Texas Dentists for Medicaid Reform

For more information call 956-507-7264

  • Home
  • Issues
  • Medicaid Forum
  • * Medicaid Difficulty Alert *
    • About the Medicaid Difficulty Alert
    • Alert Form
  • Articles
    • TDMR articles
    • Medicaid Media
    • Compliance Articles
  • Archive
    • The Facts About the Medicaid Orthodontic Scandal 2007 to 2012
    • HHSC-OIG Archive 2012 to 2014
      • TMHP
      • Antoine Dental Case
      • Harlingen Family Dentistry Case
        • Further HFD articles
      • OIG Never Returns Funds
      • Webinar March 19 2012
      • 2008 TMHP Audit by OIG
      • 2012 TMHP Audit by OIG
      • OIG Legislative Testimony
        • OIG Testimony March 19 2013
        • OIG Testimony February 13 2013
        • OIG Testimony February 4 2013
        • OIG Testimony January 30 2013
      • Jack Stick Arrest for DWI
    • Due Process Archive
      • Survey Results
      • Committees
        • Hearing Videos
      • TDMR Submission
      • HB 1536/SB 785
        • House Committee on Human Services
        • Written Testimony
        • Attorney Testimony Videos
        • Dental Provider Testimony Videos
      • SB 1803
        • Overview
        • Bill Moves to House
        • Public Testimony Videos
        • Passes House Committee
        • Bill Changed Before House Vote
        • SB 1803 Has Passed the House!
      • Other Proposed Bills
      • Due Process Legal Articles
      • Legislative Media
      • Media Archive
  • About
    • Gregory Ewing – President
    • Dr. Juan D. Villarreal
    • Dr. Tara Rios
    • Dr. Paul Dunn
  • Contact
You are here: Home / Medicaid Reform News / Testimony Shock: Texas MCOs Recover Only $2 Million in Alleged Fraud from $20 Billion Budget in 2015

Testimony Shock: Texas MCOs Recover Only $2 Million in Alleged Fraud from $20 Billion Budget in 2015

December 13, 2016 By TDMR Leave a Comment


In testimony before the Senate Committee on Health and Human Services in September, Inspector General Stuart Bowen shocked committee chairman Sen. Charles Schwertner with the revelation that the 22 MCOs (managed care organizations) operating in Texas had only found and recovered $2 million in alleged fraudulent payments in 2015 out of a $20 billion budget.

Sen. Schwertner then questioned Bowen further and found that many of the “special investigative units” (SIUs) of the MCOs are relatively inactive, some having only one person in the unit.

IG published a report in February on SIU activity

Bowen and his agency published a little-known audit in February of this year that looked more specifically at the overall performance of the special investigative units of the MCOs.

The executive summary of that report states (the full report can be downloaded here):

WHY IG IS CONDUCTING THIS AUDIT

At approximately $27 billion a year, the Medicaid and CHIP programs constitute over 26 percent of the total Texas budget. Approximately 84 percent of individuals enrolled in Medicaid or CHIP are members of a managed care organization (MCO).

MCOs are required to establish a special investigative unit (SIU) to investigate fraudulent claims and other program waste and abuse by members and service providers. Effective SIUs are essential to ensuring that state and federal funds spent on managed care are used appropriately.

The Texas Health and Human Services Commission is responsible for oversight of MCO contracts. IG is responsible for approving SIU annual plans and evaluating and sometimes investigating SIU referrals. The IG Audit Division is currently conducting a performance audit to determine how effective the MCO SIUs are at (a) preventing, detecting, and investigating fraud, waste, and abuse and (b) reporting reliable information on SIU activities, results, and recoveries

WHAT IG FOUND

MCOs produce limited results in their SIU fraud, waste, and abuse detection, investigation, recovery, and referral efforts. MCOs in Texas received over $17 billion in Medicaid and CHIP capitation payments in 2015, and their health care providers submitted approximately $12.5 billion in medical claims for services provided in 2015. In the same year, MCO SIUs reported a total of only $2.5 million in recoveries, about two-hundredths of one percent of total aggregate medical claims dollars. This was down from three-hundredths of one percent in the previous year.

$ 11,734,344,625 $ 3,883,525 0.03%
$ 12,508,070,928 $ 2,479,941 0.02%

National studies indicate that fraud represents at least 3 percent of medical costs in the United States, while fraud, waste, and abuse collectively represent at least 20 percent of medical costs.

Though SIU results varied in 2015, each one of the 22 MCO SIUs recovered far less than one percent of medical claims dollars. Most MCOs reported less than $20,000 in recoveries per full-time equivalent (FTE) personnel assigned to the SIU and most reported less than $40,000 in total referrals to IG Investigations in 2015. Three MCOs did not recover or refer any dollars in 2015.

The highest performing SIU in 2015, through its efforts to combat fraud, waste, and abuse, recovered or referred to IG Investigations less than one-half of one percent of the MCO’s Medicaid and CHIP medical claims dollars.

There is a wide variation in MCO personnel resources committed to the SIU function. For example, MCOs reported a range from less than one FTE allocated to
SIU activities to a single MCO that reported over 11 SIU FTEs. MCOs ranged from one SIU FTE for every $6.3 million in capitation payments to one FTE for every $1.5 billion, with an average of one SIU FTE for every $266 million.

