Special investigative units help prevent fraud, waste and abuse

One tool managed care organizations (MCOs) use to reduce fraud, waste and abuse (FWA) is a team of in-house investigators known as the special investigative units (SIUs). This team reviews all services provided under an MCO’s contract with Texas Medicaid. A 2019 contract amendment requires these teams to include a full-time SIU manager and credentialed investigator, which examine improper claims by Texas Medicaid clients and service providers. To support these efforts, the OIG has a dedicated coordinator to assist with referrals, investigations and training. MCOs and the OIG also work collaboratively through the Texas Fraud Prevention Partnership, which helps identify, investigate and refer cases. These changes likely contributed to a 33 percent increase in SIU referrals for provider investigation from fiscal year 2020 to 2021.

The OIG uses its access to referrals and encounter data across all MCOs and programs to identify potentially widespread issues. Running analytics on a referral set helps the agency determine if something that looks like a small problem with one MCO is a repeated issue across the Medicaid program. The OIG’s data analytics process can uncover systemic trends that might not be visible at the MCO level. For example, a provider may bill multiple MCOs for the same hours worked, establishing an issue where Medicaid pays a single healthcare provider for “impossible hours.”

The OIG routinely audits SIU activities to verify that MCOs provide all contractually required information, including.

Source: Special investigative units help prevent fraud, waste and abuse / Inspector General Texas Health and Human Services

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