U.S. Department of Health and Human Services Office of Inspector General Louisiana Medicaid Fraud Control Unit: 2020 Inspection Suzanne Murrin Deputy Inspector General for Evaluation and Inspections August 2021, OEI-12-20-00650 U.S. Department of Health and Human Services Office of Inspector General Report in Brief August 2021, OEI-12-20-00650 Louisiana Medicaid Fraud Control Unit (MFCU or Unit) Louisiana Medicaid Fraud Control Unit: Case Outcomes 2020 Inspection Federal Fiscal Years 2018-2020 What OIG Found • 227 indictments We found that the Louisiana Unit generally adhered to the performance standards and complied with applicable laws, regulations, and policy • 162 convictions transmittals during Federal fiscal years (FYs) 2018-2020, with one exception: • 50 civil settlements and • One case in our review of case files was ineligible for Federal judgments matching funds during the review period. • $48.9 million in recoveries We also identified two beneficial practices that may be useful as a model to other Units. Unit Snapshot • The Unit hired an outreach coordinator to promote the Unit's mission among its stakeholders. The Unit is part of the Louisiana Department of Justice's Criminal • The Unit and a neighboring Unit sponsored combined training Division. events for employees of both Units. The 64-person Unit staff-36 What OIG Recommends and How the Unit Responded investigators, 12 attorneys, To address the one finding, we recommend that the Louisiana Unit repay 8 auditors, and 8 support staff-is Federal matching funds spent on the case that was ineligible for Federal located in Baton Rouge, Lafayette, funding. The Unit concurred with our recommendation. Monroe, and Shreveport. TABLE OF CONTENTS BACKGROUND 1 Methodology PERFORMANCE ASSESSMENT 5 Case Outcomes 5 The Unit reported 227 indictments, 162 convictions, and 50 civil settlements and judgments for fiscal years 2018-2020 The Unit reported total recoveries of $48.9 million for fiscal years 2018-2020 Performance Standard 1: Compliance with requirements 6 On the basis of the information we reviewed, the Unit generally complied with applicable laws, regulations, and policy transmittals, with one exception One case in our review of case files was ineligible for Federal matching funds during the review period Performance Standard 2: Staffing 6 During our review period, the Unit maintained reasonable staff levels and employed staff consistent with levels in accordance with its approved budget Performance Standard 3: Policies and procedures 7 The Unit maintained a policies and procedures manual specific to its operations; this manual was available to all staff on a shared network drive Performance Standard 4: Maintaining adequate referrals 7 The Unit took steps to maintain its referrals of fraud and of patient abuse or neglect The Unit hired an outreach coordinator to promote the Unit's mission among its stakeholders Performance Standard 5: Maintaining a continuous case flow 8 The Unit maintained a continuous case flow Performance Standard 6: Case mix 8 During our review period, the Unit investigated 1,750 cases, of which 1,301 involved fraud and 449 involved patient abuse or neglect; the cases covered 51 different provider types Performance Standard 7: Maintaining case information 8 The Unit maintained case files in an effective manner and retained a case management system that allowed access to case information Performance Standard 8: Cooperation with Federal authorities on fraud cases 9 The Unit cooperated at a high level with its Federal partners Performance Standard 9: Program recommendations 9 During our review period, the Unit made a program recommendation to the State Medicaid agency Performance Standard 10: Agreement with Medicaid agency 9 The Unit's memorandum of understanding with the State Medicaid agency reflected current practice, policy, and legal requirements Performance Standard 11: Fiscal control 9 In our limited review, we identified no significant deficiencies in the Unit's fiscal control of its resources during our review period Performance Standard 12: Training 10 The Unit maintained a training plan for each professional discipline The Unit and a neighboring Unit sponsored combined training events for employees of both Units CONCLUSION and RECOMMENDATION 11 Repay Federal matching funds spent on the case that was ineligible for Federal funding 11 UNIT COMMENTS and OIG RESPONSE 12 DETAILED METHODOLOGY 13 APPENDICES 16 A. Referrals by Source for Fiscal Years 2018-2020 16 B. Unit Comments 17 ACKNOWLEDGMENTS AND CONTACT 18 ABOUT THE OFFICE OF INSPECTOR GENERAL 19 BACKGROUND Objectives To examine the performance and operations of the Louisiana Medicaid Fraud Control Unit (MFCU or Unit). Medicaid Fraud Control Units Medicaid Fraud Control Units investigate (1) Medicaid provider fraud and (2) patient abuse or neglect in facility settings 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 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) 2020, combined Federal and State expenditures for the MFCUs totaled approximately $306 million. 