The Office of the Inspector General website now has a report detailing the 2012 fraud detection and recovery activity of all managed care organizations (MCOs) that participate in Texas Medicaid.
Under Texas Government Code, Section 531.113, the MCOs are required to establish and maintain a special investigative unit within their organization or contract with another entity to investigate fraudulent claims and other types of program abuse by HHSC clients and service providers. MCOs are required to utilize payment recovery efforts and are allowed to retain any money recovered. They must submit a quarterly report to OIG detailing the amount of money they recover and HHSC then prepares an annual report to submit to the legislature.
The first such report is now online in a Word file for the state fiscal year (SFY) 2012 but is shown below. The results are staggeringly contradictory.
In contrast to the Office of Inspector General’s allegations of massive dental fraud in Texas Medicaid and error rates that approach 99%, managed care organizations for dental – Delta Dental, DentaQuest USA and Managed Care of North America – reported that they uncovered $0 in Medicaid fraud for 2012.
In fact, for all MCOs in the Medicaid system across the entire state, less than $2 million in fraudulent billings were uncovered and recovered. This would seem a very lack luster performance by MCOs considering that OIG’s budget to uncover and detect fraud was dramatically increased based on their testimony this past legislative session that Medicaid fraud was rampant.
Somebody should be embarrassed.
HHSC OIG Annual Report on Certain Fraud and Abuse Recoveries
by Managed Care Organizations (MCOs) – SFY 2012
|
MCO/Special Investigative Unit |
Amount Recovered by MCO |
Amount Retained by MCO |
| Aetna Better Health |
$0.00 |
$0.00 |
| Amerigroup Texas |
$1,010,573.21 |
$1,010,573.21 |
| Blue Cross & Blue Shield (Contracted 3/1/12) |
$0.00 |
$0.00 |
| Bravo Health, Inc. |
$42,572.18 |
$42,572.18 |
| Christus Health |
$0.00 |
$0.00 |
| Community First Health Plan |
$520,080.07 |
$520,080.07 |
| Community Health Choice |
$155,889.84 |
$155,889.84 |
| Cook Children’s Health Plan |
$3,763.61 |
$3,763.61 |
| Delta Dental |
$0.00 |
$0.00 |
| DentaQuest USA |
$0.00 |
$0.00 |
| Driscoll Children’s Health Plan |
$31,943.48 |
$31,943.48 |
| El Paso First Health Plans, Inc. |
$90,953.09 |
$90,953.09 |
| FirstCare Health Plan |
$37,062.84 |
$37,062.84 |
| Managed Care of North America |
$0.00 |
$0.00 |
| Molina Healthcare |
$105.25 |
$105.25 |
| Parkland Community Health Plan |
$3,824.73 |
$3,824.73 |
| Scott & White Health Plan |
$0.00 |
$0.00 |
| Sendero Health Plan (Contracted 3/1/12) |
$0.00 |
$0.00 |
| Seton Health Plan |
$0.00 |
$0.00 |
| Superior Health Plan |
$1,506.80 |
$1,506.80 |
| Texas Children’s Health Plan |
$79,466.67 |
$79,466.67 |
| United Healthcare of Texas |
$0.00 |
$0.00 |
| ValueOptions |
$8,172.40 |
$8,172.40 |
| Totals |
$1,985,914.17 |
$1,985,914.17 |