Data Reviews Division
The Data Reviews Division leverages data and technology to build tools and processes that effectively and efficiently prevent, detect and deter fraud, waste and abuse within Texas Medicaid and other health care programs, helping ensure that taxpayer funds for health and human services are spent properly.
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 HHS claims administration contractor and managed care organizations to collect and compile data to support OIG’s work; and serves as the liaison with HHS IT staff 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 indicative of potential fraud, waste or abuse 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 enrolling 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 fraud waste and abuse, 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 retrospective payment reviews of Medicaid and other Texas public health care program providers using advanced algorithms that identify indicators of fraud, waste or abuse in data. The TQ model employs replicable data analysis techniques to detect, deter and prevent new and ongoing fraud, waste and abuse patterns, and recover misspent Medicaid funds.
Third Party Recoveries
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. 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 for accidents or injuries. 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.