Report to the Medicaid and Public Assistance Fraud Oversight Task Force
First Quarter – Fiscal Year 2000
09/01/99 – 11/30/99
During the first quarter of the Fiscal Year 2000, the Texas Health and Human Services Commission’s Office of Investigations and Enforcement received a total of 544 referrals of potential Medicaid fraud and/or abuse. The referral sources and number of potential cases breakdowns as follows:
|
Referral Source |
Total Received |
|
Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU) |
5 |
|
Citizens Commission on Human Rights |
9 |
|
Texas Department of Health (TDH) |
5 |
|
Department of Human Services (DHS) |
13 |
|
Health and Human Services Commission-Utilization Review Division |
1 |
|
Health and Human Services/Office of Inspector General |
1 |
|
Medicaid Fraud and Abuse Detection System (MFADS) |
323 |
|
National Heritage Insurance Company (NHIC) |
4 |
|
Health and Human Services Commission-Medicaid Program Integrity |
11 |
|
Comptroller’s Measurement of Fraud Study |
118 |
|
Surveillance & Utilization Review System (SURS) |
42 |
|
Provider |
3 |
|
Public |
9 |
|
TOTAL |
544 |
The Health and Human Services Commission’s Office of Investigations and Enforcement closed 382 cases for the first quarter in Fiscal Year 2000. The average amount of staff time spent on each of these investigations was 1090.40 hours.
September 1999
During the month of September, the Texas Health and Human Services Commission’s Office of Investigations and Enforcement closed 111 investigations on Medicaid fraud and/or abuse cases. Of these cases, 105 were within the Acute Care Program, 3 were within the Long Term Care Program, and 3 were within the Vendor Drug Program. The program areas affected are as follows:
|
Acute Care Program |
Region/County |
# Cases Per Region |
|
Ambulance |
Region 5/ Jasper |
1 |
|
Ambulance |
Region 6/ Harris |
1 |
|
Ambulance |
Region 11/ Hidalgo |
1 |
|
Ambulatory Surgical, Outpatient Service |
Region 3/ Dallas |
1 |
|
CCP Providers |
Region 10/ El Paso |
1 |
|
Chiropractor |
Region 3/ Denton |
1 |
|
Chiropractor |
Region 5/ Jefferson |
1 |
|
Clinic |
Region 3/ Hunt |
1 |
|
Clinic |
Region 5/ Orange |
1 |
|
Clinic |
Region 7/ Bosque |
1 |
|
Clinic |
Region 7/ Brazos |
1 |
|
Clinic |
Region 7/ Brazos |
1 |
|
Clinic |
Region 7/ Llano |
1 |
|
Clinic |
Region 8/ Maverick |
1 |
|
Clinic |
Region 11/ Hidalgo |
1 |
|
Clinic |
Region 11/ Jim Wells |
1 |
|
Clinic |
Region 11/ San Patricio |
1 |
|
Clinic |
Region 11/ Starr |
1 |
|
EPSDT |
Region 8/ Uvalde |
1 |
|
EPSDT Dental Group |
Region 3/ Dallas |
1 |
|
EPSDT Dental Group |
Region 3/ Tarrant |
1 |
|
EPSDT Dental Group |
Region 6/ Harris |
1 |
|
EPSDT Dental Group |
Region 11/ Cameron |
1 |
|
EPSDT Dentist |
Region 4/ Camp |
1 |
|
EPSDT Dentist |
Region 4/ Cherokee |
1 |
|
