A board certified orthodontist hired by HHSC-OIG was apparently reluctant to "second guess" Xerox/Conduent prior authorization (PA) approvals per a March 2009 email contained as an exhibit in the July 2018 Xerox court filing mentioned in last week's TDMR articles.
However, the consultant was not told that TMHP (Texas Medicaid & Healthcare Partnership with Xerox as the lead contractor) was "not routinely looking at cephalometric films with tracings, models and other radiographs..."
The email is written by Brian Klozik, the director of Medicaid Provider Integrity for the HHSC Office of Inspector General. The consultant he mentions is a "Dr. Natoli" which is apparently Dr. James Richard Natoli Jr. from Houston who is now retired per a quick internet search.
Review of ortho cases to be undertaken
Klozik goes on to mention that he is asking Dr. Natoli to "start looking at the records from a prior authorization perspective and give his expert opinion on whether he feels P.A. should have been granted (for specific services, to include full banding) based on existing guidelines in the TMPPM [Texas Medicaid Provider Procedures Manual]. We have at least three cases involving ortho that are pending a review. I know this does not help now, but perhaps in the near future, we could offer some numbers on the services that were incorrectly P.A.'d."
We do not have any documentation at this time as to the results of Dr. Natoli's review or if it was done at all.
Klozik is responding to an email from Dr. Linda Altenhoff, the state's dental director, who has already concluded that there is a "percentage of orthodontic services that are incorrectly/inappropriately prior authorized by TMHP."
Legal conundrum already apparent
Already in March of 2009, Klozik is aware that there is a legal problem with Xerox/Conduent's PA process as far as attempting to collect overpayments from providers.
He states: "There was also a legal question as to whether or not OIG would be successful in pursuing overpayments if we retrospectively determined something was inappropriately P.A.'d. How would a defense attorney challenge this? TMHP grants P.A., but OIG's consultant states P.A. should [sic] have been given? "
There is no mention of Medicaid fraud by providers or even fraud by Xerox.
State officials knew problems in 2009, sues Xerox/Conduent in 2014
Documentation is rife that state officials knew about the inadequate ortho PA process by early 2009 if not earlier. Yet the process remained in place for another three years until Medicaid managed care came in and then another two years before the state fired and sued Xerox for Medicaid fraud.
Note the state is not suing Xerox/Conduent for breach of contract.