Section I. Medicaid Fee-for-Service (FFS) Study
Medicaid Fee-for-Service Study Recommendations
Texas Health and Human Services Commission
- The Office of Inspector General should continue including the following items in its Medicaid Fraud and Abuse Detection System (MFADS) model:
- queries of professional health care providers billing potential overpayments in the following ways:
- physician providers billing for complex office visits to maximize reimbursement (potential estimated annual recoupments = $18.6 million); and
- dental providers billing for full debridement procedures on a consistent basis (potential estimated annual recoupments = $409,141).
- HHSC should continue to pursue efforts to prevent providers from billing for services they did not provide. HHSC is testing smart card technology to deter this type of abuse.
- HHSC should follow-up with Texas Medicaid Healthcare Partnership to correct system processing areas that result in potential overpayments with:
- procedures with diagnosis-specific requirements, such as an eye exam billed without the required diagnosis of aphakia or eye injury for a Medicaid/Medicare client; and
- additional laboratory blood test procedure codes that should be included in the obstetric panel.
Texas Comptroller of Public Accounts
- The Comptroller's office should evaluate the feasibility of performing parallel state and federal measurement studies on the Medicaid fee-for-service program to conserve state funds.
These recommendations can be implemented within these agency's current appropriations.