OIG audits MCO’s Special Investigative Unit

October 7, 2021
The OIG Audit Division conducted an audit of special investigative unit (SIU) activities at Aetna Better Health of Texas, a Medicaid and Children’s Health Insurance Program managed care organization.

MCOs are required to establish an SIU to investigate fraudulent claims and other program waste and abuse by members and service providers. Aetna received $297 million in 2019 and $313 million in 2020 to administer Texas managed care programs for an average of 86,888 and 87,797 members per month, respectively. The audit objective was to determine if, for the period from September 1, 2018 through August 31, 2020, Aetna’s SIU was in compliance with state and contractual requirements related to (a) preventing, detecting and investigating fraud, waste and abuse and (b) reporting reliable information on SIU activities, results, and recoveries to HHSC.

The audit determined Aetna complied with most state and contractual requirements related to preventing, detecting and investigating fraud, waste and abuse, and reporting reliable information on SIU activities, results and recoveries to HHSC. During the audit period, Aetna’s SIU had required staff, conducted required training and monitored provider and member service patterns. Furthermore, it ensured all required elements of a preliminary investigation and extensive investigation were completed, maintained a log of incidences of suspected fraud, waste and abuse, and submitted required reports and referrals to the OIG within required deadlines.

However, Aetna’s SIU did not comply with timeframes for completing required preliminary and extensive investigation activities listed in Texas Administrative Code, including those for (a) completing preliminary investigations and timelines for selecting a sample of provider claims, (b) making requests for medical records and encounter data and (c) completing the review of requested records and data for extensive investigations. The OIG recommended to Aetna that it should implement processes to ensure all required elements of preliminary and extensive investigations are completed timely and are sufficiently documented.

Read the full audit on the OIG website. https://oig.hhs.texas.gov/sites/default/files/documents/siu-aetna-final-8-18-21.pdf

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