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Rider 7, Health and Human Services Commission,
Senate Bill 1 - 77th Legislature, Regular Session
First Quarter - Fiscal Year 2002
September 1, 2001 - November, 2001

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January  2002
Texas Health and Human Services Commission (HHSC)
Office of Investigations and Enforcement (OIE)


OPENED CASES – 09/01/2001 to 11/30/2001

Referral Source

Received

U.S. Attorney's Office

1

Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU)

11
US Department of Justice

2

Board of Nurse Examiners

21
Pharmacy Board

3
Texas Health and Human Services Commission (HHSC)/Office of Investigations and Enforcement (OIE)/Medicaid Program Integrity/Self Initiated

7

HHSC - Utilization Review Department

3
Health and Human Services/Office Inspector General

75
National Heritage Insurance Company (NHIC)

1
HMO Blue

1
Surveillance & Utilization Review System (SURS)

3
Texas Commission on Alcohol & Drug Abuse

8
Texas Department of Health

5

Texas Department of Human Services (DHS)

2

Texas Department of Human Services (DHS) Long Term Care

5
Public

7
Recipient

2

Total Cases Opened in 1st Qtr. 2002

157

Cases Opened and Closed during the 1st Qtr. 2002

(54)

* Remaining Open Cases in FY Qtr 2001

261

* Remaining Open Cases in FY 2000

* 306

* Remaining Open Cases in FY 1999

* 311

*Remaining Open Cases in FY 1998:

*170

*Remaining Open Cases Prior to FY97:

*138

Total cases opened:

1289

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

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STATUS OF OPEN CASES

Status Code
Definition of Status Code
Total Number

1

Preliminary Investigation

373

2

Full Scale Investigation

397
 

Total

770

 

 

Referred To:

  

R0

Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU)

78

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

21

R6

 State Board of Licensed Vocational Nurses

1

R7

State Board of Medical Examiners

9

R10

 Board of Pharmacy

2

R12

Medicaid Part A & B

5

R19

 Department of Protective and Regulatory

1

RD

Health & Human Services Commission, Office of Investigations & Enforcement/Compliance, Monitoring & Review (CMR)

2

RF

Health Facility Compliance

2

RH

Texas Department of Health/Long Term Care

2

RQ

Health & Human Services Commission, Office of Investigations & Enforcement/Utilization Review Division

4

RR

National Heritage Insurance Company/Claims/Records Review

7

RS

National Heritage Insurance Company/Education Visit

9

O3

Pending Sanctions

99

S19

Pending Appeals

10
  Sanctions Imposed:  

S4

 Recoupment

72

S1

 Notice Sent

5

S2

 Vendor Hold

103

S23

 Request for Reinstatement

2

@16

 Pending Exclusion

79

Total

519

Total Number of Open Cases for 1st Qtr FY02

1289

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RECOUPMENT DOLLARS – 1st QUARTER FISCAL YEAR 2002

Office of Investigation & Enforcement Area

 1st Qtr FY02
Total

Medicaid Program Integrity

 $5,124,723
Civil Monetary Penalties $944,801

Utilization Review – DRG (Hospitals)

 $5,059,154

TEFRA Claims – Children’s Summary

 $2,985

TEFRA Claims – Psychiatric Summary

 $0
Case Mix Review (nursing homes) $2,454,842

Compliance Monitoring and Referral (CMR)

 $2,216,641
(CARTS only)

Medicaid Fraud & Abuse Detection System (MFADS) --
dollars identified

 $578,426

TOTAL

$16,845,661

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

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Recoupments for Fiscal Year 2002:

Office of Investigation & Enforcement Area

 1st Qtr FY02
Total

Third Party Liability and Recovery
     Recoveries (Provider):
  • Provider Refunds
 $951,031
  • Texas Automated Recovery System (TARS)
 $2,646,468
  • Recipient Refunds
 $0
  • Pharmacy
 $452,183
     Recoveries (Recipient):
  • Credit Balance Audit
 $895,316
  • Amnesty Letter
 $45
  • Tort
 $5,158,216*
Total $10,103,259

Note: Above information provided by NHIC

Medicaid Operating Agencies Cost Avoidance/Program Savings For Medicaid Fraud, Abuse, And Waste - FY2002

Office of Investigation and Enforcement Area

 1st Qtr FY02
Total
Medicaid Program Integrity
 *based on total dollars identified
 *does not include civil monetary penalties		 $9,517,033
Utilization Review (DRG-hospitals) $7,088,039
Nursing Home Reviews $2,344,549
Surveillance and Utilization Review Subsystems (SURS) $285,875
Medicaid Fraud and Abuse Detection System (MFADS) $463,531
Compliance Monitoring & Referral $2,311,803
Total $22,010,830

Note: Cost savings for above chart are estimates based on FY2001 performance that will be adjusted in the 4th quarter based on actual recoveries and error rates in FY2002.

Cost Savings for Fiscal Year 2002:

Office of Investigation and Enforcement Area

 1st Qtr FY02
Total
Third Party Liability and Recovery:
  • Cost Avoidance
 $40,782,165
  • Other Insurance Credits
 $20,074,253
Total: $60,856,418