Latest Medicaid provider investigation result data released

The OIG released provider investigation results for the fourth quarter of fiscal year 2022 in the latest edition of the quarterly report.

Investigator efforts led to 500 completed preliminary investigations and 43 full-scale investigations during the quarter, with 209 cases being referred to the Office of the Attorney General's Medicaid Fraud Control Unit for additional investigation and possible prosecution. 

The OIG's Medicaid Provider Field Investigation (PFI) team reviews allegations against medical and service providers enrolled in the Texas Medicaid Program. For the final quarter of fiscal year 2022, pharmacies were an area of interest as investigators searched for patterns that indicate potential fraud, waste and abuse. Among the indicators that could lead to further investigation were pharmacies who billed for medication which they lacked the inventory to dispense or a pharmacy with a high percentage of complete refill rates. During these investigators OIG team members may:

• Review invoices compared to inventory levels to identify unsupported claims for payment.
• Review pharmacy records to determine if medications were dispensed according to the prescriptions.
• Interview clients and prescribers as needed, based on allegations or other evidence.

Investigators with PFI also delivered evidence to the OIG Litigation team that supported potential fraud, waste or abuse related to home health care providers. If these cases are substantiated the OIG may take action against home health providers and agencies, including provider education, prepayment review of claims, penalties, required repayment of Medicaid overpayments and potential exclusion from the Medicaid program. To address allegations without court proceedings, OIG Litigation may agree to settle some cases. These home health care allegations were settled during the fourth quarter of 2022:

• In June, the OIG settled a case involving a Plano pediatric home health care provider who incorrectly billed Medicaid for some services and lacked doctors' authorizations to support some submitted claims. The provider agreed to pay $54,014 in overpayment and $143,029 in penalties to resolve this case.
• The OIG settled cases in June with four home health providers in Hidalgo County. A personal care attendant working for all four providers double-billed each home health agency for services provided to separate clients who lived in the same residence. The settlement led to the attendant being excluded from working for any Medicaid provider for the next 10 years. Additionally, the four providers agreed to pay a $30,840 settlement to the state.