The Investigations Division protects the integrity of the Texas Medicaid and other health and human services programs through investigations of provider and recipient fraud, waste, and abuse. It also analyzes trends and patterns of behavior and billing and refers cases for sanctions or prosecution to appropriate state or federal regulatory and law enforcement authorities.
Additionally, the Investigations Division conducts personnel investigations at the State Supported Living Centers as well as within the HHSC system.
The Investigations Division has five separate directorates: Medicaid Provider Integrity; Intake Resolution; Law Enforcement; General Investigations; and Internal Affairs.
Medicaid Provider Integrity
MPI investigates allegations of fraud, waste, and abuse committed by Medicaid providers. Some referrals come through the IG Fraud Hotline or complaints from the Inspector General’s online Waste, Abuse and Fraud Electronic Referral System. Referrals are also received from the 23 managed care organizations (MCOs) throughout the state.
The directorate receives investigative leads through data analytics of Medicaid billing, evidence acquired through contacts with Medicaid recipients, and through liaison within the Medicaid provider community. MPI makes referrals to the Attorney General's Medicaid Fraud Control Unit (AG-MFCU) when there are indicators of criminal Medicaid fraud. MPI and AG-MFCU work together on joint investigations by sharing resources and information that will lead to successful administrative or criminal prosecution.
Intake Resolution consists of the former Research Analysis and Detection unit and the former MPI Preliminary Intake unit.
The Research Analysis and Detection unit identifies inappropriate Medicaid payments. The unit conducts a variety of research activities designed to identify potential fraud, waste, and abuse within the Medicaid program. They are responsible for the Centers for Medicare and Medicaid Services' Surveillance Utilization Review requirements. They monitor various sources of information such as Medicare Alerts, Medicaid Integrity Institute newsletters, as well as the U.S. Health and Human Services Office of Inspector General reports and audits to identify patterns of potential aberrant billing. The information is used to comparatively analyze Texas Medicaid claims and encounter billing data to ensure compliance.
The Intake Unit handles complaint intake and resolution activities. It improves processes, resolves older cases, addresses backlogs, and implements legislative mandates. The unit also meets with internal and external stakeholders to refine referral criteria requirements and improve communication.
Law Enforcement consists of both commissioned and non-commissioned investigators who conduct criminal investigations surrounding violations involving State Supported Living Centers and State Hospitals, Electronic Benefits Transfers, and Medicaid fraud. The three units comprising this directorate are the State Centers Investigative Team; the Electronic Benefit Transfer Trafficking Unit; and the Medicaid Law Enforcement Unit.
GI conducts investigations of state publicly funded health and human services recipients. Specifically, it pursues allegations of overpayments made to recipients in the Supplemental Nutrition Assistance Program; Temporary Assistance for Needy Families; Medicaid; Children’s Health Insurance Program; and the Women, Infants, and Children program.
Referrals to GI come from data analysis performed by GI staff, referrals from the Office of Eligibility Services, other HHSC entities, and the general public. Referrals come either through calls to the Fraud Hotline or online complaints to our website. Any dollars identified for recovery are referred for collection to HHSC’s Fiscal Division through the Accounts Receivable Tracking System. Additionally, GI conducts criminal investigations of the above recipients, which are referred to district attorneys throughout Texas for criminal prosecution.
IA conducts investigations of fraud, waste, abuse, employee misconduct, and contract fraud within the HHSC system. Referrals come from multiple sources including the Hotline, online referrals, and other developed sources.
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