The Office of Inspector General (OIG) has more than 700 employees working in various disciplines, including investigators, auditors, nurses, statisticians, actuaries, attorneys, peace officers, and medical and dental experts. Here is how we are organized to focus those employees on the detection, prevention, and pursuit of fraud, waste, and abuse in the Texas health and human services system.
OIG Functions and Divisions
The OIG is led by the Inspector General, and is comprised of five divisions, each led by a deputy inspector general: Chief Counsel, Compliance, Enforcement, Internal Affairs, and Operations. In addition, the OIG employs a medical director and dental director to provide subject matter expertise and consultation on OIG cases.
Chief Counsel Division
The Chief Counsel Division, led by the Chief Counsel, is comprised of two sections, Legal and Sanctions.
Legal provides OIG with general support and advice on legal matters in OIG's everyday operations and its responsibilities and interaction with health and human services programs. In addition, Legal advises OIG on policies, procedures, and practices.
Sanctions imposes a variety of administrative sanctions on Medicaid providers and other recipients of funds from Health and Human Services agencies. Sanctions has the authority to levy penalties, suspend payments to providers, restrict a provider’s reimbursement, exclude or terminate providers from participation in the Medicaid program, cancel a provider’s contract with Medicaid, and establish an overpayment.
Sanctions specialists handle cases referred from the Office of the Attorney General Medicaid Fraud Control Unit and requests to exclude providers from the Medicaid program. Sanctions has a Pre-trial Team that takes initial action on cases referred from Compliance and Enforcement. In the event that the matter cannot be resolved, the Pre-trial Team transfers the case to the Trial Team. The Trial Team represents OIG in contested case proceedings before HHSC Hearing Appeals or the State Office of Administrative Hearings. Once an overpayment or penalty has been established, the Sanctions personnel in Collections monitor payments of amounts owed.
The Compliance Division is led by the Deputy Inspector General of Compliance. Staff conducts audits and reviews providers, vendors, and contractors, to ensure compliance with all state and federal laws, rules, regulations, and guidelines related to payment for reimbursable services. This division also facilitates, through HHS System agencies, HHS contractors, or OIG Sanctions, the collection of overpayments identified by OIG’s Utilization Review unit, Audit Division, and Women, Infants, and Children Vendor Monitoring. In addition, the Compliance Division educates providers, vendors, and contractors on how to submit accurate information for reimbursable services, and refers cases of suspected fraud, waste, and abuse by providers, vendors, and contractors for investigation to the Office of Attorney General or OIG's Enforcement Division. The Compliance Division has two sections: Audit and Quality Review.
The Audit section is comprised of five business units: the Contract Audit Unit; the Hospital Audit Unit; the Managed Care Organization (MCO) Audit Unit; the Cost Report Review Unit; and Sub-Recipient Financial Review Unit.
o The Contract Audit Unit conducts audits of intermediate care facilities to ensure the proper management of residents’ trust funds, audits prescription drug claims made through the Medicaid Vendor Drug program, and audits high-risk contractors within the HHS System.
o The Hospital Audit Unit audits hospital cost reports to ensure that all outpatient hospital costs charged to Medicaid are reasonable, necessary, and allowable.
o The MCO Audit Unit conducts audits of MCO plans from a financial, operational, contractual, and medical perspective. The unit reviews MCOs for financial, operational, and medical compliance. Nurses audit MCO medical claims to ensure medical necessity of treatment and help prevent patient harm by identifying areas of non-compliance. These audits provide the MCO with information to ensure the timely and accurate implementation of policies, procedures, and processes to prevent patient harm.
o The Cost Report Review unit conducts audits and desk reviews (non-audit services) to ensure that certain Medicaid funded facilities are accurately reporting their service costs. These include long-term care facilities, intermediate care facilities for persons with mental illness, community care services for the aged and disabled, 24-hour child care facilities, and other state and federally funded programs. The HHSC Rate Analysis Division uses these cost reports, which show the actual cost of services provided, to determine reimbursement rates for long-term care and other facilities.
o The Sub-Recipient Financial Review unit conducts desk reviews of single audit reports, and audits of providers who contract for services with HHSC.
o Also housed within the Audit Section are the Quality Assurance Team (QA) and the Information Technology Audit Team (IT). The QA ensures that Audit section personnel adhere to professional standards, including continuing professional education, as well as legal and regulatory requirements, and also ensures that an external entity performs a required peer review of the Audit section at least once every three years. The IT conducts information technology audits of contractors and participates on operational and compliance audits, creating an integrated audit team capable of auditing through existing technology, instead of around it.
