and prosecute (or refer for prosecution) an appropriate volume of case referrals and workload for both Medicaid fraud and abuse or neglect of patients or residents. B. The Unit employs an appropriate mix and number of attorneys, auditors, investigators, and other professional staff that is commensurate with the State's total Medicaid program expenditures and that allows the Unit to effectively investigate and prosecute (or refer for prosecution) an appropriate volume of case referrals and workload for both Medicaid fraud and abuse or neglect of patients or residents. C. The Unit, when warranted for the number of employees, designates one or more supervisory staff, such as senior investigators, to supervise the activities of individual investigators or other employees. D. The Unit employs a number of administrative staff in relation to its overall size that allows the Unit to operate effectively. E. The Unit, consistent with State requirements, offers a competitive salary and benefits package that permits the Unit to recruit and retain qualified professional staff in the region where the Unit operates. F. To the extent that a Unit maintains multiple office locations, such locations are distributed throughout the State and are adequately staffed, commensurate with the volume of case referrals and workload for each location. <HD SOURCE="HD2">Performance Standard 3—Policies and Procedures</HD> A Unit establishes written policies and procedures for its operations and ensures that staff are familiar with, and adhere to, policies and procedures. To determine whether a Unit meets this standard, OIG will consider the following performance indicators: A. The Unit has written guidelines or manuals that contain current policies and procedures, consistent with these performance standards and any applicable laws, regulations, and policy transmittals, for the investigation and (for those Units with prosecutorial authority) prosecution of Medicaid fraud and abuse and neglect of patients or residents. B. The Unit adheres to current policies and procedures in its operations. C. The Unit periodically reviews and updates its policies and procedures and creates and implements new policies and procedures as appropriate. D. Policies and procedures also address, at a minimum, the following: 1. A timeframe for conducting periodic supervisory case reviews (see Standard 5C); 2. A process for referring cases, when appropriate, to Federal and State agencies; 3. Training standards for Unit employees; 4. A policy to ensure collaboration with Federal partners as required by 42 CFR 1007.11(e)(5); and 5. For those Units with sworn law enforcement agents, policies and procedures to address the exercise of the Unit's law enforcement authorities. E. Written guidelines and manuals are readily available to all Unit staff, either electronically or in hard copy. <HD SOURCE="HD2">Performance Standard 4—Maintaining Adequate Referrals</HD> A Unit takes steps to maintain an adequate volume and quality of referrals from the State Medicaid agency and other sources. To determine whether a Unit meets this standard, OIG will consider the following performance indicators: A. The Unit takes steps to ensure that the State Medicaid agency, managed care organizations, and other pertinent entities refer to the Unit suspected provider fraud. Steps to ensure referrals may include having consistent communication and meetings with referring entities, providing feedback on the quality and volume of referrals, and training on the characteristics of an effective referral. B. The Unit, unless prohibited by law, provides timely information to the referring entity when the entity requests information on the status of MFCU investigations, including when the Medicaid agency requests quarterly certification pursuant to 42 CFR 455.23(d)(3)(ii). C. The Unit takes steps to encourage pertinent entities to refer complaints of patient or resident abuse or neglect to the Unit. Pertinent entities may include licensing and certification agencies, the State Long-Term Care Ombudsman, and adult protective services offices. D. The Unit takes steps through public outreach or other means to encourage the public to make referrals to the Unit. <HD SOURCE="HD2">Performance Standard 5—Maintaining Case Progression</HD> A Unit takes steps to maintain reasonable case progression and to complete cases within an appropriate timeframe based on the complexity of the cases. To determine whether a Unit meets this standard, OIG will consider the following performance ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ Preview showing 10k of 23k characters. Full document text is stored and available for version comparison. ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━