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Rider 7, Health and Human Services
Commission, ( November 2002
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|
Referral Source |
Received |
|
Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU) |
8 |
| Anonymous |
5 |
| Board of Medical Examiners |
7 |
| Board of Licensed Vocational Nurse Examiners |
75 |
| Board of Nurse Examiners |
29 |
| Citizens Commission on Human Rights |
1 |
| Health and Human Services/Office Inspector General |
15 |
| HHSC-Medicaid Program Integrity-Office of Investigations and Enforcement-Self-Initiated |
7 |
| HHSC-Surveillance, Utilization, Review System |
1 |
| HHSC-Utilization Review Division |
1 |
| National Heritage Insurance Company (NHIC) |
7 |
| Provider |
2 |
| Public |
19 |
| Recipient |
9 |
| State Medicaid Office | 1 |
| Texas Department of Health | 10 |
| Texas Department of Human Services (DHS) | 17 |
| Texas Department of Human Services (DHS) Long Term Care | 4 |
| Texas Department of Human Services (DHS) Office Inspector General | 1 |
| Texas Health STEPS |
2 |
| Office of the Attorney General's Medicaid Fraud Control Unit |
2 |
| Anonymous |
5 |
|
Total Cases Opened in 4th Qtr. 2002 |
234 |
|
Cases Opened and Closed during the 4th Qtr. 2002 |
(85) |
|
Remaining Open Cases in 3rd Qtr 2002 |
96 |
|
Remaining Open Cases in 2nd Qtr 2002 |
94 |
|
Remaining Open Cases in 1st Qtr 2002 |
39 |
|
Remaining Open Cases in FY Qtr 2001 |
219 |
|
*Remaining Open Cases in FY 2000 |
*234 |
|
*Remaining Open Cases in FY 1999 |
*186 |
|
*Remaining Open Cases in FY 1998 |
*127 |
|
*Remaining Open Cases Prior to FY97: |
*93 |
|
Total cases opened: |
1237 |
* Many of these cases are in Sanction status and will not be closed until the Sanction is completed.
STATUS OF OPEN CASES
|
Status Code |
Definition of Status Code |
Total Number |
|
|
1 |
Preliminary Investigation |
114 |
|
|
2 |
Full Scale Investigation |
272 |
|
|
Total |
386 |
||
|
Referred To: |
||
|
R0 |
Office of the Attorney General’s/Medicaid Fraud Control Unit (MFCU) |
150 |
|
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 |
28 |
|
R6 |
State Board of Licensed Vocational Nurses |
2 |
|
R7 |
State Board of Medical Examiners |
19 |
|
R8 |
State Board of Nurse Examiners |
19 |
|
R10 |
Board of Pharmacy |
1 |
|
R12 |
Medicaid Part A & B |
18 |
|
R14 |
Mental Health Mental Retardation (MHMR) |
2 |
|
R17 |
Texas Department of Human Services |
3 |
|
R18 |
Texas Department of Health PLC |
1 |
|
R19 |
Department of Protective and Regulatory |
2 |
|
R20 |
Federal Bureau Investigations (FBI) |
2 |
|
R22 |
Board of Social Worker Examiners |
3 |
|
RN |
HHSC - Research, Analysis & Detection (MFADS) |
1 |
|
RE |
Health and Human Services Office of Inspector General |
8 |
|
RF |
Health Facility Compliance |
3 |
|
RH |
Texas Department of Health/Long Term Care |
6 |
|
RI |
Managed Care |
2 |
|
RQ |
Utilization Review Division |
6 |
|
RR |
NHIC - Claims/Records Review |
6 |
|
RS |
NHIC Education Visit |
18 |
|
RT |
HHS OIG (Recipient Fraud) |
1 |
|
RX |
Third Party Resources |
1 |
|
RZ |
Vendor Drug |
1 |
| Sanctions Imposed: | ||
|
O3 |
Pending Sanctions |
111 |
|
O11 |
Default of Recovery |
13 |
|
S19 |
Pending Appeals |
28 |
|
S4 |
Recoupment |
89 |
|
S1 |
Notice Sent |
27 |
|
S2 |
Vendor Hold |
157 |
|
S23 |
Request for Reinstatement |
6 |
|
S16 |
Pending Exclusion |
131 |
|
Total |
851 |
|
|
Total Number of Open Cases for 4th Qtr FY02 |
1237 |
|
Recoupments for Fiscal Year 2002:
|
Office of Investigation & Enforcement Divisions |
4th
Quarter FY2002 |
|
Medicaid Program Integrity |
$2,750,126 |
| Civil Monetary Penalties | $1,005,072 |
|
Utilization Review – (DRG Hospitals)* |
*$9,743,362 |
|
TEFRA Claims – Children’s Summary |
$0 |
|
TEFRA Claims – Psychiatric Summary |
$0 |
| Case Mix Review (nursing homes) | $1,566,031 |
| Surveillance and Utilization Review Subsystems (SURS) | $182,689 |
|
Compliance Monitoring and Referral (CMR) |
$26,763 |
|
Medicaid Fraud & Abuse Detection System (MFADS) -- |
$654,591 |
|
TOTAL |
$15,928,634 |
Note: Total recoupment dollars reflect all active cases within OIE. Investigations refer only to active, full, fraud and abuse investigations.
