October 2003
Office of Investigations and Enforcement (OIE)
Texas Health and Human Services Commission (HHSC)

1. Number of fraud referrals to HHSC and origin of each referral?

During the fourth quarter of the fiscal year 2003, the Texas Health and Human Services Commission's Office of Investigations and Enforcement received a total of 191 referrals of potential Medicaid fraud and/or abuse. The referral sources and number of potential cases breakdowns as follows:

Referral Source	Received
Anonymous	4
Assistant US Attorney	1
Office of the Attorney General’s Medicaid Fraud Control Unit (MFCU)	5
Board of Dental Examiners	5
Board of Licensed Vocational Nurse Examiners	36
Board of Medical Examiners	5
Board of Nurse Examiners	16
Board of Pharmacy	1
Texas Department of Human Services (DHS)	4
Texas Department of Human Services (DHS) Long Term Care	3
Health and Human Services/Office Inspector General	6
Heritage Pharmacy Audit	6
HHSC Medicaid/CHIP Division	1
HHSC-MPI-OIE Self-initiated (MPI)	6
HHSC-Hot-line	1
Mental Health Mental Retardation (MHMR)	1
National Heritage Insurance Company (NHIC)	1
Parent or Guardian	5
Provider	4
Public	7
Recipient	3
Star Plus Managed Care Division	1
Evercare Health Plans	1
Superior Health Plans	1
State Dental Director	2
State Legislator	1
State Medicaid Office	1
Surveillance, Utilization, Review System (SURS)	50
Texas Department of Health	6
Federal Qui Tam	1
Vendor Drug	2
Total Cases Received:	191

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2. Time spent investigating each case?

The Health and Human Services Commission's Office of Investigations and Enforcement closed 156 cases for the fourth quarter in fiscal year 2003. The average amount of staff time spent on each of these investigations was 1,321,25 hours.

3. Number of cases investigated each month, by program and region?

June 2003

During the month of June, the Texas Health and Human Services Commission's Office of Investigations and Enforcement closed 96 investigations on Medicaid fraud and/or abuse cases. Of these cases 42 were within the Acute Care program, 2 were within the Vendor Drug program, 43 were within the Long Term Care program, and 9 were within the Individual/Other program. The program areas affected are as follows:

Acute Care Program	Region	County	# Cases Per Region
Chiropractor	Region 3	Dallas	1
Dental Group	Region 6	Harris	1
Dental Group	Region 7	Brazos	2
Dentist	Region 7	Brazos	1
Home Health DME	Region 7	Hill	1
Home Health DME	Region 8	Bexar	1
Hospital	Region 5	Angelina	1
Hospital	Region 6	Harris	1
Licensed Professional Counselor	Region 6	Harris	1
Orthodontist	Region 7	Travis	1
Physician	Region 1	Lubbock	1
Physician	Region 11	Cameron	1
Physician	Region 11	Hidalgo	2
Physician	Region 11	Jim Wells	1
Physician	Region 11	Nueces	1
Physician	Region 3	Dallas	2
Physician	Region 3	Hunt	1
Physician	Region 3	Kaufman	1
Physician	Region 3	Palo Pinto	1
Physician	Region 4	Gregg	1
Physician	Region 5	Jasper	1
Physician	Region 5	Jefferson	1
Physician	Region 6	Harris	4
Physician	Region 6	Montgomery	1
Physician	Region 7	Bell	1
Physician	Region 7	McLennan	1
Physician	Region 7	Travis	1
Physician	Region 8	Bexar	2
Physician	Region 9	Menard	1
Physician Group	Region 3	Dallas	1
Physician Group	Region 6	Harris	1
Physician Group	Region 8	Bexar	1
Psychologist	Region 6	Harris	1
Psychologist	Region 8	Bexar	1
Rehabilitation Center	Region 8	Bexar	1
Total:			42

 

Vendor Drug Program	Region	County	# Cases Per Region
Pharmacist	Region 6	Harris	1
Pharmacy	Region 6	Harris	1
Total:			2

 

Long Term Care Program	Region	County	# Cases Per Region
Long Term Care Facility	Region 8	Bexar	1
Licensed Vocational Nurse	Ohio	NA	1
Licensed Vocational Nurse	Region 1	Lubbock	1
Licensed Vocational Nurse	Region 1	Swisher	1
Licensed Vocational Nurse	Region 2	Taylor	1
Licensed Vocational Nurse	Region 3	Grayson	1
Licensed Vocational Nurse	Region 4	Lamar	1
Licensed Vocational Nurse	Region 5	Tyler	1
Licensed Vocational Nurse	Region 8	Bexar	1
Licensed Vocational Nurse	Region 8	Victoria	1
Licensed Vocational Nurse	Region 9	Sterling	1
Licensed Vocational Nurse	Region 11	Aransas	1
Licensed Vocational Nurse	Region 11	San Patricio	1
Certified Nurse Aide	Region 9	Pecos	1
Nurse Practitioner	Region 5	Angelina	1
Nurse Practitioner	Region 5	Jefferson	1
Registered Nurse	Arizona	NA	2
Registered Nurse	Florida	NA	2
Registered Nurse	Georgia	NA	1
Registered Nurse	Kansas	NA	1
Registered Nurse	Missouri	NA	2
Registered Nurse	New Jersey	NA	1
Registered Nurse	Tennessee	NA	1
Registered Nurse	Washington	NA	1
Registered Nurse	Region 3	Collin	1
Registered Nurse	Region 3	Dallas	3
Registered Nurse	Region 3	Rockwall	1
Registered Nurse	Region 4	Lamar	1
Registered Nurse	Region 5	Hardin	1
Registered Nurse	Region 6	Harris	2
Registered Nurse	Region 6	Montgomery	1
Registered Nurse	Region 7	Travis	1
Registered Nurse	Region 8	Dallas	1
Registered Nurse	Region 8	Victoria	1
Registered Nurse	Region 9	Dawson	1
Registered Nurse	Region 11	Nueces	2
Total:			43

