Special investigative units help prevent fraud, waste and abuse
One tool managed care organizations (MCOs) use to reduce fraud, waste and abuse (FWA) is a team of in-house investigators known as the special investigative units (SIUs). This team reviews all services provided under an MCO's contract with Texas Medicaid. A 2019 contract amendment requires these teams to include a full-time SIU manager and credentialed investigator, which examine improper claims by Texas Medicaid clients and service providers. To support these efforts, the OIG has a dedicated coordinator to assist with referrals, investigations and training. MCOs and the OIG also work collaboratively through the Texas Fraud Prevention Partnership, which helps identify, investigate and refer cases. These changes likely contributed to a 33 percent increase in SIU referrals for provider investigation from fiscal year 2020 to 2021.
The OIG uses its access to referrals and encounter data across all MCOs and programs to identify potentially widespread issues. Running analytics on a referral set helps the agency determine if something that looks like a small problem with one MCO is a repeated issue across the Medicaid program. The OIG's data analytics process can uncover systemic trends that might not be visible at the MCO level. For example, a provider may bill multiple MCOs for the same hours worked, establishing an issue where Medicaid pays a single healthcare provider for "impossible hours."
The OIG routinely audits SIU activities to verify that MCOs provide all contractually required information, including.
- Fraudulent practices referrals.
- Fraud, waste and abuse compliance plans.
- Open case list reports.
- Annual lock-in action reports.
- Annual reports on certain fraud and abuse recoveries.
- Pre-payment review monthly reports.
OIG audits evaluate MCO compliance related to preventing, detecting and investigating FWA and reporting information on SIU activities, results and recoveries to Texas Health and Human Services. For example, audits examine whether MCOs have the required staff, conduct training and monitor provider and member service patterns. Audits also check that SIUs ensure all required elements of their investigations are completed, maintain a log of suspected incidences of FWA, and meet deadlines for submitting required reports and referrals to the OIG.
Recent audits revealed that MCOs did not always meet the required timelines for completing mandatory preliminary and extensive investigation activities listed in the Texas Administrative Code, such as:
- Completing preliminary investigations and timelines for selecting a sample of provider claims.
- Making requests for medical records and encounter data.
- Completing the review of requested records and data for extensive investigations.
The OIG uses audit findings to collaborate with MCOs on process improvements related to SIU activities, developing efficient and effective fraud prevention and detection.
Texas Fraud Prevention Partnership
The OIG engages with SIUs three times yearly alongside the Attorney General Medicaid Fraud Control Unit during the TFPP. These gatherings allow the OIG to discuss referrals, provider and client investigations and compliance best practices. In addition, MCO representatives report on the improper billing patterns they observe. The OIG also holds one-on-one meetings with the largest MCOs’ investigative teams to discuss current FWA trends and detection practices. Also, the Inspector General and the executive staff meet with the MCOs' executive leadership. You can explore the audits of various SIUs on the OIG website. Effective SIUs are essential to support overall MCO cost containment efforts and to ensure that MCOs use state and federal funds appropriately.
To learn more about the OIG’s collaboration with SIUs, read the quarterly report on the OIG website.