Provider Investigations reports Q3 results

The OIG's Provider Investigations unit (PI) completed 415 preliminary investigations and 37 full-scale investigations in the third 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 third quarter includes:

• The OIG settled a case in May with a pediatric office in Rio Grande City. The provider had been excessively ordering expensive polymerase chain reaction (PCR) testing for clients presenting with standard symptoms, who were otherwise healthy. These tests substantially exceeded the recipients’ needs, and a $74,500 penalty was assessed.
• The OIG settled a case in April against one of the largest durable medical equipment suppliers in the state. The investigation found evidence supporting one or more alleged program violations consistent with missing a doctor’s authorization. The provider agreed to a settlement of $103,845.
• As part of an OIG initiative, investigators identified providers who were billing over the daily allowable amount for private duty nursing and, in some instances, submitting duplicate claims. Three separate full-scale investigations related to one home health agency with locations in Dallas, Fort Worth and Tyler reached settlements in April to repay a total of $130,950.

You can read more about the OIG’s efforts to fight fraud, waste and abuse by clicking here to read our latest quarterly report.