The OIG conducted an inspection to determine the program integrity activities pharmacy benefit managers (PBM) use to detect fraud, waste, and abuse of Medicaid-funded prescriptions.

The two PBMs selected by OIG rely on three program integrity activities to detect FWA in overbilling, unauthorized refills, and unauthorized drug substitutions in Medicaid-funded prescriptions. The three program integrity activities are: a.) Edit Checks of Submitted Prescription Claims, b.) Daily Prepayment Review of Covered Prescription Claims, and c.) Audit of Paid Prescription Claims.

The results of an OIG audit found that a Texas Medicaid and Children’s Health Insurance Program (CHIP) managed care organization (MCO) incorrectly reported encounter data. Encounter data are detailed records an MCO submits to Texas Health and Human Services (HHS) about services delivered to its managed care members by network providers.

The OIG completed an inspection to determine if documentation requirements are being met when Medicaid clients receive power wheelchairs from DME (durable medical equipment) suppliers. The OIG made the following observations:

Not all power wheelchairs were received as prescribed or used by clients in nursing facilities.

A review of prior authorization and supporting documentation identified incomplete or inadequate information.

The Office of Inspector General recovered nearly $98 million in the second quarter of fiscal year 2019, identified almost $42 million for future recoveries, and achieved $37 million in cost avoidance.

The cost avoidance amount includes funds that were not spent or uses more efficiently. These results are included in the OIG’s Quarterly Report for the second quarter. The report details the office’s efforts in detecting, preventing, and deterring fraud, waste, and abuse in the expenditure of funds in Texas health and human services programs.

The OIG conducted an inspection to determine if managed care organization member complaint intake processes are consistent with the Uniform Managed Care Contract and Uniform Managed Care Manual requirements. The inspection also assessed the validity, accuracy, and reliability of data contained in quarterly MCO member complaint reports.

Among the findings, the OIG Inspections and Investigations Division found that complaint reporting amongst the MCOs differs due to:

An OIG audit of a Texas hospital’s transport program found funds reimbursed in error. The OIG recommended the overpayments be returned to the state.

The audit of Cook Children’s Medical Center Teddy Bear Transport was to determine whether paid Medicaid fee-for-service claims and managed care claims for air ambulance services and their associated ground transports were billed in accordance with state rules and guidelines, and contract requirements.