No Law Allows MCOs To Place “Credible Allegations of Fraud” Payment Holds Against Providers

TDMR has learned from a staffer in the office of Sen. Juan “Chuy” Hinojosa that they have been informed by Health and Human Services that managed care organizations, including MCNA, do not have any right under any Texas or federal law to place a “credible allegations of fraud” payment hold on Medicaid providers – only the HHS Inspector General can do that.

Meetings with HHS

Since the January 4 letter from Sen. Hinojosa to HHS Executive Commissioner Charles Smith, asking Smith if MCOs such as MCNA could place CAF holds, representatives from Sen. Hinojosa’s office have met twice with Smith, the last meeting held last week.  HHS has determined that no MCO has a legal right to place a CAF hold for any reason on any provider.  MCOs are to contact the IG if they encounter provider fraud. HHS will be issuing a notice to all MCOs to inform them of this fact.

The representative from Sen. Hinojosa’s office expressed surprise that they had to look into this.

MCO told to stop placing CAF holds

TDMR also learned that representatives from HHS sat down with representatives from an unnamed MCO (we assume it was MCNA) and told them that their practice of placing CAF holds was to end.  If the MCO discovered any provider fraud, they were to alert the IG, not take matters into their own hands.  Apparently, the MCO has promised to end the practice of placing CAF holds and has told HHS that there are currently none any longer in Texas.

Let us know if they have

We would like to hear back from dental providers if this is indeed the case.

Apology to providers minimum action

We also wonder if there will be an apology to those providers affected or any sanction made against the company for its unlawful action against providers.




4 Responses

  • Can our state legislators please address this company and adjudicate MCNA to TEXAS! Texas need a LAW addressing these issues … they will just find another way to skirt through the law and use words like… willful misrepresentation or Program Violations … to justify how to scam dollars.
    MCOs need oversight and penalties written into statue. MCNA proudly showcases who they have hired on their board as an intimidation tactic!

    Why are MCOs treated above the law ? WHY?!

    Taxpayers pay heavily to support Medicaid and to an agency that continues to refuse and DEMAND ANSWERS from MCNA’s illegal mafia ways!
    I am taxed to death and sick of reading how MCNA continues to mismanage an administrative role contracted by hhs and continues to make headlines from profit incentive tactics – stealing from the government and taxpayer!

    Big Corporate Company Wins Again….

  • I just want to thank TDMR for this great piece of work and great push on our legislators. This is terrific news for dental providers and almost takes the bully from the schoolyard..
    Dr. J

  • Thank you TDMR for keeping tabs on the good, the bad, and the ugly. If it was not for this site of information – not sure if these topics would ever get the media coverage they deserve. Great platform of news and updates.

  • What about Denta Quest. are they allow to recoup moneys with false allegations of no medical necessity and further terminate provider when complaining MCOs for no following the protocols and the agreements??

    Apology ????what about the $$$ loses.

    Are they going to reimburse and compensate accordingly the providers ,that had no other option than terminate the relation with MCO’s and Medicaid as providers ,and that had to close their practice because could not see patients through traditional Medicaid once out of the MCO’s.

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