IG Wants to Make It Easier to Place Payment Holds

There have been rumors flying by the last few weeks that Inspector General Stuart Bowen wants to make it easier to place “credible allegation of fraud” (CAF) payment holds against Medicaid providers. We had no idea that this was difficult at all for the state since MCNA seems able to do so without any problems.

However, we were directed to a recent public hearing and found it was true.

This past September 13 at a hearing before the Senate Committee on Health and Human Services, IG Stuart Bowen testified (see video) that because of SB207 his office has had a tough time placing CAF payment holds against Medicaid providers.  In fact, he said it is a tool he hasn’t been able to use until recently and he wants to make it easier for him to use by changing the changes that SB207 made to government legislation.

SB207 is, of course, the Sunset review legislation that reformed the Office of Inspector General because of systemic abuses including the placement of CAF payment holds without apparently having the requisite scintilla of evidence that is necessary per federal law.

Testimony short and without specifics

Bowen’s testimony on the matter was short and he did not tell the committee as a whole or the attending public what exactly the problem was with the legislation.  He apparently has done this only in private conversations with the committee chair Sen. Charles Schwertner and committee member Sen. Lois Kolkhorst.

He simply told the whole committee and public that Texas has a “one-in-a-nation” standard now that other states do not have.

What did SB 207 do?

This statement caused us to look up the exact changes that SB 207 made in government legislation on placing CAF holds and attempt to find what Bowen finds so objectionable and hampers his job.  This is not a full legal review although we will seek this.

Because of SB 207,  Government Code 531.102, as of August 2016, that governs of the Office of Inspector General, now states:

(g)(2)  As authorized under state and federal law, and except as provided by Subdivisions (8) and (9), the office shall impose without prior notice a payment hold on claims for reimbursement submitted by a provider only to compel production of records, when requested by the state’s Medicaid fraud control unit, or on the determination that a credible allegation of fraud exists, subject to Subsections (l) and (m), as applicable.  The payment hold is a serious enforcement tool that the office imposes to mitigate ongoing financial risk to the state.  A payment hold imposed under this subdivision takes effect immediately.

So federal law, 42 CFR 455.23 (Code of Federal Regulations) is the following:

Suspension of payments in cases of fraud.
(a) Basis for suspension.

(1) The State Medicaid agency must suspend all Medicaid payments to a provider after the agency determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual or entity unless the agency has good cause to not suspend payments or to suspend payment only in part.

(2) The State Medicaid agency may suspend payments without first notifying the provider of its intention to suspend such payments.

(3) A provider may request, and must be granted, administrative review where State law so requires.

Credible allegation of fraud is usually defined as:

A credible allegation of fraud may be an allegation, which has been verified by the State, from any source, including but not limited to the following:
(1) Fraud hotline complaints.
(2) Claims data mining.
(3) Patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered to be credible when they have indicia of reliability and the State Medicaid agency has reviewed all allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis.

What makes Texas different?

So what makes Texas different?  Well, section 8 above is the same as federal regulation but section 9 is the following:

(9)  The office may not impose a payment hold on claims for reimbursement submitted by a provider for medically necessary services for which the provider has obtained prior authorization from the commission or a contractor of the commission unless the office has evidence that the provider has materially misrepresented documentation relating to those services.

Also, (l) and (m):

(l) The office shall employ a medical director who is a licensed physician under Subtitle B, Title 3, Occupations Code, and the rules adopted under that subtitle by the Texas Medical Board, and who preferably has significant knowledge of Medicaid. The medical director shall ensure that any investigative findings based on medical necessity or the quality of medical care have been reviewed by a qualified expert as described by the Texas Rules of Evidence before the office imposes a payment hold or seeks recoupment of an overpayment, damages, or penalties.

(m) The office shall employ a dental director who is a licensed dentist under Subtitle D, Title 3, Occupations Code, and the rules adopted under that subtitle by the State Board of Dental Examiners, and who preferably has significant knowledge of Medicaid. The dental director shall ensure that any investigative findings based on the necessity of dental services or the quality of dental care have been reviewed by a qualified expert as described by the Texas Rules of Evidence before the office imposes a payment hold or seeks recoupment of an overpayment, damages, or penalties.

So what makes Bowen’s job so tough is that he can’t place a payment hold on services that received prior authorization UNLESS he has material evidence that the provider misrepresented something.  That seems pretty fair.

Also, if the allegation is against a doctor or dentist, those allegations need to be reviewed by an expert to make sure the payment hold is valid.  Considering past actions by OIG and waste of administrative court time in the Nazari and Rhoden cases, this seems quite reasonable.

Asked for comment

We have sent a request to the IG for comment on this.

Our job is not to prevent the finding of fraud and those committing it, but to ensure there is due process for all providers.


One Response

  • Are we considered respectable health professional any longer?

    I felt comfortable and committed to my service when our earn dental license make us respectable dentist and was the only valid legal credential under control of our clinical practice, knowledge, and the professional relations with our patients . I was eager full of enthusiastic learning and practicing about every dental procedure only for the benefit of my patients . I admired my senior colleges about their knowledge , experience and skills which could be represented in such a good results in their patients treatment and that was my goal be like my senior colleges. And now day every thing has changed.To many third parties ( Insurances, vendors, staff training facilities . management care, etc., ), rules and regulations . New generation of practitioners conditioned , limited and with other expectations. Conclusion we have lost control of our profession and practices..

    My enthusiastic demeanor has gone low, third parties want my enthusiasm for them not for my patients. Now days every body want to tell me how to practice dentistry ,what can I do , when to do it and even how much money I should made .Worse make me no to charge for services agreed with the patients and already rendered .

    Now Medicaid add withholding payments and recoups for any services performed by agreed terms in advance ????? .Regulating their subjective patterns which could be any procedure routinely done as exams , prophylaxis, taking x-ray, OHI, preventive , restoration , sealants , ETC.Scrutiny in Medically necessity diagnosis and definition when a subjective means of diagnosis must used are allow with the practitioner clinical visual exam judgment. HMO experts Scrutiny accepted by presuming the used of accurate diagnosis means is possible disregarding the fact that the only could be done with expensive sophisticated technology means no affordable and no cover by Medicaid.

    To our patients the implementing Pre authorization will only delay treatments and is time consuming ( time is money).The Medicaid patient population is low income population and forcing them for having several appointments made patients health condition worse. In addition of the costs of several visits logistics for having patients for treatment that could be done in one visit. and what worse missing treatment for good.

    The name experts from where it comes from? how are they elected( finger point?) or why considered experts? from whom they get the title ????

    When must of these name experts persons are not better in clinical daily knowledge than any other license dentist practitioners investigated. What about when experts had the need to support them as experts. .It Is then when the expert will arbitrary misrepresent no applicable subjective aid diagnosis means for medically necessity conditions which do not need other than the clinical provider visual diagnostic evaluation as objective documentation for medically necessary conditions all for they own convenience. At that stage is when provider words confront against expert word and guess who will be consider right and who is going to judge that decision ??

    Are we dentist criminals after fraud?? I though I was a health provider.

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