Provider Investigations releases third quarter results

During the third quarter of fiscal year 2023, the OIG Provider Field Investigations team opened 559 preliminary investigations, completing 543 and transferring 55 cases to full-scale investigations. They also completed 48 full-scale investigations and referred 205 cases 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. During the last quarter, billing for hearing tests and behavioral therapy was a focus for investigators. 

During a review of billing submitted to Medicaid for pure tone audiometry tests, it was often found that the service occurred on the same day as the client's well-child check-up. This separate billing violates Medicaid rules because well-child check-ups are a comprehensive service that includes hearing tests. 

Investigators also concentrated on billing submitted by licensed professional counselors after data analytics pointed to issues, including charging for services that were never provided, miscoding the type of counseling service and exceeding the number of therapy hours allowed per day. Record reviews and client interviews will be used to identify if providers were improperly reimbursed. 

These focused investigations occur concurrently with the cases involving every provider type in Texas Medicaid. Upon completion of an investigation, PFI 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 a case against a Houston dental provider who improperly billed Medicaid for a variety of dental services. Violations included services not rendered, up-coded services, missing or inadequate records to support billing, billing for services not covered, medically unnecessary services, and inadequate quality of care. The provider worked with the OIG and agreed to repay $24,000 in overpayments over 24 months.

• OIG litigators agreed to a settlement of $12,232 to resolve a case involving a Laredo home health provider that improperly billed Medicaid for personal care attendant services. The provider worked collaboratively with OIG Litigation to resolve these issues after one of their employees admitted to falsifying documentation on a patient's status and care.

• An OIG audit revealed a Pearland pharmacy had insufficient evidence to show prescriptions billed to Medicaid were accurate. The provider appealed the final audit report but, while it was pending, worked with OIG Litigation to resolve the remaining issues and settle for $9,021.