Investigations and Reviews Division

Inspections graph

The Investigations and Reviews Division includes these units:

Benefits Program Integrity investigates allegations of overpayments to clients enrolled in the Supplemental Nutrition Assistance Program (SNAP); Temporary Assistance for Needy Families (TANF) program; Medicaid; Children’s Health Insurance Program (CHIP); and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Electronic Benefits Transfer (EBT) Trafficking Unit conducts investigations of allegations of the use, misuse or trafficking of SNAP at the retailer level.

Internal Affairs investigates Texas Health and Human Services (HHS) employee and contractor misconduct. The team also investigates concerns about the administration and operation of HHS programs.

Provider Enrollment Integrity Screenings is responsible for conducting certain federal and state-required screening activities for providers seeking to enroll in Medicaid, CHIP and other HHS programs.

State Centers Investigations Team conducts criminal investigations of allegations of abuse, neglect and exploitation at state-supported living centers and state hospitals.

Surveillance Utilization Review (SUR) conducts claim and medical record reviews on a variety of HHS programs, including acute care utilization, hospital utilization, nursing facility utilization and pharmacy lock-in. SUR also provides clinical consultation to other OIG teams.

WIC Vendor Monitoring Unit conducts oversight activities of vendors that participate in WIC. This is accomplished through vendor coordination and reviews of vendor activities.

Medicaid Program Integrity consists of the following teams:

Data Initiatives Project Team (DIPT) initiates and investigates data trends and patterns regarding the reimbursement behavior of Texas Medicaid providers by using an integrated, cognitive data-driven approach to investigate fraud, waste and abuse (FWA). DIPT provides a framework to scale the capabilities of provider investigations by reducing the investigation time and simplifying the issues involved. DIPT coordinates cross-divisional teams to focus on data-driven cases in order to recover funds with the strongest supportive evidence and the greatest potential for recovery of money.

Intake Resolution Team performs preliminary investigations of FWA allegations involving Texas Medicaid providers. When criminal Medicaid fraud is suspected, the team refer the matter to the Attorney General's Medicaid Fraud Control Unit (MFCU). 

Investigative Strategy Team provides investigative support to Provider Field Investigations regarding focus, sample design and institutional knowledge to maintain consistency across all investigations.

Major Case Unit (MCU) investigates select cases that may require specialized accounting, data analysis and complex investigative techniques. MCU is a small unit comprised of personnel with exceptional expertise in complex investigations, public accounting, data analyses and legal considerations.

Program Integrity Development and Support provides support and process improvements to other teams. Responsibilities include developing projects to improve investigative outcomes, reporting statistics, acting as the managed care organization special investigative unit liaison, planning and conducting investigative initiatives, including the OIG Fraud Detection Operations.

Provider Field Investigations Team investigates and reviews allegations of FWA involving Medicaid providers who may be subject to a range of administrative enforcement actions such as education, prepayment review of claims, penalties, required repayment of Medicaid overpayments and/or exclusion from the Medicaid program. Complaints come through the OIG Fraud Hotline and website. When criminal Medicaid fraud is suspected, the team refers the matter to MFCU. The OIG collaborates with MFCU on joint investigations by sharing resources and information that supports successful administrative disposition or criminal prosecution.

Recovery Audit Contractor is a vendor contracted with HHS to identify and recover Medicaid overpayments using data analytics and clinical reviews of medical records.

Targeted Query team performs advanced queries to identify, deter and prevent potential waste in Medicaid.

NFUR stakeholder information

Hospital stakeholder information

Lock-In Program information