EPSDT Dentist |
Region 5/ Jefferson |
1 |
|
EPSDT Dentist |
Region 6/ Brazoria |
1 |
|
EPSDT Dentist |
Region 6/ Fort Bend |
1 |
|
EPSDT Dentist |
Region 6/ Harris |
4 |
|
EPSDT Dentist |
Region 8/ Bexar |
6 |
|
EPSDT Dentist |
Region 11/ Hidalgo |
2 |
|
EPSDT Dentist |
Region 11/ Webb |
1 |
|
Federally Qualified Health Centers (FQHC) |
Region 1/ Bailey |
1 |
|
Federally Qualified Health Centers (FQHC) |
Region 6/ Fort Bend |
1 |
|
Federally Qualified Health Centers (FQHC) |
Region 9/ Tom Green |
1 |
|
Hospital |
Region 2/ Jones |
1 |
|
Hospital |
Region 2/Taylor |
1 |
|
Hospital |
Region 3/ Dallas |
1 |
|
Hospital |
Region 6/ Brazoria |
1 |
|
Hospital |
Region 7/ Brazos |
1 |
|
Hospital |
Region 11/ Cameron |
1 |
|
Laboratory |
Florida |
1 |
|
Laboratory |
Region 3/ Denton |
1 |
|
Laboratory |
Region 3/ Dallas |
3 |
|
Laboratory |
Region 5/ Jefferson |
1 |
|
Laboratory |
Region 6/ Harris |
2 |
|
Laboratory |
Region 7/ Travis |
3 |
|
Laboratory |
Region 8/ Bexar |
2 |
|
Licensed Professional Counselor |
Region 8/ Bexar |
1 |
|
Medical Supplier |
Region 11/ Hidalgo |
1 |
|
Orthodontist |
Region 4/ Smith |
1 |
|
Orthodontist |
Region 7/ Hamilton |
1 |
|
Physician |
Oklahoma |
1 |
|
Physician |
Region 1/ Lubbock |
1 |
|
Physician |
Region 1/ Terry |
1 |
|
Physician |
Region 2/ Brown |
1 |
|
Physician |
Region 5/ Taylor |
1 |
|
Physician |
Region 6/ Galveston |
1 |
|
Physician |
Region 6/ Harris |
8 |
|
Physician |
Region 6/ Liberty |
1 |
|
Physician |
Region 7/ McLennan |
1 |
|
Physician |
Region 8/ Uvalde |
1 |
|
Physician |
Region 10/ El Paso |
2 |
|
Physician |
Region 11/ Cameron |
1 |
|
Physician |
Region 11/ Hidalgo |
3 |
|
Physician Group |
Region 1/ Lubbock |
1 |
|
Physician Group |
Region 3/ Dallas |
2 |
|
Physician Group |
Region 3/ Johnson |
1 |
|
Physician Group |
Region 3/ Tarrant |
1 |
|
Physician Group |
Region 6/ Harris |
3 |
|
Physician Group |
Region 8/ Kerr |
1 |
|
Physician Group |
Region 9/ Midland |
1 |
|
Physician Group |
Region 10/ El Paso |
1 |
|
Physician Group |
Region 11/ Cameron |
1 |
|
Physician Group |
Region 11/ Hidalgo |
3 |
|
Total |
111 |
|
|
Long Term Care Program |
Region/County |
# Cases Per Region |
|
Nurse |
Region 8/ Victoria |
1 |
|
Nursing Home |
Region 11/ Refugio |
1 |
|
Nursing Homes |
Region 4/ Hopkins |
1 |
|
Total |
3 |
|
|
Vendor Drug Program |
Region/County |
# Cases Per Region |
|
Pharmacy |
Region 3/ Kaufman |
1 |
|
Pharmacy |
Region 5/ Orange |
1 |
|
Pharmacy |
Region 8/ Bexar |
1 |
|
Total |
3 |
|
October 1999
During the month of October, the Texas Health and Human Services Commission’s Office of Investigations and Enforcement closed 149 investigations on Medicaid fraud and/or abuse cases. Of these cases, 136 were within the Acute Care Program, 7 were within the Long Term Care Program, and 6 are classified as Other Programs. The program areas affected are as follows:
