Message to hospital stakeholders:

Dear Stakeholder,

The Health and Human Services Commission is committed to fostering transparency, responsiveness, and positive provider relationships.  As such, and in response to recent communications with some of our hospital association stakeholders, the Inspector General (IG), with stakeholder input, is updating its DRG review process so that it complies fully with federal coding guidelines. 

During the pendency of the updating process, only hospital utilization reviews for medical necessity and quality will be conducted.  Additionally, the IG will offer an opportunity for hospitals to request a re-review of claims that were the subject of an IG DRG Change Notification letter dated September 1, 2015, or later.

We will disseminate soon more information related to timelines, the process for DRG reviews, and the submission of re-reviews.  In the interim, the IG will continue its efforts to increase opportunities for stakeholders to provide further input and feedback.  We appreciate the efforts of the stakeholder groups that have been working with the IG over the past several months to strengthen our application of federal coding guidelines. We look forward to further collaboration to develop strategies to root out fraud, waste, and abuse in the Texas Medicaid System.

Thank you,

David Griffith, CPA, CIA, CGFM

Deputy Inspector General for Audit

Texas Health and Human Services Commission

Document links

DRG Validation Process Revision Update

Overview of Hospital Utilization Review

Hospital Utilization Review Quarterly Stakeholders Meetings Jan., April, July, and Oct. 2018 

Hospital Utilization Review Quarterly Stakeholders Meeting Oct. 2017

Hospital Utilization Review Quarterly Stakeholders Meetings Jan., April, and July 2017

Stakeholder Meeting Presentation: April 18, 2016

Stakeholder Meeting Presentation: Jan. 22, 2018