HHS-OIG Completes Review of West Virginia Medicaid Fraud Control Unit
The Department of Health and Human Services (HHS) Office of Inspector General (OIG) has conducted an inspection of the West Virginia Medicaid Fraud Control Unit. These annual audits are conducted to assess each Unit’s performance in accordance with the requirements of the grant awards and to recertify each unit.
The review spanned Fiscal Years 2020-2022, during which time the Unit obtained 37 indictments, 34 convictions, 41 civil settlements, and $75.3 million in recoveries. The Unit’s performance was generally good, with ample training provided to staff members, strong working relationships maintained with stakeholders, and measures implemented to ensure continuous case flow. HHS-OIG identified some areas where adherence to performance standards could be improved.
A new case management system was introduced that allowed managers to effectively monitor cases, but there were some reporting issues. The new system did not allow accurate reporting of Unit performance to HHS-OIG, adverse actions were not reported to the National Practitioner Data Bank (NPDB) from 2017 through 2022, and convictions were not consistently reported to OIG for exclusion within the required timeframe.
HHS-OIG conducted a review of permissions on case files and identified some files that could be accessed by unauthorized staff members. Program recommendations were made to the State Medicaid agency, but there was insufficient monitoring of the State’s response to those recommendations. Some of the settlement proceeds from its actions were retained by the Unit, rather than working with the Medicaid agency to ensure the appropriate return of the Federal Government’s share of recoveries. HHS-OIG made five recommendations to address these issues, and the Unit concurred with five of the six.
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The Unit did not concur with the recommendation to work with the Bureau of Medicaid Services to ensure the return of the Federal Government’s share of all recoveries, maintaining that “additional recoveries” beyond restitution do not constitute “overpayments,” therefore the Federal Government is not entitled to receive a proportionate share at the FMAP rate. HHS-OIG said the Federal Government is entitled to receive a pro-rata share of all recoveries, including penalties, fees, and investigative costs.
