MPI identifies education opportunities amid recoveries

Our Medicaid Program Integrity (MPI) team recovered $46,121,529 in fiscal year 2019. This division investigates and reviews fraud, waste and abuse allegations against providers; reviews hospital and nursing facility claims and medical records; and screens providers seeking to enroll in Medicaid.

A notable case from the fourth quarter demonstrates how claims reviews can point to possible wrongdoing. A private duty registered nurse in Pflugerville billed for impossible hours. An MPI investigation revealed the nurse was billing for continuous 24-hour shifts for weeks at a time. Texas Medicaid procedures prohibit reimbursing a registered nurse more than 16 hours of private duty nursing services in one day. The provider was overpaid by $93,945.

The OIG also reached two settlements in attendant care cases in the fourth quarter. One investigation identified an attendant billing for services that were not performed. The other involved an attendant billing for services while the client was incarcerated. Although they generally involve relatively lower dollar amounts than other cases, attendant care complaints comprised more than half of the complaints received by MPI during the fourth quarter of fiscal year 2019. This trend inspired prevention and education efforts that included an email to providers with an advisory and letters in English and Spanish for attendants and clients highlighting fraudulent behavior.