The 2022 Quarter Four Fiscal Report of the Texas Health and Human Services OIG was issued in September 2022 with highlights from another very successful year. The report reflects the continued focus of the OIG on enhanced data analytics to identify fraud waste and abuse, as well as the importance of collaboration with Medicaid providers to prevent FWA from happening in the first place.
The OIG’s evolution in fraud, waste and abuse (FWA) detection is grounded on a foundation of data analytics. Harnessing the power of data has resulted in increasingly efficient and investigations, reviews, audits and inspections. The OIG made significant strides in fiscal year 2022 (FY 2022) in broadening its use of data analytics to uncover fraud, waste and abuse by assessing potentially problematic behavior, including improper billing trends, by Texas Medicaid providers.
To do this, the OIG formed a Data Initiatives Project Team (DIPT), which is a multi-disciplinary team comprised of investigators, data analysts, policy specialists, clinicians and attorneys who work collaboratively to increase FWA prevention and detection. DIPT uses data to identify billing trends that indicate potential violations of Medicaid policy across providers. As stated in the Report, when DIPT identifies a billing pattern with one provider that may indicate FWA, it works with the OIG’s data team to conduct data analysis across the Texas health care system to determine whether similar issues are occurring with other Medicaid providers. Depending on the results of this analysis, provider education and/or the recovery of overpayments can occur, as appropriate.
The OIG’s data team facilitates cross-divisional data analytics information-sharing with data analysis staff throughout HHS. Representatives from the OIG and HHS Medicaid/CHIP Services, Actuarial Analysis, and the Office of Data, Analytics, and Performance meet regularly to share data anomalies and utilization trends. This cross-pollination of information is used by the OIG when performing data analysis and determining areas for future review and helps the OIG to identify new threats to program integrity at an earlier stage.
The OIG has leveraged in-house expertise, both in HHS and other agencies, to increase FWA prevention and detection. However, to stay cutting edge, the OIG has also engaged external sources to further increase the reach of data analytics needed to find and address FWA. In 2022, the Texas OIG contracted with a vendor to develop more advanced analytical tools to help identify potential indicators of FWA. The work performed with the vendor will allow the OIG’s data team to further enhance the agency’s ability to perform highly complex data analysis work, increase operational efficiencies, and advance its analytical capabilities. This data-driven approach can identify risks program-wide and the OIG is hiring additional data analysts, investigators and attorneys will allow the state to fully realize the benefit the OIG’s data initiatives.
Collaboration to Support Fraud Prevention Strategy
The OIG Fraud, Waste and Abuse Prevention Strategy emphasizes stakeholder partnerships and opportunities for training, education and raising awareness while developing recommendations to improve HHS programs and inform future OIG work.The OIG also proactively engages providers, encouraging them to voluntary disclose errors.
Through the Texas Fraud Prevention Partnership (TFPP). the OIG continued to prioritize formal discussions and collaboration with the Texas Medicaid MCOs. The OIG held three TFPP MCO Leadership Meetings during FY 2022 to discuss current initiatives and combined efforts to prevent, detect and investigate fraud, waste and abuse.
Stakeholder engagement activities included the OIG’s development of an educational video for home health providers and their staff related to personal care attendants. This work led to presentations to attendant care providers. As noted in the Quarter 4 FY 2022 Report, 38 percent of cases settled by the OIG litigation team in 2022 related to home health care and personal attendant issues, more than double the next category of provider type. In 2022 Quarter 4, 41 percent of cases opened by the HHS OIG elated to personal attendants.
The OIG Communications Team has been very active as well, publishing prevention messages through both the agency’s digital media channels as well as working with Texas health care associations. Articles addressed a variety of topics including:
- the OIG’s self-report process for providers;
- the importance of verifying that current/potential employees are not excluded from Medicaid program participation;
- reporting suspected wrongdoing to the OIG Fraud Hotline; and
- the collaboration between the OIG and Managed Care Organization (MCO) special investigative units.
Cost Avoidance. In FY 2022, the OIG achieved nearly $44.3 million in cost avoidance, which deterred potentially questionable spending before it could occur. This was achieved through front-end claims denials, client disqualifications, Medicaid provider exclusions, the Pharmacy Lock-In Program and WIC vendor monitoring. The Texas OIG in 2022 excluded a total of 174 providers from participation in Medicaid, which fortunately represents a decrease from the 201 providers excluded in 2021. Medicaid provider exclusions in FY 2022 led to cost avoidance in the amount of $16,910,119.
Collaboration Activities. The OIG Fraud, Waste and Abuse Prevention Strategy emphasizes stakeholder partnerships and opportunities for collaboration, training, education and raising awareness while developing recommendations to improve HHS programs. In FY 2022, the OIG initiated 42 targeted prevention activities directed at clients, the public, providers, HHS staff and contractors.
Self-Reporting. Medicaid providers are increasingly using the OIG’s self-report process to resolve cases. Self-reports in FY 2022 led to the resolution of 50 cases. This is compared to 45 cases resolved through self-reporting in FY 2021. The OIG closed 33 self-reports in FY 2020. The provider types that utilized the self-report process include clinics, hospitals, home health agencies and mental health rehabilitative services. The resolved self-reports in FY 2022 resulted in settlements totaling $6,375,481. In FY 2021, settlements totaled $8,171,252.
Using both internal and external resources, OIG teams master increasingly sophisticated technology to identify FWA trends in their early stages and more quickly respond to those emerging threats. By assessing billing trends and patterns of providers, clients and retailers participating in HHS programs, data analytics enables faster recognition of potential problems across the health care system. As the Texas OIG fraud detection becomes increasingly sophisticated, it becomes even more vital for Texas Medicaid providers and MCOs to stay ahead of the regulators to head off problems by assuring that their providers have no history of criminal or professional misconduct. Streamline Verify can work with Medicaid providers to confirm that their staff and contractors have not been sanctioned, debarred, suspended or excluded and to avoid Texas OIG concerns. An overview of Texas laws, requirements and enforcement information related to exclusion screening is available on the Streamline Verify webpage.
The impact of partnership collaboration through education, meetings and articles on recoveries, settlements and cost avoidance is harder to quantify financially, other than the provider self-disclosure rates and resulting repayments. However, MCOs often are the first line of defense against FWA, and the required disclosure of reported allegations of fraud by MCO Special Investigations Units to the OIG is critical to OIG efforts to address fraud. Therefore, partnerships between the OIG and Medicaid MCOs, based on trust and mutual interest, remain an essential component to address FWA in Texas Medicaid.