TMA Backs Plan to Revamp Medicaid Fraud Cops

The state's use of freezing payments to physicians suspected of possible Medicaid fraud "has gone beyond the law's intent," according to a 225-page report on the Texas Health and Human Services Commission (HHSC) by the Texas Sunset Advisory Commission. The report describes the HHSC Office of Inspector General (OIG) as an agency with poorly trained staff and little accountability or transparency. 

TMA has long championed improvements in the Medicaid system and in OIG's investigations of physicians accused of fraud, waste, and abuse. In comments submitted to the commission, John Holcomb, MD, chair of the TMA Select Committee on Medicaid, CHIP, and the Uninsured, iterated TMA's support for the commission's recommendations "to improve the efficiency and effectiveness of OIG's administrative and investigative processes" and to "clarify OIG's payment hold authority and streamline the CAF [credible allegation of fraud] hold hearing process."

In the comments, TMA outlines its support for the report's recommendations to: 

  • Have a fair administrative process designed to define, detect, and prevent fraudulent and abusive conduct that wastes taxpayer funds;
  • Improve the efficiency of the investigation process, reserve CAF holds for serious situations to mitigate ongoing financial risk to the state, and streamline the administrative appeal hearing process;
  • Include the expertise of medical practitioners with appropriate training and experience in investigations concerning the practice of medicine;
  • Implement quality assurance reviews and consistency in investigations;
  • Clarify organizational oversight and accountability in an effort to ensure OIG is efficiently and effectively accomplishing its mission to combat fraud, waste, and abuse;
  • Better clarify the roles and responsibilities among and between OIG, managed care organizations, and special investigative units; and
  • Require OIG to pay the full hearing costs for CAF hold appeals at the State Office of Administrative Hearings (SOAH). 

TMA encourages the commission to align the overpayment and appeal hearings process with requiring the agency to pay for SOAH hearings.

The letter stresses TMA's desire for clear Medicaid rules and regulations that would allow physicians who care for this patient population to "dedicate their time, talent, and staff resources to patient care, as opposed to administrative hassles, burdensome audits, and fear of fraud and abuse accusations."

TMA also advocates education and outreach to prevent administrative errors and improper payments. The commission's report discusses the need to "promote compliance and help prevent fraud, waste, abuse, and certainly errors, by educating providers on Medicaid policies and procedures." 

TMA worked with lawmakers in 2013 to craft legislation that improves due process when a physician faces Medicaid fraud or overpayment accusations. The hard work paid off in the passage of Senate Bill 1803, which clarifies the definition of "credible allegation of fraud" and establishes timelines for when OIG must notify doctors of an investigation or can withhold payments in the process. 

Sunset Commission recommendations serve as a starting point for deliberations by the 2015 legislature.

As reported in a previous issue of Action, TMA is also pushing the legislature to "take bold action" to increase "utterly inadequate physician payment rates" in Texas Medicaid and the Children's Health Insurance Program.

Action, Oct. 31, 2014

Last Updated On

January 06, 2020

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Fraud and Abuse | Medicaid | Sunset