Data Reviews Division
Data Initiatives Project Team
The Data Initiatives Project Team (DIPT) uses an integrated, data-driven approach to analyze, identify and investigate trends and patterns in the billing of Texas Medicaid providers. DIPT leverages interdisciplinary expertise to focus on initiatives with the greatest potential for recovery based on clear, data-informed evidence.
Data Operations
Data Operations oversees data management functions, conducts data-informed policy research, develops data intelligence solutions, and provides data system support to the OIG. The team develops sampling and statistical models to support OIG investigations, reviews, audits, and inspections; designs, develops, and maintains OIG data visualization tools and operational dashboards; performs data queries and analysis; coordinates with the HHSC Claims Administration contractor and Managed Care Organizations to collect and compile data to support OIG’s work; and serves as the liaison with HHSC Information Technology (IT) and external vendors to enhance and maintain OIG’s fraud, waste, and abuse technology systems.
Fraud Analytics
Fraud Analytics is responsible for performing advanced data analytics to identify trends and patterns that might be indicative of potential FWA to help drive investigations, reviews, audits and inspections. Fraud Analytics develops complex algorithms and models to analyze the behavior and billing practices of providers, clients, and managed care organizations.
Provider Enrollment Integrity Screenings
The Provider Enrollment Integrity Screenings (PEIS) team conducts certain federal- and state-required screening activities for providers seeking to enroll in Medicaid, the Children’s Health Insurance Program (CHIP), and other state health care programs. The screenings and reviews promote compliance with federal and state provider enrollment program integrity requirements, increase accountability for the appropriate use of taxpayer resources by helping to prevent FWA, and protect the health and safety of Texans.
Recovery Audit Contractor
The Medicaid Recovery Audit Contractor program (RAC) is a federally established program integrity measure through which the state contracts with a vendor to identify and recover Medicaid overpayments using both data analytics and clinical reviews of medical records.
Targeted Queries Team
The Targeted Queries (TQ) team conducts reviews of Medicaid and other Texas public health care program providers using advanced algorithms that identify indicators of FWA in data. The TQ model employs replicable data analysis techniques to detect, deter and prevent new and ongoing FWA patterns and recover misspent Medicaid funds.
Third Party Recoveries
A third party is any individual, entity or program liable for medical assistance provided to a Medicaid participant. Examples include private insurance carriers, cash medical assistance from child support arrangements, and responsible party insurance coverage related to accidents or injuries. Third Party Recoveries (TPR) works to ensure that Medicaid is the payor of last resort, preventing payments and recovering Medicaid funds spent on services that a third party is primarily responsible for paying. TPR also oversees the Medicaid Estate Recovery Program (MERP), a federally mandated program that recovers the costs of Medicaid long-term care benefits received by certain Medicaid recipients.