Provider investigations average less than 24 days for preliminary investigations

Over the first half of fiscal year 2024, the Medicaid Program Integrity team has demonstrated its efficiency by successfully concluding 796 preliminary investigations into allegations against providers. This was achieved within an average of 23.6 days, a significant improvement over fiscal year 2023's average of 25.88 days. It's worth noting that these investigations were well within the 45-day limit provided by statute. Out of these, 107 cases were escalated to full-scale investigations, while 170 were referred to the Office of the Attorney General's Medicaid Fraud Control Unit.

The OIG's Medicaid Provider Field Investigation team reviews allegations against medical and service providers enrolled in the Texas Medicaid Program. More than half of these allegations come from Managed Care Organizations and the public, with healthcare providers, anonymous reports, government agencies and OIG initiatives providing the remainder.

In the first two quarters, the OIG Intake and Resolution Unit noticed a trend in complaints against dentists and endodontists alleging substandard and unnecessary procedures. Case management services were also noted as an increasing topic in the second quarter, as reports of uncredentialed or unlicensed providers submitted claims for these services.  

These focused investigations occur concurrently with the cases involving every provider type in Texas Medicaid. Upon completion of an investigation, Provider Field Investigations delivers findings to OIG litigators who work to recapture funds from providers and may pursue administrative, civil or criminal penalties. Included in these results:

  • The OIG settled cases with two Houston pharmacies that improperly submitted claims to the Texas Medicaid program. One pharmacy failed to identify the correct prescriber on a majority of the reviewed prescriptions and contained incomplete directions for use on one prescription. The second pharmacy did not consistently comply with requirements for dosage directions, medication strength, maintaining records, signing or dating written prescriptions, and dispensed opioid and Schedule II prescriptions received by fax, which is not allowed. The pharmacies worked with the OIG to resolve the issues and agreed to settlements of $12,683 and $18,675, respectively.
  • The OIG settled with a home health provider whose medical records did not support the use of the UA modifier billed for some clients. The UA modifier provides additional reimbursement for patients who are ventilator-dependent or have a tracheostomy. The provider worked with the OIG to resolve these issues, and the OIG agreed to a settlement of $147,291.