8 _____________________________________________________________________________________________________________________________ 1 SSA § 1903(q)(3). Regulations at 42 CFR § 1007.11(b)(1) clarify that a Unit's responsibilities include the review of complaints of misappropriation of patients' private funds in health care facilities. 2 Asof 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. 7SSA § 1903(a)(6). For a Unit's 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. 8OIG analysis of MFCU annual statistical reporting data for FY 2020. The FY 2020 was from October 1, 2019, through September 30, 2020. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Background | 1 OIG Grant Administration and Oversight of Medicaid Fraud Control Units The 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 as part of 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 desk review, OIG examines the Unit's reapplication materials, case statistics, and questionnaire responses from Unit stakeholders. Through the recertification review, OIG assesses a Unit's performance, as measured by the Unit's adherence to published performance standards; 11 the Unit's compliance with applicable laws, regulations, and OIG policy transmittals; 12 and the Unit's case outcomes. OIG further assesses Unit performance by conducting inspections and reviews on selected Units. 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. Finally, OIG provides training and technical assistance to Units during inspections and reviews, as appropriate, and on an ongoing basis. Louisiana MFCU The Unit is an autonomous entity within the Criminal Division of the Louisiana Department of Justice (LA DOJ). The Unit has a main office, headquartered in Baton Rouge, and three satellite offices, located in Lafayette, Monroe, and Shreveport. At the time of our inspection, the Unit employed 64 staff-36 investigators (including the chief investigator, 5 investigative teams each led by a different supervisory investigator, and an operations manager), 12 attorneys (including the director and 2 supervising attorneys), 8 auditors, and 8 support staff (including 1 outreach _____________________________________________________________________________________________________________________________ 9As 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. 10The 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. 11MFCU performance standards are published at 77 Fed. Reg. 32645 (June 1, 2012) and are located at https://oig.hhs.gov/authorities/docs/2012/PerformanceStandardsFinal060112.pdf. 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. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Background | 2 coordinator). 13 In its 4 offices across Louisiana, the MFCU staffed 53 employees in Baton Rouge, 6 in Lafayette, 4 in Monroe, and 1 in Shreveport. Referrals When the Unit receives referrals, the Unit's support staff assigns them to one of seven Unit attorneys through the Unit's case management system. Each attorney screens his/her assigned referrals to determine whether the referrals should be opened as cases and sends these case recommendations to the chief investigator and operations manager. The chief investigator makes the final decision to open referrals as cases by approving the Unit's opening memorandum. Investigations and Prosecutions After the Unit opens a case, the Unit's operations manager assigns an investigator, attorney, and auditor to the case. Throughout the investigation, the investigator and his/her supervisory investigator meet quarterly with Unit management to discuss the progress of the case. If warranted, the assigned attorney, in consultation with the U.S. Attorney's Offices or the District Attorney's Office, prosecutes the case. Louisiana Medicaid Program The Louisiana Department of Health (LDH) administers the State's Medicaid program. As of July 1, 2019, 90 percent of the Louisiana Medicaid program's beneficiaries were enrolled in a managed care plan for some or all of the beneficiary's care.14 In FY 2020, Louisiana's total Medicaid expenditures were $12.9 billion. 15 The LDH's Medicaid program integrity unit is responsible for identifying potential fraud cases and submitting them to the Louisiana Unit. Prior OIG Report OIG conducted a previous onsite review of the Louisiana Unit in 2012. 16 In that review, OIG found that (1) 28 percent of the Unit's case files lacked documentation in _____________________________________________________________________________________________________________________________ 13The Unit had three directors during our review period of FYs 2018-2020. In July 2018, the director left, and a new director served until June 2019. The current director accepted the position beginning in July 2019. 