OPENED CASES – 09/01/97 TO 11/30/97

Section 8, Article II, House Bill 1, 76th Legislature
Third Quarter -- Fiscal Year 2001
03/01/00 - 05/31/01

July 2001
Texas Health and Human Services Commission
Office of Investigations and Enforcement (OIE)

OPENED CASES – 03/01/2001 to 05/31/2001

Referral Source	Received
Office of the Attorney General’s Medicaid Fraud Control Unit	19
Board of Dental Examiners	1
Board of Medical Examiners	2
Board of Licensed Vocational Nurse Examiners	30
Board of Nurse Examiners	3
Pharmacy Board	1
Community First Health Plans	1
Texas Department of Health (TDH)/Vendor Drug	2
Health and Human Services Commission (HHSC)/Office of Investigations & Enforcement/Medicaid Program Integrity (Self Initiated)	6
HHSC-Compliance, Monitoring & Review	2
Health and Human Services/Office Inspector General	14
National Heritage Insurance Company	1
ICF-MR	9
Texas Department of Mental Health and Mental Retardation	1
Surveillance & Utilization Review System	8
Texas Department of Human Services	8
Texas Department of Human Services/Long Term Care	3
TDH	4
Texas Health Steps	1
Public	8
Recipient	4
Provider	5
Opened Cases in 3^rd Qtr. 2001	133
Cases Opened and Closed during the 3^rd Qtr 2001	(2)
Opened Cases in 1^st Qtr 2001	66
Opened Cases in 2^nd Qtr 2001	193
Remaining Open Cases in FY00	351
Remaining Open Cases in FY99	337
* Remaining Open Cases in FY98:	*189
* Remaining Open Cases Prior to FY97:	*159
Total cases opened:	1426

* Many of these cases are in Sanction status and will not be closed until the Sanction is completed.

STATUS OF OPEN CASES

	Referred To:
R0	Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU)	104
R1	Office of the Attorney General’s Tort Litigation Division	2
R1	Office of the Attorney General’s Elder Law Section	3
R3	State Board of Certified Nurse Aides	1
R5	State Board of Dental Examiners	20
R6	State Board of Licensed Vocational Nurses	1
R7	State Board of Medical Examiners	3
R10	Board of Pharmacy	1
R12	Medicaid Part A & B	2
R19	Department of Protective and Regulatory	1
RD	HHSC - Compliance, Monitoring & Review (CMR)	2
RF	Health Facility Compliance	1
RH	Texas Department of Health Long Term Care	1
RQ	Utilization Review Division	3
RR	NHIC – Claims/Records Review	3
RS	NHIC Education Visit	9
O3	Pending Sanctions	148
S19	Pending Appeals	8
	Sanctions Imposed:
S4	Recoupment	82
S1	Notice Sent	65
S2	Vendor Hold	102
S23	Request for Reinstatement	2
S8	Global Settlement	8
S16	Pending Exclusion	133
Total		705
Total Number of Open Cases for 3^rd Qtr FY01		1,426

RECOUPMENT DOLLARS – 3^rd QUARTER FISCAL YEAR 2001

Office of Investigation & Enforcement Area	3^rd Qtr FY01 Total
Compliance Monitoring and Referral	$2,309,684
Medicaid Fraud & Abuse Detection System -- Dollars recovered	$485,195
Utilization Review – Case Mix (Nursing Homes)	$2,588,041
Utilization Review – DRG (Hospitals)	$7,609,978
Utilization Review – Tax Equity & Fiscal Responsibility Act (TEFRA) – Children’s Summary	$0
Utilization Review – Tax Equity & Fiscal Responsibility Act (TEFRA) – Psychiatric Summary	$0
Surveillance and Utilization Review Subsystems – SURS	$332,231
Medicaid Program Integrity	$1,517,066
Medicaid Program Integrity – Civil Monetary Penalties	$82,146
TOTAL	$14,924,341

Note: Total recoupment dollars reflect all active cases within OIE. Investigations refer only to active, full, fraud and abuse investigations.

OTHER STATISTICS – 3^rd QUARTER FISCAL YEAR 2001

Action	3^rd Qtr FY01 Total
Medicaid Program Integrity:
Cases Opened	133
Cases Closed	150
Providers Excluded	23
Utilization Review:
Case Mix (nursing homes) – Cases Closed	380
Case Mix (nursing homes) – # of reviews	6,207
Hospitals – Cases Closed	322
Hospitals - # of reviews	9,667
Medicaid Fraud & Abuse Detection System
# of cases identified	734
Dollars identified for recovery *This amount represents claims inappropriately paid based on policy and/or investigations. It does not represent the actual dollars that may be recoverable.	17,513,067*