- 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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- 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.
- 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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- 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.
- 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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