14 Kaiser Family Foundation, Share of Medicaid Population Covered under Different Delivery Systems, https://www.kff.org/medicaid/state-indicator/share-of-medicaid-population-covered-under-different- delivery- systems/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7 D. Accessed on February 19, 2021. OIG, MFCU Statistical Data for FY 2020, https://oig.hhs.gov/fraud/medicaid-fraud-control-units- 15 mfcu/expenditures_statistics/fy2020-statistical-chart.pdf. Accessed on March 22, 2021. 16OIG, Louisiana State Medicaid Fraud Control Unit: 2012 Onsite Review, https://oig.hhs.gov/oei/reports/oei- 09-12-00010.pdf. Accessed on February 17, 2021. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Background | 3 accordance with the Unit's periodic supervisory reviews, while 22 percent of the Unit's case files did not have any documentation of periodic supervisory reviews at all; (2) the Unit did not refer 14 percent of sentenced providers to OIG for program exclusion within an appropriate timeframe; (3) the Unit had not updated its memorandum of understanding (MOU) with the LDH to reflect current law and practice; and (4) the Unit did not report its program income appropriately. In its report, OIG recommended that the Unit (1) revise its policies and procedures to ensure that periodic supervisory reviews are documented in Unit case files; (2) ensure that it refers all sentenced providers for exclusion to OIG within an appropriate timeframe; (3) revise its MOU with the LDH to reflect current law and practice; and (4) ensure that all program income is reported properly. On the basis of information received from the Unit in 2013, OIG considered the recommendations implemented. Methodology OIG conducted the inspection of the Louisiana MFCU in December 2020. Due to the COVID-19 public health emergency, the OIG team was not able to conduct the inspection onsite as planned and conducted the inspection remotely. Our inspection covered the 3-year period of FYs 2018-2020. We based our inspection on an analysis of data and information from the following 6 sources: (1) Unit documentation; (2) financial documentation; (3) structured interviews with key stakeholders; (4) structured interviews with the Unit's managers and selected staff; (5) a review of a random sample of 98 case files from the 1,682 nonglobal case files that were open at some point during our review period; and (6) a review of all convictions submitted to OIG for program exclusion and all adverse actions submitted to the National Practitioner Data Bank (NPDB) during our review period. We were unable to observe Unit operations. In examining the Unit's operations and performance, we applied the published performance standards, but we did not assess adherence to every performance indicator for every standard. (See the Detailed Methodology.) Standards We conducted this inspection in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. These inspections differ from other OIG evaluations in that they support OIG's 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. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Background | 4 PERFORMANCE ASSESSMENT In assessing the performance and operations of the Louisiana Unit, OIG identified the Unit's case outcomes and found that the Unit generally complied with all legal requirements except that we made one compliance-related finding. For each of the performance standards, we made a finding and/or observation(s), including highlighting two beneficial practices. CASE OUTCOMES 17 The Unit reported 227 indictments, 162 convictions, and 50 civil Observations settlements and judgments for FYs 2018-2020. Of the 162 convictions, 131 involved provider fraud and 31 involved patient abuse or neglect. The Unit reported total recoveries of $48.9 million for FYs 2018-2020. Source: OIG analysis of Unit statistical data, FYs 2018-2020. 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. _____________________________________________________________________________________________________________________________ 17 OIG provides information on MFCU operations and outcomes but does not direct or encourage MFCUs to investigate or prosecute a specific number of cases. MFCU investigators and prosecutors should apply professional judgment and discretion in determining what criminal and civil cases to pursue. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Performance Assessment | 5 STANDARD 1 A Unit conforms with all applicable statutes, regulations, and policy directives. On the basis of the information we reviewed, the Unit generally complied with applicable laws, regulations, and policy transmittals, with one exception. One case in our review of case files was ineligible for Federal matching Finding funds during the review period. According to statute and regulations in effect during our review period, MFCUs can receive Federal funds only for the investigation and prosecution of cases of patient abuse or neglect, including misappropriation of funds or property, that occur in Medicaid- funded health care facilities or in board and care facilities. 