|
Acute Care Program |
Region/County |
# Cases Per Region |
|
CCP Providers |
Region 1/ Lubbock |
1 |
|
CCP Social Worker |
Region 6/ Harris |
1 |
|
Clinic |
Region 9/ Andrews |
1 |
|
Dental Group |
Region 6/ Harris |
2 |
|
Dentist |
Region 6/ Harris |
8 |
|
EPSDT |
Region 5/ Jefferson |
1 |
|
EPSDT Dental Group |
Region 6/ Harris |
9 |
|
EPSDT Dental Group |
Region 11/ Nueces |
1 |
|
EPSDT Dentist |
Region 1/ Potter |
1 |
|
EPSDT Dentist |
Region 2/ Taylor |
2 |
|
EPSDT Dentist |
Region 3/ Dallas |
2 |
|
EPSDT Dentist |
Region 3/ Tarrant |
1 |
|
EPSDT Dentist |
Region 4/ Cherokee |
1 |
|
EPSDT Dentist |
Region 4/ Gregg |
1 |
|
EPSDT Dentist |
Region 6/ Harris |
5 |
|
EPSDT Dentist |
Region 6/ Montgomery |
1 |
|
EPSDT Dentist |
Region 7/ Travis |
1 |
|
EPSDT Dentist |
Region 8/ Bexar |
2 |
|
EPSDT Dentist |
Region 8/ Victoria |
1 |
|
EPSDT Dentist |
Region 9/ Midland |
1 |
|
EPSDT Dentist |
Region 10/ El Paso |
1 |
|
EPSDT Dentist |
Region 11/ Cameron |
1 |
|
EPSDT Dentist |
Region 11/ Nueces |
1 |
|
Home Health Agencies |
Region 1/ Lubbock |
2 |
|
Home Health Agencies |
Region 2/ Jones |
1 |
|
Home Health Agencies |
Region 3/ Dallas |
2 |
|
Home Health Agencies |
Region 5/ Jefferson |
1 |
|
Home Health Agencies |
Region 6/ Harris |
5 |
|
Home Health Agencies |
Region 6/ Montgomery |
1 |
|
Home Health Agencies |
Region 8/ Bexar |
1 |
|
Home Health Agencies |
Region 10/ El Paso |
1 |
|
Home Health Agencies |
Region 11/ Nueces |
2 |
|
Home Health Agencies |
Region 11/ Webb |
1 |
|
Hospital |
Region 3/ Dallas |
1 |
|
Hospital |
Region 3/ Tarrant |
1 |
|
Hospital |
Region 6/ Harris |
1 |
|
Laboratory |
California |
1 |
|
Laboratory |
Region 8/ Bexar |
1 |
|
Licensed Professional Counselor |
Region 6/ Harris |
1 |
|
Medical Supply Company |
Region 6/ Harris |
2 |
|
Medical Supply Company |
Region 11/ Hidalgo |
2 |
|
Optometric Group |
Region 8/ Bexar |
1 |
|
Optometrist |
Region 6/ Harris |
4 |
|
Optometrist |
Region 11/ Nueces |
1 |
|
Orthodontist |
Region 8/ Uvalde |
1 |
|
Physician |
Region 1/ Hutchinson |
1 |
|
Physician |
Region 3/ Dallas |
1 |
|
Physician |
Region 3/ Tarrant |
1 |
|
Physician |
Region 6/ Harris |
31 |
|
Physician |
Region 7/ Brazos |
1 |
|
Physician |
Region 11/ Cameron |
1 |
|
Physician |
Region 11/ Hidalgo |
8 |
|
Physician |
Region 11/ Nueces |
1 |
|
Physician Group |
Region 2/ Wichita |
1 |
|
Physician Group |
Region 3/ Dallas |
4 |
|
Physician Group |
Region 6/ Fort Bend |
1 |
|
Physician Group |
Region 6/ Harris |
1 |
|
Physician Group |
Region 8/ Maverick |
1 |
|
Physician Group |
Region 11/ Hidalgo |
2 |
|
Psychologist PhD |
Region 6/ Harris |
1 |
|
Total |
136 |
|
|
Long Term Care Program |
Region/County |
# Cases Per Region |
|
Nursing Home |
Region 2/ Wichita |
3 |
|
Nursing Home |
Region 3/ Dallas |
1 |
|
Nursing Home |
Region 3/ Tarrant |
2 |
|
Pediatric Nurse Practitioner |
Region 5/ Jefferson |
1 |
|
Total |
7 |
|
|
Other Program |
Region/County |
# Cases Per Region |
|
Individual/Other |
Region 2/ Taylor |
2 |
|
Individual/Other |
Region 4/ Cherokee |
1 |
|
Individual/Other |
Region 6/ Harris |
1 |
|
Individual/Other |
Region 7/ Milam |
1 |
|
Individual/Other |
Region 7/ Travis |
1 |
|
Total |
6 |
|
November 1999
During the month of November the Texas Health and Human Services Commission’s Office of Investigations and Enforcement closed 122 investigations on Medicaid fraud and/or abuse cases. Of these cases, 121 were within the Acute Care Program, and 1 was within the Long Term Care Program. The program areas affected are as follows:
|
Acute Care Program |
Region/County |
# Cases Per Region |
|
Ambulance |
Region 3/ Tarrant |
1 |
|
Ambulance |
Region 5/ Jefferson |
1 |
|
Ambulance |
Region 6/ Harris |
1 |
|
CCP Providers |
Region 4/ Bowie |
1 |
|
Chiropractor |
Region 7/ Milam |
1 |
|
Chiropractor |
Region 11/ Hidalgo |
1 |
|
Chiropractor |
Region 11/ Refugio |
1 |
|
Clinic |
Region 4/ Upshur |
1 |
|
Clinic |
Region 5/ Hardin |
1 |
|
Clinic |
Region 7/ Hill |
1 |
|
Clinic |
Region 8/ Gonzales |
1 |
|
Clinic |
Region 8/ Zavala |
1 |
|
EPSDT Dental Group |
Region 3/ Tarrant |
1 |
|
EPSDT Dental Group |
Region 6/ Fort Bend |
1 |
|
EPSDT Dental Group |
Region 6/ Harris |
2 |
|
EPSDT Dental Group |
Region 8/ Bexar |
2 |
|
EPSDT Dental Group |
Region 11/ Nueces |
1 |
|
EPSDT Dentist |
Region 1/ Lubbock |
1 |
|
EPSDT Dentist |
Region 2/ Eastland |
1 |
|
EPSDT Dentist |
Region 2/ Young |
1 |
|
EPSDT Dentist |
Region 3/ Dallas |
1 |
|
EPSDT Dentist |
Region 4/ Gregg |
1 |
|
EPSDT Dentist |
Region 4/ Titus |
1 |
|
EPSDT Dentist |
Region 4/ Van Zandt |
4 |
|
EPSDT Dentist |
Region 6/ Fort Bend |
1 |
|
EPSDT Dentist |
Region 6/ Harris |
1 |
|
EPSDT Dentist |
Region 7/ Travis |
6 |
|
EPSDT Dentist |
Region 7/ Williamson |
1 |
|
EPSDT Dentist |
Region 8/ Bexar |
1 |
|
EPSDT Dentist |
Region 8/ Calhoun |
1 |
|
EPSDT Dentist |
Region 8/ Victoria |
1 |
|
EPSDT Dentist |
Region 9/ Ector |
2 |
|
EPSDT Dentist |
Region 9/ Midland |
1 |
|
EPSDT Dentist |
Region 11/ Hidalgo |
1 |
|
EPSDT Dentist |
Region 11/ Webb |
1 |
|
EPSDT Dentist |
Region 11/ Willacy |
6 |
|
Federally Qualified Health Centers (FQHC) |
Region 8/ Atacsosa |
1 |
|
Home Health Agencies |
Region 6/ Harris |
1 |
|
Home Health Agencies |
Region 7/ McLennan |
1 |
|
Home Health Agencies |
Region 11/ Hidalgo |
4 |
|
Home Health Agencies |
Region 11/ Nueces |
1 |
|
Hospital |
Region 4/ Bowie |
1 |
|
Hospital |
Region 6/ Harris |
2 |
|
Hospital |
Region 2/ Wichita |
1 |
|
Hospital |
Region 3/ Dallas |
1 |
|
Hospital |
Region 5/ Jefferson |