· Quality Review
The Quality Review section of the Compliance Division is comprised of three business units: the Lock-In Program; Utilization Review; and Women, Infants, and Children (WIC) Vendor Monitoring.
o The Lock-In Program works to prevent the inappropriate use of medical services, including primary care physicians and pharmacies, in the Medicaid program. The unit limits certain Medicaid recipients to designated primary care providers or pharmacies, which occurs when evidence indicates recipients have received duplicative, excessive, contraindicated, or conflicting health care services or prescription drugs.
o The Utilization Review Unit conducts nursing facility and hospital utilization reviews that verify the correct reimbursement of services provided. These reviews validate whether the facility has correctly assessed and documented the resident’s care needs in order to receive the proper reimbursement. This unit also reviews the medical necessity of the patient to reside in a nursing facility or be admitted as an inpatient to a hospital. This unit also has a quality review unit that reviews patient care issues and refers concerns to HHSC’s Office of the Medical Director, who might subsequently refer to regulatory entities. The QR refers its findings to the Department of Aging and Disability Services to recoup nursing facility overpayments and adjust underpayments, and refers hospital recoveries to TMHP (Texas Medicaid Healthcare Partnership). The Sanctions Division of OIG handles the medical necessity recoveries.
o The WIC Vendor Monitoring unit monitors providers of nutritional items, including grocery stores and farmers markets, to ensure they are in compliance with state and federal law, administrative rules, and the WIC Vendor Agreement. The unit performs these services by conducting provider inspections, covert compliance buys, and conducting inventory audits. The WIC Vendor Monitoring unit may refer suspected fraud to the United States Department of Agriculture, Office of Inspector General.
The Enforcement Division, led by the Deputy Inspector General of Enforcement, is comprised of the Medicaid Provider Integrity (MPI) Section, the General Investigations (GI) section, and the Data Analytics and Fraud Detection unit (also called the Intelligence Unit).
· Medicaid Provider Integrity
The MPI section investigates allegations of fraud, waste, and abuse against Medicaid providers. If MPI determines that criminal conduct may have occurred, OIG refers the case to the Office of the Attorney General’s Medicaid Fraud Control Unit for further criminal investigation. MPI investigators may conduct law enforcement investigations in coordination with the Office of Attorney General. MPI may refer any allegation to the provider’s licensing board for administrative action, to the federal Medicare program, or to other regulatory or law enforcement entities. MPI also has the authority to conduct its own investigations and refer its findings to the OIG Sanctions section or other appropriate enforcement or prosecution authorities. MPI also monitors the activities of Special Investigative Units (SIUs) used by managed care entities. MPI receives regular reports from these SIUs of fraud in managed care settings and has the authority to take any investigation from the SIUs in order to conduct a state investigation – particularly useful when investigating providers who belong to multiple managed care networks. MPI also reviews the managed care companies themselves.
· General Investigations
The GI section investigates recipients and retailers who participate in the Supplemental Nutrition Assistance Program (SNAP). Specifically, GI investigates allegations of overpayments made to recipients in the SNAP, Temporary Assistance for Needy Families (TANF), Medicaid, Children’s Health Insurance Program (CHIP), and the Women, Infants, and Children (WIC) programs. Referrals to GI primarily originate from data match clearances performed by GI staff, referrals from the Office of Eligibility Services, and from the general public, either through calls to the OIG Fraud Hotline or online complaints from OIG’s website. The GI section also investigates individuals suspected of the unauthorized possession or use of an Electronic Benefit Transfer (EBT) card. In many instances GI works these cases jointly with local, state or federal law enforcement agencies.
· Data Analytics and Fraud Detection
The Data Analytics and Fraud Detection unit uses highly advanced technology that allows OIG to detect hidden relationships in cyber, intelligence, and financial transactions with the goal of identifying fraud and other aberrant practices.
Internal Affairs Division
Led by the Deputy Inspector General of Internal Affairs, the Internal Affairs Division works to ensure the accountability of health and human services resources, programs, employees, and contractors by identifying misconduct, violations of the law and serious violations of policy. The Internal Affairs Division is comprised of five functional units: the Vital Statistics Investigations unit, the Special Investigative Response Team, the Program Investigations unit, the Forensic Research and Analysis unit, and the State Supported Living Center and State Hospital Investigations unit. Incidents substantiated by the Internal Affairs Division may result in disciplinary action, termination, counseling, or criminal prosecution.
· Vital Statistics Investigations
This unit has two primary responsibilities, administrative and investigative. The administrative duties include conducting identity theft prevention programs (cross matching), working with the Texas Department of Public Safety in the Missing and Exploited Children Program, providing verification and validation of identity inquiries by law enforcement agencies, tracking and flagging abused and misused vital records, and assisting with document preparation for administrative hearings on questioned vital records. Investigative duties involve the use or misuse of Texas vital records including birth and death certificates, marriage licenses, divorce decrees and paternity submissions.
