We want to close out 2015 with a round-up of the year’s most important stories relating to TDMR issues.
It has been an exceptional year for changes at the Health and Human Services Commission. The implosion that occurred at HHSC and its Office of Inspector General late last year over the improper no-bid contract for Medicaid fraud detection software from Austin-based 21CT continued to play out as well as the ramifications of the Sunset Advisory Commission review of the agencies.
Last December saw both then-Inspector General Doug Wilson and his former deputy but then-HHSC chief counsel Jack Stick resign in an incredible upheaval that shook the foundations of the agencies and incurred investigations from the State Auditor, the Governor’s own appointed HHSC strike force and interest from the FBI.
However, HHSC’s fever broke in 2015 and there have been resultant advances in due process rights for Medicaid providers generally, and Medicaid dentists specifically.
Our most important stories for 2015:
1. New HHSC Inspector General Stuart Bowen Sends Out Settlement Offers On Outstanding Medicaid Investigations
This is our top story because Bowen’s actions are a total reversal of the operating basis that HHSC-OIG had under the dismal reign of Doug Wilson and Jack Stick.
TDMR came into being in early 2012 in response to unfair allegations of Medicaid fraud being made against Texas dentists and orthodontists over the dramatically increased cost of the Medicaid orthodontic program from 2007 to 2011. Stick and Wilson at that time had put providers holus-bolus under “credible allegations of fraud” payment holds and denied due process, bankrupting and placing under financial duress many providers. Stick and Wilson, using questionable extrapolation methods, ballooned overpayment amounts that providers were to repay and happily reported to the Legislature massive findings of Medicaid dental fraud, which they used to push for an increase to their agency budget and wheedle the 21CT deal.
Their machinations unraveled over the last few years. The only two dentists to make it to an administrative hearing before 2015 on their payment holds, Harlingen Family Dentistry and Antoine Dental, were exonerated of the allegations of fraud, waste and abuse. Then, there was the Trueblood settlement. OIG was caught fudging the overpayment amount of $16 million they were pushing to collect from Trueblood and settled for $39,000. Finally, among other things, they were done in by the sunlight being wielded by the Sunset Commission on their activities which led to condemnation and a total lack of legislative confidence.
With the appointment of Bowen by Gov. Greg Abbott back last January and his subsequent review of the situation, these offered settlements mean a recognition that all has not been well and that it is time to set things right. We applaud a government that can do the right thing.
2. Federal Audit Determines State Owes $133 Million for Medicaid Orthodontic Program Spending, Not Dentists
The death knell to allegations of massive Medicaid fraud on the part of Texas dentists was sounded this past June when the Department of Health and Human Services Office of Inspector General released its long-awaited second audit report about the Texas Medicaid orthodontic program from 2008 to 2011. The agency was looking at medical necessity and who was responsible for the massive spending increases of the program from 2008 to 2011.
In short, the report placed responsibility on HHSC and its mismanagement of its claims administrator Xerox and found that the state owed the federal government some $133 million in misspent Medicaid dollars.
3. Courts Continued to Find in Favor of Medicaid Dentists
In May, Corpus Christi dentist Cheryl Rhoden and her Medicaid practice went before the State Office of Administrative Hearings for a payment hold hearing brought by HHSC-OIG and the Office of Attorney General. The SOAH judges were so unimpressed with the case that they not only ruled in favor of the dentist but in a rare move awarded her court costs as well.
In July, Antoine Dental Centers of Houston went before Travis County District Court to appeal the final ruling that was issued by then-HHSC Executive Commissioner Kyle Janek. Janek had overturned a “proposal for decision” made by two SOAH judges that had found Antoine Dental innocent of allegations of Medicaid fraud and overturned the HHSC-OIG payment hold on the practice. Shortly afterward the judge issued her decision and found that indeed Antoine was innocent.
This leads to our next big story as the Office of Attorney General is appealing this decision.
4. The Office of the Attorney General Continues to Prosecute Medicaid Dentists Already Found Innocent
Just before Christmas in 2014, a number of cases with HHSC-OIG were severed and sent to Travis County District Court for hearing. These were some of the oldest Medicaid orthodontic cases and included two practices that had already gone before SOAH and been found innocent of allegations of Medicaid fraud, waste and abuse – Antoine Dental Centers and Harlingen Family Dentistry. The move was perceived at the time as positive as it allowed these practices to get an impartial hearing before a district court rather than be subjected to the lengthy and flawed Medicaid process.
As matters have played out over the year, this has not turned out to be a good thing.
Where the new IG has done an excellent job of reviewing their cases and determining that settlements should be offered due to the excesses of the previous agency personnel (our top story), the Civil Medicaid Fraud division of the OAG which is responsible for the severed cases has without thoughtful review apparently carried forward those excesses.
This leads to the ridiculous situation of two dental practices that have already been found innocent of Medicaid fraud, waste and abuse by SOAH continuing to be prosecuted in the style of Jack Stick and Doug Wilson by the Civil Medicaid fraud division of OAG.
In fact, the agency continues to tie up resources and spend big money to do so.
5. HHSC Sunset Legislation Provides More Due Process Rights Protection for Medicaid Providers
The Texas Legislature again was concerned about due process rights for Medicaid providers and unanimously passed Senate Bill 207 this year which was then signed by Gov. Abbott. SB 207 is the legislation that resulted from the review of the Sunset Advisory Commission of HHSC and its OIG. Thanks to legislators such as Rep. Richard Peña Raymond, Rep. Bobby Guerra, Rep. Four Price, Sen. Juan “Chuy” Hinojosa, Sen. Jane Nelson and Sen. Charles Schwertner, Medicaid providers are better protected than they were several years ago. Again we applaud a government that can do the right thing.
6. Dental Medicaid Fraud Minimal Per HHSC Report
In January, HHSC issued a report on Medicaid fraud found by managed care organizations across all its sectors for 2014. Looking over the MCNA and Dentaquest entries in the report, clearly dental fraud is not a huge problem. The DMOs only identified and collected some $303,000 out of $1 billion in Medicaid billings. That is .03%.
That’s our top six.
There were a number of events that deserve mention so we list those stories here in date order, earliest first.
- Texas “Insiders” Entitlement Program Pays Off: Free College for Janek’s Aide!
- Medicaid Dentists Accuse HHSC and Xerox of Conspiracy, Negligence, and Seek Damages
- Jack Stick’s Golden Throne Cost Taxpayers Same as Full Ortho Treatment for a Medicaid Child
- Pay Up or Go Bankrupt: The Smile Magic Settlement
- State Medicaid Investigations Produce Paltry Results | The Texas Tribune
- Time for Agency Officials to “Take Seriously” State Regulations
- HHSC Commissioner Kyle Janek to Resign
- HHSC Allegedly Paid Out $104 Million to 8,000 Medicaid Providers the Agency Suspected Of Fraud
- Dentist’s Nightmare Over – Settles for $120,000 Withheld Medicaid Funds
- Dental Practice Victimized by OIG Actuary Should Have Settled Case for $41,000 not $323,000
- Former HHSC Chief Counsel Jack Stick Hits Bottom with Long Avoided DWI Conviction
- In Medicaid, It Appears Little Guys Go To Jail, Big Guys Don’t Get Contacted
- Taxpayers Left Holding the Bag Again on Massive Cost Overruns and Bureaucrats Sitting at Home on Paid Leave