The recently released HHSC-OIG Quarterly Report for the 1st Quarter of 2020 shows that the rate of provider investigations opened into dentists and doctors is roughly three times the rate of the number of complaints received by the agency. The rate for dentists is slightly higher than that of doctors. This is roughly double the rate of investigations opened from their previous Quarterly report which was 1.5x the rate of complaints.
Looking over the statistics, it appears that OIG is no longer focussing on complaints about "attendants" which account for 46% of all complaints. In this quarter, investigations into such complaints only accounts for 1% of all provider investigations launched.
Recovery amounts for quarter
Overall, OIG reports they recovered a total of $73, 284,379 this quarter, roughly $17 million from Medicaid Program Integrity. OIG states:
"MPI is opening more cases as the result of an initiative to focus on fraud, waste and abuse trends involving multiple providers. For example, an investigator identifying or receiving an allegation concerning the behavior of one provider will conduct data analysis and investigative research to determine if the pattern of behavior is exhibited in other providers. This proactive and efficient use of resources results in an increase in self-initiated cases as investigators uncover more potential waste or wrongdoing. The percentage of self-initiated cases transferred to Provider Field Investigations (PFI) increased from 49 percent to 66 percent in the first quarter, which can ultimately provide opportunities for more provider education, program exclusion or recoveries."
We just picked out a few interesting points to mention. Two cases highlighted by OIG in its report are:
"The OIG entered into settlement agreements with two Central Texas hospitals related to Emergency Department services for $370,872 and $412,926, respectively. The first hospital self-reported that it discovered an overpayment was due to Texas Medicaid related to services billed for certain ineligible patients. The second hospital billed and was paid for non-reimbursable injections/infusions in the emergency department when the same services were already covered by another code paid for the same date of service."
"The OIG entered into a settlement agreement in October with a dental provider for $50,000 in penalties and a three-year exclusion from Medicaid. The investigation found that the provider subjected a recipient to unnecessary treatment, and the treatment was below the standard of care. Failed procedures on 14 teeth resulted in their extraction by a subsequent and unrelated provider. The provider paid the penalties in a lump sum, and their exclusion took effect November 1."
There is more in the report.
In relation to MCOs,
"The OIG requested amendments to the Texas Medicaid and CHIP managed care contracts that went into effect September 1. Texas Medicaid and CHIP managed care organizations are required to hire a full-time special investigative unit (SIU) manager dedicated solely to Texas Medicaid and CHIP. MCOs are also required to designate the SIU manager as a key employee and employ a qualified investigator. The goal of these changes is to strengthen the SIU requirements for MCOs to provide sufficient resources dedicated to fraud, waste, and abuse (FWA) detection and prevention activities."
Lastly, we received notification that OIG has added a new domain name, ReportTexasFraud.com, which points to their website, Just to be clear, this is not a separate website but simply a new domain which points to the current OIG website at https://oig.hhsc.texas.gov/. It was added "to highlight its mission and connect with stakeholders."
The full Quarterly report is below: