Health Information Management

News: Texas HHS reports 'record year' in fraud/waste recovery

CDI Strategies, February 4, 2010

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In January, the Texas Health and Human Services Commission released its fiscal year 2009 annual report. In it, the agency touts a state-wide recovery of more than $300 million—a nearly $70 million recovery jump from fiscal year 2008.
Of that $300 million total, the state OIG recovered $30 million through the efforts of its Utilization Review (UR) unit. In fiscal year 2009, the UR unit conducted on-site and desk reviews of 29,843 hospital claims to identify overpayments to these entities by the Medicaid program. The UR unit identified $22.2 million in overpayments to hospitals, according to the report.
In regard to inpatient hospital claims for fee-for-service Medicaid recipients, the Texas OIG’s UR staff evaluates the claims for services rendered in light of medical necessity, DRG validation, and the quality of care provided, the report states. This action can identify both underpayments and overpayments, the latter of which are then recovered by the state. In the case of the former, the claims are adjusted and the facility is reimbursed for the correct amount.
Generally news of such reviews falls under the purview of a facility’s compliance department. Nevertheless, CDI program leaders need to understand the importance of governmental scrutiny to their documentation improvement roles. The report suggests that healthcare providers who participate in Medicaid and other state-funded programs can expect increased inspections from the OIG in 2010.

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