MCO reported information indicates no apparent correlation between the referral and recovery results produced by SIUs and the personnel resources committed to the SIU function.

The IG Audit Division will publish audit reports during its ongoing audit of Medicaid and CHIP SIUs once it enters fieldwork and completes audit testing and validation for selected MCOs.

DMO mentions in the report

There is only one mention each relating to dental managed care organizations MCNA and Dentaquest.

Dentaquest is mentioned as the largest MCO in the state with some 1.7 million members.

MCNA’s claim to fame is that it has the highest number of full-time equivalent SIU employees of any MCO in Texas with 11.  The poor reputation of recoveries for MCOs and this fact may be prime factors in the number of payment holds that MCNA has placed against dental providers this year.

Share this:

  • Click to share on Facebook (Opens in new window)
  • Click to share on Twitter (Opens in new window)
  • Click to share on LinkedIn (Opens in new window)
  • Click to print (Opens in new window)
  • More
  • Click to share on Reddit (Opens in new window)
  • Click to share on Pinterest (Opens in new window)
  • Click to share on Tumblr (Opens in new window)

Filed Under: Medicaid Reform News, Slider Tagged With: dentaquest, due process rights, MCNA, mcos, office of inspector general, Texas legislature

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Receive Updates on TDMR Activities

Search the TDMR Website

Conduent Stock Price Watch

As the Texas Medicaid fraud suit against Xerox/Conduent moves towards trial, watch the company's stock price. The company's 52-week high was on June 14 at $20.85.

Most Viewed Posts & Pages

  • Whistleblowers File Motion for Their Share of $235 Million Xerox/Conduent Settlement
    Whistleblowers File Motion for Their Share of $235 Million Xerox/Conduent Settlement
  • Texas Settles with Xerox for $235 Million Out of "Desire to Buy Peace and Avoid Further Litigation"
    Texas Settles with Xerox for $235 Million Out of "Desire to Buy Peace and Avoid Further Litigation"
  • Smelling Like a Rose: Xerox/Conduent Settles Texas for $235 Million, Renews Contract in Indiana for $232 Million
    Smelling Like a Rose: Xerox/Conduent Settles Texas for $235 Million, Renews Contract in Indiana for $232 Million
  • "I approved all of them regardless" - Xerox/Conduent Dental Director on Ortho PAs
    "I approved all of them regardless" - Xerox/Conduent Dental Director on Ortho PAs
  • No Penalty or Fine for Xerox Using High School Dropouts to Approve Medicaid Prior Authorizations for Eight Years?
    No Penalty or Fine for Xerox Using High School Dropouts to Approve Medicaid Prior Authorizations for Eight Years?

Recent Comments by Readers

  • Kenneth Bolin on “I approved all of them regardless” – Xerox/Conduent Dental Director on Ortho PAs
  • Kenneth Bolin on Texas Settles with Xerox for $235 Million Out of “Desire to Buy Peace and Avoid Further Litigation”
  • Joe Knows on “I approved all of them regardless” – Xerox/Conduent Dental Director on Ortho PAs
  • Beans on “I approved all of them regardless” – Xerox/Conduent Dental Director on Ortho PAs
  • Graham D. Shea, DDS on Texas Settles with Xerox for $235 Million Out of “Desire to Buy Peace and Avoid Further Litigation”
  • TDMR on “I approved all of them regardless” – Xerox/Conduent Dental Director on Ortho PAs

Recent Media of Interest

Virginia couple accused of defrauding Medicaid

February 22, 2019

Jury convicts former Missouri dental clinic owners of $1 million health care, payroll tax fraud

February 22, 2019

Firm announces $232M contract with Indiana, just two days after settling huge Medicaid fraud case in Texas

February 21, 2019

Xerox Reaches $235M Deal to Settle Medicaid Fraud Claims

February 19, 2019

Sentencing delayed in Texas medical equipment fraud case

February 18, 2019

Walgreens to Pay $269.2 To Settle Civil Fraud Lawsuits

February 17, 2019

Voters in four states have approved Medicaid expansion by ballot. Will Texas do the same?

February 15, 2019

Thousands of Texans shocked by surprise medical bills. Requests for help overwhelm the state.

February 15, 2019

Ohio joins alleged overbilling and fraud settlement with Walgreens

February 15, 2019

Lessons for Distributors from Dental Lawsuits

February 14, 2019

Minnesota Attorney General Ellison’s office wins state’s largest medicaid fraud case

February 12, 2019

DOJ Announces More Than $21M in Home Health Fraud, Kickback Schemes

February 12, 2019

Texas lawmaker introduces bill requiring name and photo be added to Lone Star card to fight fraud

February 11, 2019

Federal indictment in Ohio charges 6 in $48M Medicaid fraud

February 8, 2019

Georgia hospital enters $5M settlement with feds to resolve false claims case

February 8, 2019

California man sentenced, ordered to pay $1.5 million for healthcare fraud

February 7, 2019

More Articles...

Copyright © 2019 · All Rights Reserved. Texas Dentists for Medicaid Reform · Privacy Policy