Provider Investigations reports third-quarter results

The OIG's Provider Investigations unit (PI) completed 498 preliminary investigations and 68 full investigations in the third quarter of fiscal year 2022.

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 investigations settled by OIG Litigation for the third quarter includes:

• In April, the OIG settled a case against a Dickinson pharmacy. The provider lacked documentation to support the medication quantities billed to the Texas Medicaid program compared to medications purchased from vendors over a four-year period. The provider worked collaboratively with the OIG to resolve these issues, and the OIG agreed to a settlement of $1,333,660.
• The OIG settled a case in March against a Houston home health agency that offers private duty nursing services. From January 2015 to June 2021, the home health agency billed Medicaid using a modifier reserved for patients who have a tracheostomy or are ventilator-dependent, when the patients did not have either condition. The provider agreed to pay $400,000 to resolve the case. 
• In May, the OIG settled a case with a San Antonio licensed professional counselor. The provider was investigated for billing for individual therapy sessions but providing group therapy. During the investigation, it was discovered that the provider had a privacy data breach when a former employee lost flash drives containing patient files and records. The provider worked collaboratively with OIG Litigation to resolve these issues, accepted responsibility for what occurred and presented information on corrective actions. The provider agreed to pay $126,012 to resolve the case.