Investigations and Utilization Reviews
The Investigations and Reviews Division protects the integrity of HHS through investigations and reviews regarding HHS programs and systems. This includes oversight of providers, retailers and clients, as well as oversight of HHS system employees through Internal Affairs (IA) and the State Centers Investigative Team (SCIT).
Medicaid Program Integrity
Provider Investigations (PI) investigates allegations of fraud, waste or abuse by Medicaid providers. Some referrals come through the OIG fraud hotline or complaints from the Inspector General’s online Waste, Abuse and Fraud Electronic Referral System. Referrals are also received from the twenty managed care organizations (MCOs) throughout the state.
PI makes referrals to the Attorney General's Medicaid Fraud Control Unit (AG-MFCU) when there are indicators of criminal Medicaid fraud. PI and AG-MFCU work together on joint investigations by sharing resources and information that will lead to successful administrative or criminal prosecution.
Program Integrity Development and Support
The PIDS team develops and revises PI Intake and Field Investigations Policies and Procedures, acts as a liaison between PI and other OIG areas, state and federal agencies and their contractors, prepares reports related to PI’s activities, and develops and conducts staff training. PIDS acts as liaison to MCO’s Special Investigative Units (SIUs). In collaboration with DAT and Medical Services, PIDS examines and provides preliminary analysis related to provider encounter and claims data and is responsible for storing and managing all evidence related to PI investigations. The team is responsible for conducing deconfliction checks with other investigative or review areas, conducts bill analysis, and coordinates open records requests. PIDS conducts quarterly Fraud Detection Operations (FDOs), contributes to investigative activities on high profile or complex cases, and is responsible for other special projects as needed.
Benefits Program Integrity
Benefits Program Integrity (BPI) investigates allegations of overpayments to health and human services program 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 Women, Infants, and Children (WIC) program.
Clinical Subject Matter Experts
The Clinical Subject Matter Expert (CSME) team includes a physician, dentist, dental hygienist, and pharmacist who provide clinical expertise to Inspector General staff. The CSME team also communicates with Managed Care Organization (MCO) and Dental Maintenance Organization (DMO) compliance departments to educate and to clarify questions of clinical documentation and policy interpretation.
Surveillance Utilization Review
Hospital Nursing Facility Review and Nursing Facility Utilization Review
The Hospital Utilization Review (HUR) team and Nursing Facility Utilization Review (NFUR) team perform onsite and desk reviews of hospital claims and nursing facility Minimum Data Set forms for appropriate billing.
Lock-In Program staff work with managed care organizations to monitor recipient use of prescription medications and acute care services.
Acute Care Surveillance
The Acute Care Surveillance (ACS) team identifies patterns of aberrant billing, performs Surveillance Utilization Reviews required by the federal Centers for Medicare and Medicaid Services and collects Medicaid overpayments.
Electronic Benefit Transfer Trafficking Unit
The EBT Trafficking Unit is comprised of Law Enforcement commissioned and non-commissioned investigators who conduct criminal investigations regarding the Electronic Benefits Transfers misuse. EBT investigates those that intentionally violate provisions related to the Supplemental Nutrition Assistance Program (SNAP).
Women, Infants, and Children (WIC) Vendor Monitoring Unit
The WIC Vendor Monitoring Unit (VMU) conducts in-store reviews, compliance buys, and invoice audits to monitor vendors participating in the WIC program.
Internal Affairs investigates fraud, waste, abuse, employee misconduct and contract fraud within the HHS System.
State Centers Investigations Team
SCIT is comprised of Law Enforcement commissioned investigators who conduct criminal investigations of State Supported Living Centers and State Hospitals violations. A peace officer employed and commissioned by the OIG is a peace officer for the purpose of assisting the office in the investigation of fraud, waste and abuse in the financial assistance program in keeping with Article 2.12, Code of Criminal Procedure.
Cooperative Disability Investigations
The Cooperative Disability Investigations team investigates statements and activities that raise suspicion of disability fraud. These teams conduct administrative and criminal investigations related to those benefit programs.