· Program Investigations Unit / Special Investigative Response Team
Conducts fair, impartial, independent, fact-based investigations of administrative and criminal allegations of fraud, waste, abuse, employee misconduct, vital statistics fraud, and misconduct by vendors, contractors, and subcontractors associated with the Texas Health and Human Services system. These investigators will form Special Investigative Response Teams when needed. Types of investigations include allegations of violations of HHS policies and/or procedures, contract fraud, thefts, forgeries, child deaths and altering government documents.
· Forensic Research and Analysis Unit
The Forensic Research and Analysis Unit provides Internal Affairs investigators and other authorized personnel with independent computer forensic examinations, technical support, and research on electronic devices and peripherals associated with allegations of fraud, waste, abuse and misconduct by employees, contractors, subcontractors, clients, and/or vendors associated with the Texas Health and Human Services system.
· State Supported Living Center / State Hospital Investigations
These units conduct investigations and assist state or local law enforcement agencies in the investigation of alleged criminal activities involving a resident or client of a State Supported Living Center and/or State Hospital.
Led by the Deputy Inspector General of Operations, the Operations Division is comprised of four sections: Business Operations; Technology Analysis, Development, and Support; the Center for Policy and Outreach; and the Managed Care Unit.
· Business Operations
Business Operations directs the administrative, resource, budget, financial management, and quality assurance and decision support functions. It consists of two business units: Administrative Services and Quality Assurance and Decision Support. The Administrative Services unit handles functions such as human resources, contracts, purchasing, administration, and facilities support. The Quality Assurance and Decision Support unit assists OIG’s Enforcement and Compliance divisions with determining statistically valid samples for investigations and audits, performs essential budget and data analysis, and maintains the OIG Performance Measures Report System (PDC), which allows OIG management and staff to assess agency performance.
· Technology Analysis, Development and Support
The Technology Analysis, Development and Support (TADS) section directs and monitors the development, implementation, and coordination of OIG’s information technology systems and conducts and monitors a variety of utilization review activities and tools. TADS consists of three business units: Business Analysis and Support Services (BASS); Research, Analysis and Detection (RAD); and Third Party Liability (TPL). BASS supports OIG’s automation and information technology processes, and maintains OIG's external and internal portals. RAD monitors the utilization of Acute Care Fee for Service billing and Managed Care (encounter data) Medicaid services. In addition to helping OIG address quality-of-care issues, RAD also identifies and initiates recovery of inappropriate Medicaid payments. The RAD unit also oversees the Surveillance and Utilization Review Subsystems (SURS), a federally required utilization review function, as well as oversees the Medicaid Fraud and Detection System, a computer system that detects, identifies, and analyzes provider billing patterns. The system consists of a robust case management system, a data warehouse and detection tools designed to assist the end users in identifying and monitoring potential fraud, waste and abuse. The RAD unit is also responsible for the Voluntary Repayment Program (VRP) that assists clients who choose to repay the state for any Medicaid services previously received. TPL helps to ensure that all responsible parties pay their share of recipients’ expenses by redirecting claims to the liable third party, resulting in cost avoidance, or by pursuing a liable third party for claims previously paid by the Medicaid program, which results in cost recovery. This unit ensures that the state’s Medicaid program is the payer of last resort, and avoids costs it otherwise would pay.
· Center for Policy and Outreach
The Center for Policy and Outreach includes the Provider Integrity Research unit, the Fraud, Waste and Abuse Hotline, the Policy and Communications unit, and External Relations. The Program Integrity Research unit performs background checks on providers enrolling or re-enrolling in the Medicaid program. The Fraud, Waste, and Abuse Hotline receives allegations of fraud, waste, and abuse from the public. The Policy and Communications Unit conducts Medicaid policy analyses and develops policy recommendations, develops policies, procedures, and manuals for OIG, develops interoffice communication materials, and provides training services for OIG staff and managers, as well as providers. External Relations handles external communications, legislative analysis, legislative inquiries, media inquiries, and open records requests.
· Managed Care
The Managed Care Unit (MCU) works with Medicaid managed care stakeholders, including HHSC's Medicaid/CHIP Division (MCD) program, policy, analytics, and contract oversight staff; managed care organization special investigative units; and other OIG areas to evaluate and identify risks to OIG's overall operational success. The MCU makes recommendations to HHSC's MCD for revisions to the Uniform Managed Care Contract, Uniform Managed Care Manual, and encounter and claims-related systems that may impact OIG's efforts to prevent, detect, and investigate potential fraud, waste, or abuse. The MCU also provides specialized assistance to other OIG units in matters of data and workflow analysis, research, reviews, audits, investigations, and cross-functional special projects relating to Medicaid managed care program integrity.