 

Individual/Other Program	Region	County	# Cases Per County
Individual/Other	Florida	NA	1
Individual/Other	New Jersey	NA	1
Individual/Other	Region 3	Dallas	1
Individual/Other	Region 6	Austin	2
Individual/Other	Region 6	Harris	2
Individual/Other	Region 7	Travis	1
Individual/Other	Region 11	San Patricio	1
Total:			9

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July 2003

During the month of July, the Texas Health and Human Services Commission's Office of Investigations and Enforcement closed 17 investigations on Medicaid fraud and/or abuse cases. Of these cases 15 were within the Acute Care program, 1 was within the Long Term Care program, and 1 was within the Individual/Other program. The program areas affected are as follows:

Acute Care Program	Region	County	# Cases Per Region
Chiropractor	Region 3	Rockwall	1
Home Health DME	Region 2	Wichita	1
Licensed Professional Counselor	Region 5	Angelina	1
Physician	Region 3	Dallas	1
Physician	Region 4	Hopkins	1
Physician	Region 5	Jefferson	1
Physician	Region 5	Orange	1
Physician	Region 6	Harris	1
Physician	Region 7	Brazos	1
Physician	Region 11	Hidalgo	4
Physician	Region 11	Webb	2
Total:			15

 

Long Term Care Program	Region	County	# Cases Per Region
Nurse Practitioner	Region 4	Cherokee	1
Total:			1

 

Other Program	Region	County	# Cases Per County
Individual/Other	Region 3	Ellis	1
Total:			1

 

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August 2003

During the month of July the Texas Health and Human Services Commission's Office of Investigations and Enforcement closed 43 investigations on Medicaid fraud and/or abuse cases. Of these cases, 29 were within the Acute Care program, 10 were within the Long Term Care program, and 4 were within the Individual/Other program. The program areas affected are as follows:

Acute Care Program	Region	County	# Cases Per Region
Ambulance Services	Region 4	Smith	1
Ambulance Services	Region 8	Bexar	1
Case Management	Region 3	Tarrant	1
Chiropractor	Region 2	Brown	1
Dentist	Region 1	Lubbock	1
Dentist	Region 4	Camp	2
Dentist	Region 61	Harris	1
Dentist	Region 81	Atascosa	1
Home Health Agency	Region 3	Tarrant	1
Home Health Agency	Region 7	Bell	2
Optometrist	Region 6	Harris	1
Personal Care Provider	Region 1	Potter	1
Physician	Region 1	Lubbock	1
Physician	Region 2	Taylor	1
Physician	Region 6	Harris	3
Physician	Region 2	Bexar	2
Physician	Region 2	Maverick	1
Physician	Region 10	El Paso	1
Physician	Region 11	Hidalgo	3
Physician Group	Region 7	Travis	1
Physician Group	Region 9	Tom Green	1
Radiation Treatment Center	Region 7	Travis	1
Total:			29

 

Long Term Care Program	Region	County	# Cases Per County
Long Term Care Facility	Region 1	Lamb	1
Long Term Care Facility	Region 8	Bexar	1
Certified Nurse Aide	Region 8	Bexar	1
Registered Nurse	Region 2	Nolan	1
Registered Nurse	Region 6	Harris	2
Registered Nurse	Region 6	Waller	1
Registered Nurse	Region 8	Kerr	1
Licensed Vocational Nurse	Region 6	Dallas	1
Licensed Vocational Nurse	Region 7	McLennan	1
Total:			10

 

Other Program	Region	County	# Cases Per County
Individual/Other	Region 6	Harris	2
Individual/Other	Region 7	Bell	1
Individual/Other	Region 8	Wilson	1
Total:			4

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4. Dollar value of each fraud case that results in a criminal conviction.

During the fourth quarter of fiscal year 2003, there were no fraud cases that resulted in a criminal conviction. There were 65 cases referred to the Medicaid Fraud Control Unit (MFCU), Office of the Attorney General, for potential criminal prosecution. At this time, there is no projected dollar value.

5. Number of cases the office rejected and reason for rejection by region?

During the fourth quarter of fiscal year 2003, the Texas Health and Human Services Commission's Office of Investigations and Enforcement rejected 15 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.

Month	Number Rejected	Region	County	Rejection Reason
June 2003	1	Region 8	Bexar	Insufficient Evidence
	1	Region 3	Dallas	Not Within Jurisdiction
	2	Region 6	Austin	Not Within Jurisdiction
	1	Region 6	Harris	Not Within Jurisdiction
	1	Region 7	Travis	Not Within Jurisdiction
August 2003	1	Region 1	Lubbock	Insufficient Evidence
	1	Region 4	Smith	Insufficient Evidence
	2	Region 6	Harris	Insufficient Evidence
	1	Region 7	Bell	Insufficient Evidence
	1	Region 2	Taylor	Not Cost Effective
	1	Region 6	Harris	Not Cost Effective
	1	Region 11	Hidalgo	Not Cost Effective
	1	Region 9	Tom Green	Not Within Jurisdiction
Total:	27

 

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