* Due to problems incurred during the Compass 21 conversion of the DHS Mainframe and UR hospital application, the quarter sample master lists and worksheets where not produced until February 2002. Therefore the regional staff was unable to complete the number of hospital reviews, which are routinely processed during the second and third quarter months. In addition, weekly processing by the DHS-MIS mainframe has encountered several system errors. As a result monthly reports and recoupment for DRG changes have not occurred since March 2002. Therefore, the monthly recoupment dollars for DRG is less than normal for this time period.
|
Office of Investigation & Enforcement Division |
4th
Quarter FY2002 |
|
Third Party Liability and Recovery |
|
| Recoveries (Provider): | |
| • Other Insurance Credits* | $26,550,000 |
| • Provider Refunds | $950,744 |
| • Texas Automated Recovery System (TARS) | $7,124,410 |
| • Recipient Refunds | $0 |
| • Pharmacy | $3,399,925 |
| Recoveries (Recipient): | |
| • Credit Balance Audit | $2,156,688 |
| • Amnesty Letter | $0 |
| • Tort | $5,216,023 |
| Total | $40,397,790 |
* Other insurance credits are estimated pending the completion of a data repair project.
Recoupments for Fiscal Year 2002:
|
Office of Investigation & Enforcement Division |
4th
Quarter FY2002 |
| Medicaid Audits (cost settlement based on cost reimbursement methodology)* | $3,691,960* |
| Vendor Drug: | |
| • Recoveries | $1,664,424 |
| • Manufacturer Rebates | $84,472,982 |
| Customer Services/Provider Resolutions | $15,183 |
| Total | $89,844,549 |
* Overpayments for Medicaid Audits are reported as net based on Cost Settlements. Managed care payment settlements are excluded from the calculation. Overpayments are calculated based on the difference in total interim payments and cost, less any previous settlements completed during the period.
|
Action |
4th Quarter FY2002 |
| Medicaid Program Integrity: | |
| • Cases Opened | 234 |
| • Cases Closed | 399 |
| • Providers Excluded | 250 |
| Utilization Review: | |
| • Case Mix (Nursing Homes) - Cases Closed | 238 |
| • Case Mix (Nursing Homes) - # of reviews | 4,553 |
| • Hospitals - Cases Closed | *587 |
| • Hospitals - # of ChartReviews | 11,548 |
| Medicaid Fraud & Abuse Detection System: | |
| • # of cases identified | 880 |
|
• 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 |
**$1,380,366 |
* Due to problems incurred during the Compass 21 conversion of the DHS Mainframe and UR hospital application, the quarter sample master lists and worksheets where not produced until February 2002. Therefore the regional staff was unable to complete the number of hospital reviews, which are routinely processed during the second and third quarter months. In addition, weekly processing by the DHS-MIS mainframe has encountered several system errors. As a result monthly reports and recoupment for DRG changes have not occurred since March 2002. Therefore, the monthly recoupment dollars for DRG is less than normal for this time period.
Other Statistics for Fiscal Year 2002:
|
Action |
4th Quarter FY2002 |
|---|---|
| Medicaid Program Integrity | |
| • Cases closed (appeal/complaint cases) | 2,371 |
|
• # of Administrative/Agency Hearings (oral
appeals-offered instead of informal hearing for HHSC UR cases only) |
1 |
| Action | 4th Quarter FY2002 | ||
|---|---|---|---|
| LOCK-IN* | June 02 | July 02 | August 02 |
| • Fee-for-Service (FFS) | 552 | 538 | 556 |
| • STAR | 343 | 326 | 312 |
| • STAR+PLUS | 22 | 37 | 62 |
| TOTAL | 917 | 901 | 930 |
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