Texas Commission Makes “Harsh Assessment” of Faults within HHSC-OIG Operation and Payment Holds

sunset commissionThis afternoon the staff of the Texas Sunset Commission issued its long anticipated report on their proposed recommendations for changes to the Health and Human Services Commission which is under sunset review this year.

News Coverage: Texas Tribune, Austin American Statesman [paywall], Insurancenews.net.

Sunset review process

Per the Commission’s website, the Texas Sunset Advisory Commission is a 12-member legislative commission tasked with identifying and eliminating waste, duplication, and inefficiency for more than 130 Texas state agencies.  The Commission questions the need for each agency, looks for potential duplication of other public services or programs, and considers new and innovative changes to improve each agency’s operations and activities.  Since Sunset’s inception in 1977, 79 agencies have been abolished, including 37 agencies that were completely abolished and 42 that were abolished with certain functions transferred to existing or newly created agencies. In addition, the Legislature has enacted a large majority of the Sunset Commission’s recommendations. For example, on the agencies reviewed by Sunset for the 83rd Legislature in 2013, the Sunset Commission adopted 96 percent of Sunset staff’s recommendations, and the Legislature adopted 75 percent of the Commission’s recommendations.

Article is a quick review of key recommendations

The full report has not been fully digested by any means but two issues relating to the operation of the Office of Inspector General relate directly to dental Medicaid providers that have been under the gun of OIG investigations that last two years.

The following is a quick summary.  The full report can be downloaded off the Sunset Commission website.

“Poor management” threatens OIG

Issue 10 is entitled “Poor Management Threatens the Office of Inspector General’s Effective Execution of Its Fraud, Waste, and Abuse Mission.”

Under the findings, the Sunset staff report:

The findings and discussion that follow regarding OIG present a rather harsh assessment, borne of a remarkable consistency of feedback from a range of interests and stakeholders and backed by the first-hand observations of Sunset staff, built over 11 months of review work. These conclusions are not made lightly, but are made instead in full recognition of the need for a strong and nimble OIG to ensure the integrity of these critically important HHS programs. No matter how one views the HHS system, it exists to serve a purpose, and the public must have confidence that it works properly. OIG is essential to the effort to instill that confidence.

However, OIG must serve this role the right way. OIG must have the proper mechanisms and approaches to effectively guide its efforts, to judge its own performance, and to accurately inform state leaders of the results of its work throughout the system. Much of what follows portrays aspects of bureaucracy that have become buzzwords in this business — a lack of priorities, criteria, processes, transparency, or accountability. However, behind these words is a real harm that can result when their basic tenets are missing. To question OIG’s deficiencies is in no way to condone any level of fraud or misconduct.

The recommendations under this issue are:

• Remove the gubernatorial appointment of the inspector general and require the inspector general to be appointed by and report to the HHSC executive commissioner.
• Require OIG to undergo special review by Sunset in six years.
• Require OIG to conduct quality assurance reviews and request a peer review of its sampling methodology used in the investigative process.
• Direct OIG to better define its role in managed care, and to work together with HHSC to transfer certain OIG functions to other areas of the HHS system where they would fit more appropriately.
• OIG should improve basic management practices, including establishing and tracking criteria and timelines for investigative processes and enforcement actions, narrowing its focus on the highest priority cases, and improving training and communication among staff.

Credible Allegation of Fraud payment holds go beyond legislative intent

Issue 11 is “Credible Allegation of Fraud Payment Hold Hearings Do Not Achieve the Law’s Intent to Act Quickly to Protect the State Against Significant Cases of Fraud.”

The staff made the following general findings:

  • OIG actions go beyond the intent of a CAF hold, which is to prevent financial risks to the state posed by ongoing Medicaid payments to fraudulent providers.
  • CAF hold hearings have exceeded their narrow scope, contributing to lengthy and costly hearings that duplicate the function of an overpayment hearing.
  • CAF hold hearings provide for excessive process and undue burdens on providers as compared to cases presenting more serious risks to the state and public.

Their recommendations are:

  • Require HHSC to streamline the CAF hold hearing process.
  • Clarify OIG’s payment hold authority, including adopting clearer standards for good cause exceptions and limiting payment holds to certain circumstances.
  • Require OIG to pay all costs of CAF hold hearings at the State Office of Administrative Hearings.

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