Texas OIG and Medicaid Exclusions

Posted by Frank Strafford on June 6, 2016 in Exclusions, Uncategorized,

Texas OIG and Medicaid Exclusions

Under the guidance of Inspector General Stuart W. Bowen, Jr., Texas OIG functions within a singular mission: “ To detect, prevent, and deter fraud, waste, and abuse through the audit, investigation, and inspection of federal and state taxpayer dollars used to deliver health and human services in Texas.”

For the sake of clarity and functionality, Texas OIG’s mission is broken down into specific goals. They are as follows:

Identify and eliminate fraud, waste, and abuse through timely, quality audits, investigations, and inspections.
Generate and disseminate excellent work products that demonstrate mission performance, inform our stakeholders, and educate the citizens of Texas.
Identify and implement best practices in all areas of the organization.
Develop and maintain outstanding internal and external relationships to promote transparency and accountability in all we do.
Develop an outstanding team committed to pursuing excellence in all we do.
Maintain and improve business support functions to promote the success of our mission.

These efforts are aimed to ensure that more of the tax dollars paid by the Texas community go directly into recognized health and human services that will, in turn, foster the collective well-being of the entire state of Texas.

Texas OIG enforces strict and consistent rules in detecting, deterring, and preventing fraud, waste, and abuse through regular audits under the federal “Yellow Book” standard, investigations pursuant to legitimate investigative policies, and inspections aided by the federal “Silver Book” standard.

In the value of fairness and transparency, during the 83rd Texas Legislature, necessary revisions were made to the statutes concerning the Inspector General’s authority to hold payments to Texas Medicaid providers accused of fraud. Here are three of the most notable changes:

The new statute clearly defines what constitutes an “allegation of fraud” and a “credible allegation of fraud.”
In connection to aforementioned statute, “credibility” of an allegation can now only be based on a stringent case-to-case review. This preliminary review is mandated and whether a full investigation is warranted will depend on the established “credibility” of the initial investigation.
Another mandate states that the “ Commission retain separate physician and dental directors who must ensure any investigative findings based on the necessity or quality of care be reviewed by a qualified expert.”

Some of Texas OIG’s achievements in 2015 include the following:

17 settled cases which totaled to $1,814,603.69 as of August 27, 2015.
66 cases referred to Litigation which sought out $12.9 million recoupment, 145 cases referred to local district attorneys, and 33 court dispositions since September 1, 2015.
$8.5 million identified for recovery and $4,253,075 collected as of September 1, 2015.

These achievements have been made possible through Texas OIG’s consistent display of its central virtues: Professionalism. Productivity. Perseverance.

Texas OIG Exclusion numbers from the LEIE:

249 Exclusions in the State of Texas during 2015
- Of those 77 were pharmacists
- 74 business managers
- 25 power vehicles
- 23 accounting/bookkeeper
- 17 ambulance drivers
- 10 were in sales/marketing of a healthcare facility
- 10 clerical staff
- 9 social workers
Exclusion types include among others:
- Fraud, kickbacks, and other prohibited activities.
- Felony conviction relating to health care fraud
- License revocation or suspension.
- Conviction relating to patient abuse or neglect
- Default on health education loan or scholarship obligations