1 |
|
Hospital |
Region 8/ Bexar |
1 |
|
Hospital |
Region 8/ Victoria |
1 |
|
Laboratory |
Florida |
1 |
|
Laboratory |
Missouri |
1 |
|
Laboratory |
Region 1/ Lubbock |
1 |
|
Laboratory |
Region 5/ Tyler |
1 |
|
Laboratory |
Region 6/ Harris |
1 |
|
Laboratory |
Region 8/ Bexar |
1 |
|
Laboratory |
Region 11/ Nueces |
1 |
|
Medical Supplier |
Florida |
1 |
|
Medical Supplier |
Missouri |
1 |
|
Medical Supplier |
Region 1/ Lubbock |
1 |
|
Medical Supplier |
Region 4/ Lamar |
1 |
|
Medical Supplier |
Region 6/ Brazoria |
1 |
|
Medical Supplier |
Region 7/ McLennan |
1 |
|
Medical Supplier |
Region 7/ Travis |
1 |
|
Medical Supplier |
Region 8/ Bexar |
1 |
|
Medical Supplier |
Region 11/ Webb |
1 |
|
Oral Maxillafacial Surgeon |
Region 8/ Bexar |
1 |
|
Orthodontist |
Region 3/ Tarrant |
1 |
|
Orthodontist |
Region 4/ Bowie |
1 |
|
Physician |
Region 1/ Potter |
1 |
|
Physician |
Region 2/ Wilbarger |
1 |
|
Physician |
Region 3/ Collin |
5 |
|
Physician |
Region 3/ Dallas |
1 |
|
Physician |
Region 3/ Navarro |
1 |
|
Physician |
Region 4/ Anderson |
1 |
|
Physician |
Region 6/ Harris |
4 |
|
Physician |
Region 8/ Bexar |
1 |
|
Physician |
Region 9/ Ector |
1 |
|
Physician |
Region 9/ Tom Green |
2 |
|
Physician |
Region 11/ Cameron |
1 |
|
Physician |
Region 11/ Hidalgo |
1 |
|
Physician |
Region 11/ Nueces |
1 |
|
Physician |
Region 11/ Webb |
1 |
|
Physician Group |
Region 8/ Kerr |
1 |
|
Physician Group |
Region 8/ Maverick |
4 |
|
Physician Group |
Region 10/ El Paso |
1 |
|
Physician Group |
Region 11/ Hidalgo |
1 |
|
Podiatrist |
Region 8/ Bexar |
1 |
|
Podiatrist |
Region 10/ El Paso |
1 |
|
Podiatrist |
Region 11/ Hidalgo |
1 |
|
Podiatry Group |
Region 11/ Cameron |
1 |
|
Tea Provider |
Region 7/ Travis |
1 |
|
Total |
121 |
|
|
Long Term Care Program |
Region/County |
# Cases Per Region |
|
CRNA |
Region 3/ Dallas |
1 |
|
Total |
1 |
|
During the first quarter of Fiscal Year 2000, there were no cases referred to the Medicaid Fraud Control Unit (MFCU), Office of the Attorney General, for potential criminal prosecution.
During the first quarter of Fiscal Year 2000, the Texas Health and Human Services Commission’s Office of Investigations and Enforcement rejected 49 cases for full-scale investigation. The determination of the viability of a full-scale investigation is based on a variety of factors, such as insufficient evidence, when each referral is in the preliminary investigative stage. The breakdown is as follows:
|
Month |
Region/County |
Rejection Reason |
Number Rejected |
|
September 1999 |
Region 11/ Refugio |
Insufficient Evidence |
1 |
|
October 1999 |
Region 5/Jefferson |
Insufficient Evidence |
1 |
|
Region 6/Harris |
Insufficient Evidence |
46 |
|
|
Region 7/ Milam |
Not Within Jurisdiction |
1 |
|
|
Total Rejected |
49 |
||