18 From our review of sampled case files that were open during our review period, we found one case of alleged misappropriation of funds that did not occur in a Medicaid-funded facility or board and care facility, and was therefore- according to statute and regulations-not eligible for Federal financial participation (FFP). 19 As a result, costs associated with this case were not eligible for FFP. STANDARD 2 A Unit maintains reasonable staff levels and office locations in relation to the State's Medicaid program expenditures and in accordance with staffing allocations approved in its budget. During our review period, the Unit maintained reasonable staff levels Observation and employed staff consistent with levels in accordance with its approved budget. The Unit was approved by OIG for 69-70 staff and employed between 64-67 staff over the course of the 3-year review period. _____________________________________________________________________________________________________________________________ 18 SSA § 1903(a)(6) and (q)(4)(A); 42 CFR §§ 1007.11(b) and 1007.19(d)(1). 19Although the case identified in the inspection was not eligible for FFP under existing statute during the review period, Division CC, Section 207 of the Consolidated Appropriations Act, 2021, Public Law 116-260 (December 27, 2020), amended Section 1903(q)(4)(A)(ii) of the SSA to expand MFCU statutory grant authority to investigate and prosecute patient abuse or neglect of Medicaid beneficiaries in noninstitutional or other settings. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Performance Assessment | 6 STANDARD 3 A Unit establishes written policies and procedures for its operations and ensures that staff are familiar with, and adhere to, policies and procedures. The Unit maintained a policies and procedures manual specific to its Observation operations; this manual was available to all staff on a shared network drive. The Unit reviewed and revised its entire policies and procedures manual in October 2016. At the time of our inspection, the Unit was drafting an updated manual, which was planned for completion in 2021. 20 Unit management reported to us that the Unit instructs (1) newly hired employees to read the policies and procedures manual during the Unit's "new employee orientation" process and (2) Unit supervisors to ensure their subordinate employees are adhering to the Unit's policies and procedures. STANDARD 4 A Unit takes steps to maintain an adequate volume and quality of referrals from the State Medicaid agency and other sources. The Unit took steps to maintain its referrals of fraud and of patient Observations abuse or neglect. For its fraud referrals, the Unit communicated regularly with the LDH's Medicaid program integrity unit by conducting bimonthly meetings, which included discussions about referral issues, potential cases, and data mining. Also, since the Unit directly receives referrals from the five Medicaid managed care organizations (MCOs) in the State, the Unit communicated quarterly with the MCOs to encourage referrals. For its patient abuse or neglect referrals, the Unit downloaded and screened incident reports directly from the statewide incident management system maintained by the LDH's Health Standards Section. 21 Appendix A includes all the Unit's sources of referrals for fraud and for patient abuse or neglect during FYs 2018-2020. The Unit hired an outreach coordinator to promote the Unit's mission Beneficial Practice among its stakeholders. In FY 2020, the Unit hired an outreach coordinator to promote the Unit's mission among its various stakeholders, including nursing homes, rehabilitation facilities, local law enforcement agencies, and other State agencies. The outreach coordinator's responsibilities are to (1) develop outreach training regarding the Unit's mission; (2) present this training to the Unit's stakeholders; (3) coordinate _____________________________________________________________________________________________________________________________ 20 The Unit completed the update to its policies and procedures manual in May 2021. 21 The Health Standards Section of the Louisiana Department of Health is responsible for the licensing of Louisiana's health care facilities that are subject to licensing statutes. The Health Standards Section also conducts certification surveys and complaint surveys of certified health care facilities in the Medicaid program. