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Report File
Date Issued
Submitting OIG
Department of Health & Human Services OIG
Other Participating OIGs
Department of Health & Human Services OIG
Agencies Reviewed/Investigated
Department of Health & Human Services
Report Number
A-06-16-01001
Report Description

Federal regulations effective July 1, 2011, prohibit Medicaid payments for services related to treating provider-preventable conditions (PPCs). The Centers for Medicare & Medicaid Services delayed its enforcement of the regulations until July 1, 2012, to allow States time to develop and implement new payment policies. This review is part of a series of reviews of States to determine whether the States ensured that their Medicaid managed-care organizations (MCOs) complied with these regulations for inpatient hospital services.

Report Type
Audit
Location

TX
United States

Additional Details
https://oig.hhs.gov/oas/reports/region6/61601001.asp
External Entity
State of Texas

Open Recommendations

This report has 7 open recommendations.
Recommendation Number Significant Recommendation Recommended Questioned Costs Recommended Funds for Better Use Additional Details
267607 No $0 $0

We recommend that the State agency ensure all MCOs implement edits to appropriately reduce or deny claims for other PPCs.

267603 No $0 $0

We recommend that the State agency work with the five MCOs to determine the portion of the $16,734,145 that was unallowable for claims containing PPCs and its impact on current- and future-year capitation payment rates.

267608 No $0 $0

We recommend that the State agency consider enforcing the provision in its contracts that allows liquidated damages to be imposed on the five MCOs due to their failure to process claims in accordance with Federal laws and regulations.

267604 No $0 $0

We recommend that the State agency require all its MCOs to implement policies and procedures to prohibit payments for inpatient hospital services related to treating PPCs for all provider payment methodologies.

267605 No $0 $0

We recommend that the State agency require all its MCOs to review all claims for inpatient hospital services that were paid after our audit period to determine whether any payments for services related to treating PPCs were unallowable and adjust future capitation payment rates for any unallowable payments identified.

267609 No $0 $0

We recommend that the State agency include specific measures in its contracts that would allow the State agency to recoup funds from all MCOs when contract provisions and Federal and State requirements are not met—a measure that, if incorporated, could result in cost savings for Medicaid.

267606 No $0 $0

We recommend that the State agency strengthen its monitoring of all its MCOs to ensure the MCOs comply with Federal and State requirements and its managed-care contracts relating to the nonpayment of PPCs.

Department of Health & Human Services OIG

United States