TDMR received an email update from the Texas Health and Human Services Office of Inspector General this week.  Although regular quarterly reports have been continually generated by the agency since the resignation of Stuart Bowen as IG in 2017, this is the first email notification we have received about one in quite a long time.

Previous quarterly reports can be viewed at http://oig.hhsc.texas.gov/reports?category%5B%5D=6.

Recoveries and provider investigations

The agency recovered some $97.7 million this quarter with the majority of that, $81 million, coming from Third Party Liability (TPL) recoveries. These funds come from the TPL division in the Texas Medicaid & Healthcare Partnership (TMHP).  This division “ensures Medicaid is the payer of last resort through cost avoidance and recovery efforts and other cost containment initiatives. Approximately 7 percent of people with Medicaid have other health insurance, which allows Medicaid to shift costs to the other insurance carrier.”

As far as fraud, waste and abuse, Medicaid Program Integrity accounted for the following amounts:

• Provider collections $2,695,435
• Acute care provider collections $4,020,258
• Hospital collections $3,587,522

The 76 MPI investigations undertaken in the quarter were broken down as follows:

Type of complaints received by MPI

• Personal care attendant 46%
• Physician (individual, clinic, or group practice) 15%
• Dental 8%
• Home health agency 8%
• Durable medical equipment 4%
• Pharmacy 3%
• Nursing facility 3%
• Adult day care 2%
• Hospital 2%
• Lab/radiology/X-ray 1%

MCO investigation into reporting member complaints

There is also a report on an OIG investigation into how MCOs report member complaints and whether they deal with them consistent with the Uniform Managed Care Contract (UMCC) and Uniform Managed Care Manual (UMCM) requirements.

The conclusions were:

The OIG Inspections and Investigations Division found that complaint reporting amongst the MCOs differs  due to:

• Multiple complaint definitions and lack of clarity on contract terms allows for inconsistent reporting by MCOs.
• MCOs do not report member complaints consistently with UMCC definition of the term complaints.

There is no specific written guidance on how MCOs should interpret and apply the UMCC definition of complaint. On-site interviews with MCO staff indicate there has been inconsistent direction, which leads to variances in the quarterly MCO member complaint report. Two MCOs interviewed indicated there has been direction from MCCO to not report complaints resolved the same day as received. In addition, UMCC language does not provide clear and consistent guidance…

Two other reports

One is an OIG audit of a Texas hospital’s transport program that found nearly $20,000 in funds reimbursed in error.

The other is on an OIG inspection to determine if home health providers obtain and evaluate background information on attendant care personnel to ensure client safety.

Here is the email received

OIG Update

Welcome to OIG Update – a monthly newsletter from the Texas Health and Human Services Office of Inspector (OIG). This newsletter will provide you an update about some of the OIG’s recent efforts in detecting, preventing, and deterring fraud, waste, and abuse in the delivery of Texas health and human services programs. Within this email, you’ll find hyperlinks to the OIG’s latest Quarterly Report, audits, inspections and reviews conducted by our team.

OIG Quarterly Report

The OIG released its Quarterly Report for the second quarter of fiscal year 2019. OIG recovered $98 million in the quarter. Read the report.

OIG conducts inspection of MCO complaint reporting processes

The OIG released the first inspection in a series about managed care organization member complaint intake processes. Read the report.

Audit finds transit service overpayment

An OIG audit of a Texas hospital’s transport program found nearly $20,000 in funds reimbursed in error. The OIG recommended the overpayments be returned to the state. Read the report.

OIG conducts inspection of attendant background checks

The OIG conducted an inspection to determine if home health providers obtain and evaluate background information on attendant care personnel to ensure client safety. Read the report.

Visit the OIG’s website to find a complete listing of all the agency’s audits and inspections. We also post on the site resources for providers and stakeholders, Issue and Data Briefs, and past Quarterly Reports.