DMOs Get to Keep Monies Recouped from Alleged Medicaid Fraud


The hearing before the Senate Committee on Health and Human Services September 13 held a few more surprises for Medicaid providers, particularly dental providers.  It turns out that all MCOs (managed care organizations) in Texas Medicaid including Dentaquest and MCNA get to keep any monies they recover from providers based on allegations of fraud, waste or abuse.

Not seen as returned to taxpayers

Sen. Lois Kolkhorst brought this point up to Inspector General Stuart Bowen during the hearing and she was displeased that these monies didn’t immediately get returned to taxpayers.

Said to be taken into account in setting premiums

Later in the hearing, Jamie Dudensing, the executive director of the Texas Association of Health Plans, which represents MCOs in the state, told the committee that recovery of such monies is taken into account when the premium is set by the state for the MCOs.  Therefore, if the MCOs did not receive these monies, the premium paid by the state would be higher.

2 Responses

  • MCO\\\’ s became the experts in finding fraud????

    Seems like someone is doing laundry with us the providers.

    Providers free of charge services paying MCO\\\’s with arbitrary audits $ recoveries procedures sponsored with the agreements and rules which legalizes MCOS to get into provider pockets and emptying them before laundry time.

    What a go .The easy way to built laundry cash pocket moneys. and seems tax break in recoveries filling the already premiums budget blanks.

  • The problem is that oversight has been left to the MCOs who have no incentive to find and recover fraud unless they keep it. But Mr. or Ms. Dudensing did admit what has been denied for a long time, that fraud is baked into the capitation and other reimbursement rates paid to these plans. Since they are already being paid for it, why bother reducing it if all they have to do is pay the State Treasury back? There is another reason they don’t pursue it; they don’t want to alienate providers. They sold the State on the size and breadth of their network, whom they also need for their commercial business. We all want our providers to be “in-network” and in this environment, providers bring patients, patients bring premium dollars. It is a fools errand to assume that the MCOs will jeopardize that

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