Federal Reports

The Office of Inspector General (OIG) administers the Medicaid Fraud Control Unit (MFCU or Unit) grant awards, annually recertifies the Units, and oversees the Units' performance in accordance with the requirements of the grant. As part of this oversight, OIG conducts periodic onsite reviews of all Units and prepares public reports based on these reviews. The reviews assess the Units' adherence to the 12 MFCU performance standards and compliance with applicable Federal statutes and regulations.

The Texas Health and Human Services Commission (State agency) did not always calculate supplemental payments made to the University of Texas (UT) health institutions in accordance with Federal and State requirements. Specifically, the supplemental payment calculations included overstated Medicare equivalent fees for claims that included payment modifiers and diagnostic test modifiers, Medicaid services that were performed by ineligible providers, and Medicaid services that did not have Medicare equivalent fees. As a result, the State agency claimed $57.9 million (Federal share) in unallowable supplemental payments made to the UT health institutions for the period May 1, 2004, through September 30, 2007.

A chiropractic clinic based in Michigan (Michigan Chiropractor) did not comply with Medicare billing requirements for 100 chiropractic service line items that we sampled. Specifically, the medical records did not support the medical necessity for 92 of the 100 sampled chiropractic services. On the basis of our sample results, we estimated that at least $339,000 of the $392,000 paid to the Michigan Chiropractor for chiropractic services in 2012 and 2013 was unallowable for Medicare reimbursement. These overpayments occurred because the Michigan Chiropractor did not have adequate policies and procedures to ensure that the medical necessity of chiropractic services billed to Medicare was adequately documented in the medical records.