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Performance Assessment | 7 with the LA DOJ press office to draft and disseminate public press releases of the Unit's accomplishments; and (4) act as the Unit's liaison to receive referrals from stakeholders. STANDARD 5 A Unit takes steps to maintain a continuous case flow and to complete cases in an appropriate timeframe based on the complexity of the cases. The Unit maintained a continuous case flow. Our review of the Unit's Observation case files found no significant delays in the completion of the investigations or in the subsequent prosecutions/settlements. Further, nearly all the case files contained appropriate supervisory approval for documentation of case openings and applicable case closings as well as applicable quarterly case file reviews. STANDARD 6 A Unit's case mix, as practicable, covers all significant provider types and includes a balance of fraud and, where appropriate, patient abuse and neglect cases. During our review period, the Unit investigated 1,750 cases of which Observation 1,301 involved fraud and 449 involved patient abuse or neglect; the cases covered 51 different provider types. The Unit's cases involved a variety of provider types, including personal care services, dentists, clinical social workers, and mental health facilities. STANDARD 7 A Unit maintains case files in an effective manner and develops a case management system that allows efficient access to case information and other performance data. The Unit maintained case files in an effective manner and retained a Observation case management system that allowed access to case information. Nearly 20 years ago, the Unit created its own electronic case management system, which was made available for all Unit staff to record and track case information. OIG examined the Unit's electronic case management system by reviewing the random sample of 98 case files open during our review period. In addition to assessing whether the system was efficient, we determined whether the case files contained the appropriate documentation, such as opening and closing documents, interview summaries, investigative activity summaries, and quarterly supervisory reviews. We also consulted Unit staff to allow them to explain any occasional missing documentation. In OIG's professional judgment, the Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Performance Assessment | 8 Unit's case files were maintained in an effective manner, and the case management system allowed efficient access to case information. STANDARD 8 A Unit cooperates with OIG and other Federal agencies in the investigation and prosecution of Medicaid and other health care fraud. The Unit cooperated at a high level with its Federal partners. Both OIG Observation and Unit management reported a strong working relationship between them. During our review period, the Unit and OIG agents worked on 52 joint cases, including seven cases that were investigated jointly with the Gulf Coast Strike Force. Additionally, all three U.S. Attorney's Offices in Louisiana noted the Unit's valuable assistance in resolving Federal health care fraud cases. STANDARD 9 A Unit makes statutory or programmatic recommendations, when warranted, to the State government. During our review period, the Unit made a program recommendation to Observation the State Medicaid agency. During our review period, the Unit identified a concern that program rules permitted mental health providers to bill an excessive number of hours in a single day. The Unit recommended that the LDH prohibit individual mental health providers from receiving Medicaid reimbursement for working more than 12 hours in a single day, and the LDH implemented the Unit's recommendation. STANDARD 10 A Unit periodically reviews its Memorandum of Understanding (MOU) with the State Medicaid agency to ensure that it reflects current practice, policy, and legal requirements. Observation The Unit's MOU with the State Medicaid agency reflected current practice, policy, and legal requirements. The Unit finalized its current MOU with the Medicaid agency in December 2019. STANDARD 11 A Unit exercises proper fiscal control over its resources. In our limited review, we identified no significant deficiencies in the Observation Unit's fiscal control of its resources during our review period. From the responses to a detailed fiscal controls questionnaire and from follow-up with Unit officials, we identified no significant issues related to the Unit's budget process, accounting system, case management, procurement, electronic data security, property, or personnel. