Provider Investigations reports Q2 results

The OIG's Provider Investigations unit (PI) completed 361 preliminary investigations and 44 full-scale investigations in the second quarter of fiscal year 2021. PI investigates and reviews allegations of fraud, waste and abuse involving Medicaid providers.

Based on an investigation's findings, OIG actions can include education, prepayment review of claims, penalties, required repayment of Medicaid overpayments and/or exclusion from the Medicaid program. A sample of case results for Provider Investigations settled by Litigation for the second quarter include:

The OIG settled a case against a Beaumont hospital who had been improperly reimbursed for administering injections and infusions in the outpatient emergency department. Injections and infusions are already included in an emergency room service charge and not reimbursed separately. The claims included dates of service ranging from January 2015 through April 2019. The provider worked collaboratively with OIG Litigation to resolve the issues, and the OIG agreed to a settlement of $425,391.

The OIG settled a case against a durable medical equipment (DME) provider in Houston. Based on information obtained during the investigation, the DME provider did not have appropriate documentation to support payments for claims with dates of service between January 2016 through June 2017. The provider agreed to a settlement of $85,349 to resolve the allegations.

A home health provider with locations across Texas filed a self-report involving five of its agencies. The provider’s compliance department received reports in 2020 that some of its nurses had provided care to patients in the nurses’ homes instead of in the patients’ homes. The provider’s investigation substantiated eleven cases where that behavior occurred. The provider terminated 10 registered nurses based on their investigation. The provider also self-reported that all services were provided as documented, and no evidence indicated any patient was harmed or that any of the patients’ primary caregivers objected to care being provided in the nurses’ homes. The provider agreed to pay a penalty of $28,214.