Section
8, Article II, House Bill 1, 76th Legislature
Second Quarter -- Fiscal Year 2001
12/01/00 - 02/28/01
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April
2001
Texas Health and Human Services Commission
Office of Investigations and Enforcement (OIE)
OPENED CASES – 12/01/2000 to 02/28/2001
|
Referral
Source
|
Received
|
|
Texas
Commission on Alcohol & Drug Abuse
|
4
|
|
Assistant
US Attorney
|
1
|
|
Office
of the Attorney General’s Medicaid Fraud Control Unit (MFCU)
|
11
|
|
Board
of Dental Examiners
|
1
|
|
Board
of Medical Examiners
|
11
|
|
Board
of Licensed Vocational Nurse Examiners
|
58
|
|
Board
of Nurse Examiners
|
66
|
|
Senate
|
1
|
|
Health
and Human Services/Office Inspector General
|
52
|
|
Measurement
of Fraud Study 2000
|
13
|
|
National
Heritage Insurance Company (NHIC)
|
3
|
|
Pharmacy
Board
|
6
|
|
Surveillance
& Utilization Review System (SURS)
|
3
|
|
|
4
|
|
Texas
Department of Human Services (DHS) Long Term Care
|
1
|
|
Texas
Department of Health
|
1
|
|
Public
|
4
|
|
Provider
|
1
|
|
Opened
Cases in 2nd Qtr. 2001
|
241
|
|
Cases
Opened and Closed during the 2nd Qtr 2001
|
(14)
|
|
Opened
Cases in 1st Qtr 2001
|
71
|
|
Remaining
Open Cases in FY00
|
363
|
|
Remaining
Open Cases in FY99
|
389
|
|
*Remaining
Open Cases in FY98:
|
*225
|
|
*Remaining
Open Cases Prior to FY97:
|
*178
|
|
Total
cases opened:
|
1453
|
*
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
|
493
|
|
2
|
Full
Scale Investigation
|
320
|
|
Total
|
813
|
| |
Referred
To:
|
|
|
R0
|
Office
of the Attorney General’s
Medicaid Fraud Control Unit (MFCU)
|
103
|
|
R1
|
Office
of the Attorney General’s
Tort Litigation Division
|
2
|
|
R1
|
Office
of the Attorney General’s
Elder Law Section
|
3
|
|
RQ
|
Utilization
Review Division
|
3
|
|
R5
|
State
Board of Dental Examiners
|
15
|
|
R7
|
State
Board of Medical Examiners
|
2
|
|
R3
|
State
Board of Certified Nurse Aides
|
1
|
|
RH
|
Texas
Department of Health Long Term Care
|
1
|
|
RS
|
NHIC
Education Visit
|
8
|
|
RR
|
NHIC
– Claims/Records Review
|
3
|
|
RD
|
HHSC-Compliance,
Monitoring & Review (CMR)
|
2
|
|
RF
|
Health
Facility Compliance
|
1
|
|
R12
|
Medicaid
Part A & B
|
2
|
|
O3
|
Pending
Sanctions
|
89
|
|
S19
|
Pending
Appeals
|
1
|
|
Total
|
236
|
| |
Sanctions
Imposed:
|
|
|
S4
|
Recoupment
|
136
|
|
S2
|
Vendor
Hold
|
97
|
|
S23
|
Request
for Reinstatement
|
2
|
|
S8
|
Global
Settlement
|
2
|
|
S16
|
Pending
Exclusion
|
167
|
|
Total
|
404
|
|
Total
Number of Open Cases for 2nd Qtr FY01
|
1453
|
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RECOUPMENT
DOLLARS – 2nd QUARTER FISCAL YEAR 2001
|
Office
of Investigation & Enforcement Area
|
2nd
Qtr FY01 Total
|
|
Compliance
Monitoring and Referral
|
$2,596,567
|
|
Medicaid
Fraud & Abuse Detection System -- Dollars recovered
|
$304,249
|
|
Utilization
Review – Case Mix (Nursing Homes)
|
$2,691,674
|
|
Utilization
Review – DRG (Hospitals)
|
$6,413,153
|
|
Utilization
Review – Tax Equity & Fiscal Responsibility Act (TEFRA)
– Children’s Summary
|
$7,534
|
|
Utilization
Review – Tax Equity & Fiscal Responsibility Act (TEFRA)
– Psychiatric Summary
|
$61,488
|
|
|
$193,720
|
|
Medicaid
Program Integrity
|
$286,177
|
|
Medicaid
Program Integrity – Civil Monetary Penalties
|
$0
|
|
TOTAL
|
$12,554,562
|
Note:
Total recoupment dollars reflect all active cases within OIE.
Investigations refer only to active, full, fraud and abuse
investigations.
OTHER
STATISTICS – 2nd QUARTER FISCAL YEAR 2001
|
Action
|
2nd
Qtr FY01 Total
|
| Medicaid
Program Integrity: |
|
|
241
|
|
|
135
|
|
|
56
|
|
Utilization
Review:
|
|
|
355
|
|
|
5,916
|
|
|
345
|
|
|
9,832
|
|
Medicaid
Fraud & Abuse Detection System
|
|
|
626
|
|
*This
amount represents claims inappropriately paid based on policy
and/or investigations. It does not represent the actual
dollars that may be recoverable.
|
$335,518*
|
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|