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Performance Assessment | 9 STANDARD 12 A Unit conducts training that aids in the mission of the Unit. The Unit maintained a training plan for each professional discipline. Observations The Unit maintained an annual training plan that required Unit attorneys, investigators, and auditors to complete an annual minimum number of training hours. The Unit and a neighboring Unit sponsored combined training events Beneficial Practice for employees of both Units. Since 2014, the Louisiana Unit and the Mississippi Unit alternated in hosting a combined training for their employees. The Louisiana Unit hosted the training in 2014 and 2019, while the Mississippi Unit hosted in 2017. The trainings included case studies, statistical trends, and roundtable discussions. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Performance Assessment | 10 CONCLUSION AND RECOMMENDATION The Louisiana Unit reported strong case outcomes for FYs 2018-2020. OIG observed that a number of positive practices may have contributed to the Unit's success, including strong collaboration with Federal law enforcement. From the information we reviewed, we found that the Louisiana Unit generally complied with applicable legal requirements, except that we found one case in our review of case files that was ineligible for Federal matching funds during the review period. To address the finding identified in this report, we made the following recommendation to the Louisiana Unit. We recommend that the Louisiana Unit: Repay Federal matching funds spent on the case that was ineligible for Federal funding The Unit should work with OIG to identify staff hours and expenditures associated with investigating the Unit's ineligible case and repay those Federal matching funds. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Conclusion and Recommendation | 11 UNIT COMMENTS AND OIG RESPONSE The Louisiana Unit concurred with our recommendation to repay the Federal matching funds spent on the Unit's case that was ineligible for Federal funding. The Unit stated that it identified the staff time attributed to the case and is working to repay the matching funds to the Federal government. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Unit Comments and OIG Response | 12 DETAILED METHODOLOGY Data Collection and Analysis We collected and analyzed data from the six sources listed below to identify any opportunities for improvement and instances in which the Unit did not adhere to the performance standards or was not operating in accordance with laws, regulations, or policy transmittals. 22 We also used the data sources to make observations about the Unit's case outcomes as well as the Unit's operations and practices concerning the performance standards. In examining the Unit's operations and performance, we applied the published performance standards, but we did not assess adherence to every performance indicator for every standard. Review of Unit Documentation Prior to the inspection, we reviewed the recertification analysis for FYs 2018-2020, which involved examining the Unit's recertification materials, including (1) the Unit director's recertification questionnaires, (2) the Unit's MOU with the State Medicaid agency (LDH), (3) the LDH's Medicaid program integrity director's questionnaires, and (4) the OIG Special Agent in Charge questionnaires. We also reviewed the Unit's policies and procedures manual and the Unit's self-reported case outcomes and referrals included in its annual statistical reports for FYs 2018-2020. We examined the recommendations from the 2012 OIG onsite review report and the Unit's implementation of those recommendations. Review of Unit Financial Documentation We conducted a limited review of the Unit's control over its fiscal resources. Prior to the inspection, we analyzed the Unit's response to a questionnaire about internal controls and conducted a desk review of the Unit's financial status reports. We followed up with the LA DOJ and Unit officials to clarify issues identified in the questionnaire about internal controls. Interviews With Key Stakeholders In November 2020, we interviewed key stakeholders, including officials in the LDH's Medicaid program integrity unit, Louisiana's Community Living Ombudsman Program, and the three U.S. Attorney's offices. We also interviewed officials from OIG's Office of Investigations. We focused these interviews on the Unit's relationship and _____________________________________________________________________________________________________________________________ 22 Becausewe conducted the inspection remotely due to the public health emergency, we were unable to observe the workspace and operations of the Unit's headquarters in Baton Rouge. