The Data Reviews Division assists investigators and OIG initiatives through the development of tools and processes that leverage data and technology to increase efficiency.
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 coordinates cross-divisional teams to focus on fraud, waste and abuse initiatives with the greatest potential for recovery based on clear, data-informed evidence.
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 both new and ongoing patterns of fraud, waste and abuse, and recover misspent Medicaid funds.
Recovery Audit Contractor
Data Reviews also oversees the Recovery Audit Contractor (RAC), which is a federally mandated program through which the state contracts with a vendor to identify and recover Medicaid overpayments using both data analytics and clinical reviews of medical records.
Third Party Recoveries
Third Party Recoveries (TPR) works to ensure that Medicaid is the payor of last resort and oversees the Medicaid Estate Recovery Program (MERP). A third party is any individual, entity, or program that is liable to pay for any medical assistance furnished to a participant under the approved state Medicaid plan. Recoveries from third parties include private insurance carriers, cash medical assistance associated with child support arrangements, and responsible party insurance coverage related to accidents or injuries.
Provider Enrollment Integrity Screenings
The PEIS unit is responsible for conducting certain federal- and state-required screening activities for providers seeking to enroll in Medicaid, CHIP and other state health care programs. The screenings and reviews conducted by PEIS promote compliance with federal 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.