TDMR has obtained a copy of a January 4 letter from State Sen. Juan “Chuy” Hinojosa to Charles Smith, the Executive Commissioner of Texas Health and Human Services asking Smith to review MCO “credible allegations of fraud” payment holds.
While the letter pertains to all state MCOs involved in Medicaid, he specifically mentions concerns about dental MCOs.
Surprised MCOs can do what OIG can’t
He wrote to Commissioner Smith:
One of the key goals of SB 207 was to create limitations on the use of Credible Allegation of Fraud (CAF) holds, which had been consistently abused by the prior administration at the OIG. The legislation directed the OIG to restrict unreasonable use of CAF holds and set standards for the use of such holds.
However, it has come to my attention that certain Managed Care Organizations, speciﬁcally Dental Management Organizations (DMOs) contracted to manage the state‘s Medicaid dental programs, may be abusing CAF holds in the same manner as those conducted by the OIG before the passage of SB 207. I am concerned with this abuse and request your assistance in clarifying the new statutes that resulted from this legislation.
Like the OIG, Managed Care Organizations (MCOs) have a responsibility to identify and prosecute instances of fraud, waste and abuse. However, it was surprising to learn that the language regarding CAF holds in SB 207 is not being applied to the actions of MCOs.
I am writing to ask if you could confirm that the provisions of SB 207 apply to MCOs under contract in the Texas Medicaid Program. If so, I ask that you work with your HHSC staff to develop and implement a plan for enforcement to prevent abuse by MCOs who place providers on CAF holds. If the provisions do not apply, please confirm ﬂiis so that I may work on legislation this session to correct any CAF hold abuses by MCOs.
Advocacy is appreciated
It is fantastic that honest providers have good friends like Sen. Hinojosa and someone willing to go to bat for them as he is.letter Hinojosa to Smith