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Detailed Methodology | 13 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 Unit's management and selected staff in December 2020. Of the Unit management, we interviewed the director, the chief investigator, the two supervisory attorneys, and the operations manager. Of the staff, we interviewed one attorney, four supervisory investigators, two investigators, and one auditor. In addition, we interviewed the supervisor of the Unit-the Deputy Attorney General of the LA DOJ's Criminal Division. We asked these individuals questions related to (1) Unit operations; (2) Unit practices that contributed to the effectiveness and efficiency of Unit operations and/or performance; (3) opportunities for the Unit to improve its operations and/or performance; (4) clarification regarding information obtained from other data sources; and (5) the Unit's training and technical assistance needs. Review of Case Files To craft a sampling frame, we requested that the Unit provide us with a list of cases that were open at any time during FYs 2018-2020 and include the status of each case; whether the case was criminal, civil, or global; and the dates on which the case was opened and closed, if applicable. The total number of cases was 1,750. We excluded all global cases from our review of the Unit's case files because global 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. We excluded 68 global cases, leaving 1,682 case files. We then selected a simple random sample of 98 cases from the population of 1,682 cases. This sample allowed us to make estimates of the overall percentage of case files with various characteristics with an absolute precision of +/- 10 percent at the 95-percent confidence level. We reviewed the 98 case files for adherence to the relevant performance standards and compliance with statute, regulation, and policy transmittals. During the 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 National Practitioner Data Bank We also reviewed all convictions submitted to OIG during our review period so that convicted individuals could be excluded from programs (162) and all adverse actions submitted to the NPDB during our review period (159). We reviewed whether the Unit submitted information on all sentenced individuals and entities to OIG for Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Detailed Methodology | 14 program exclusion and all adverse actions to the NPDB for FYs 2018-2020. We also assessed the timeliness of the submissions to OIG and the NPDB. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Detailed Methodology | 15 APPENDIX A Unit Referrals by Source for Fiscal Years 2018-2020 FY 2018 FY 2019 FY 2020 Grand Totals Fraud Abuse or Fraud Abuse or Fraud Abuse or Fraud Abuse or Referral Source Neglect Neglect Neglect Neglect Adult Protective 0 0 0 2 0 0 0 2 Services Anonymous 11 1 9 3 4 0 24 4 HHS-OIG 6 0 4 0 6 0 16 0 Law enforcement- 3 1 2 0 1 0 6 1 other Licensing Board 3 3 8 0 0 0 11 3 Long-Term Care 1 2 3 3 0 4 4 9 Ombudsman Managed care 238 0 442 1 121 1 801 2 organizations Medicaid agency- 570 7 706 8 387 2 1,663 17 PI/SURS1 Medicaid agency- 80 0 186 12 3 7 269 19 other Private citizen 84 13 66 18 1 3 151 34 Private health 0 0 1 0 0 0 1 0 insurer Provider 11 0 17 4 8 0 36 4 Provider 0 0 1 0 1 0 2 0 association State survey and 28 2,861 20 5,447 6 1,744 54 10,052 certification agency State agency- 9 1 13 2 12 2 34 5 other Other 10 1 13 2 34 19 57 22 Total 1,054 2,890 1,491 5,502 584 1,782 3,129 10,174 Annual Total 3,944 6,993 2,366 13,303 Source: OIG analysis of Unit Annual Statistical Reports, FYs 2018–20. 1 The abbreviation "PI" stands for program integrity; the abbreviation "SURS" stands for "Surveillance and Utilization Review System." Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Appendix A | 16 APPENDIX B Unit Comments Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Appendix B | 17 ACKNOWLEDGMENTS AND CONTACT Acknowledgments Keith Peters of the Medicaid Fraud Policy and Oversight Division served as the team leader for this inspection. Susan Burbach of the Medicaid Fraud Policy and Oversight Division also participated in the inspection. Office of Evaluation and Inspections staff who provided support include Kevin Farber and Sarah Swisher. Two agents from the Office of Investigations also participated in the inspection and provided technical assistance to the Unit. This report was prepared under the direction of 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 Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 Acknowledgments and Contact | 18 ABOUT THE OFFICE OF INSPECTOR GENERAL The mission of the Office of Inspector General (OIG), as mandated by Public Law 95- 452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components: 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. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These audits help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI reports also present practical recommendations for improving program operations. The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties. The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support for OIG's internal operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement authorities. Louisiana Medicaid Fraud Control Unit: 2020 Inspection OEI-12-20-00650 About OIG | 19