Data driving new tactics in fighting fraud

The OIG is taking an increasingly data-driven approach to protecting Texas taxpayer dollars, leveraging algorithms and data analysis processes to fight fraud, waste and abuse. During the last quarter, the Data Operations team received 260 data requests and completed 258 requests for data. The Fraud Analytics team executed 51 algorithms and developed 16 new algorithms. 

Data analysis also allows the agency to conduct fraud detection operations (FDOs), which review and analyze large volumes of data to identify providers who appear as statistical outliers among their peers. Outlier status is not an automatic indicator of wrongdoing; an FDO only highlights providers who may warrant a closer look. The goal of the FDO is then to assess—through coordinated fieldwork and research—whether this outlier status is due to program violations, fraud, waste, abuse or some other cause. 

The OIG’s current FDO is focused on chemical dependency treatment facilities (CDTF) and substance use disorders. For this FDO, the OIG Fraud Analytics team enhanced 12 existing algorithms and developed seven new algorithms to uncover four CDTF providers who had billed for substance use disorder (SUD) residential and outpatient counseling services. Each provider was flagged for one or more of the following:

• Clients exceeding outpatient counseling limitations.
• Clients billed for differing types of counseling on the same day.
• Clients billed for multiple outpatient counseling services per week.

Investigators are conducting fieldwork, including records reviews and interviews, to determine if the required documentation is available to support the services billed to Medicaid. 

The OIG is statutorily charged with ensuring that appropriated dollars for health and human services are used for their intended purposes. An FDO’s data-driven approach to fraud detection and prevention is one way the OIG fulfills its mission to protect taxpayer funds.

If you see fraud, waste or abuse taking place, contact your managed care organization, call the OIG Fraud Hotline at 800-436-6184, or use the fraud reporting form here on the OIG website.