According to OIG Audit, Texas HHS Claimed $30.3 Million in Fraudulent Charges in 2011

The Texas Department of Health and Human Services is in hot water after a new report released by the Office of the Inspector General. According to the OIG, the Texas HHS racked up at least $30.3 million in fraudulent charges during the 2011 fiscal year.

The money was claimed from Federal Medicaid reimbursement for nonemergency medical transportation services, also known as NEMT. Every state is required by Federal Regulation to make sure that Medicaid beneficiaries have access to transportation to and from medical providers. In this model, transportation expenses are defined as the costs the state considers necessary to transport beneficiaries to medical examinations and treatment.

The Texas HHS claimed total payments of $135.6 million to NEMT providers in the 2011 fiscal year. Prior audits had already discovered that the NEMT servicers hired didn’t always meet federal and state requirements, so the OIG conducted an additional investigation.

From a stratified random sample of 90 claims (all of which were for contractor-based demand-response services) the OIG was able to determine that 70 claims included services that didn’t comply with regulations, and 23 had multiple deficiencies.

An alarming 51 claims were for vehicles that couldn’t be verified as complying with state regulations or couldn’t be identified by vehicle type at all. In 19 claims, a child or children were transported in the absence of a parent or legal guardian, which is even more concerning when providers were unable to verify criminal history background checks, drug testing and driver history for 18 claims.

The state has since disputed the claims of unaccompanied minors but has no documentation to disprove the charges. They’re claiming that Texas law during the audit period permitted authorized adults to accompany a child, but the OIG maintains that this claim is not accurate.

Penalties for Medicaid fraud can be severe and often result in OIG exclusion. Health care providers are required to check individuals and entities for OIG exclusion if they bill Medicare or Medicaid, and they’re required to notify the OIG if they employ or contract such an individual. At that point the OIG can cut off payment for services rendered by that individual.

At the moment, the OIG is recommending that the state refund the amount that was overpaid for fraudulent or non-compliant NEMT claims in 2011. They also advised the state to revise policies and procedures concerning NEMT contractors.

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