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Section I. Medicaid Fee-for-Service (FFS) Study

Overview of the Texas Medicaid Program
Medicaid Fraud and Abuse Detection Activities
Medicaid FFS Study
Medicaid FFS Study Recommendations

Medicaid Fee-for-Service Study Recommendations

Texas Health and Human Services Commission

  1. 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).
  2. 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.
  3. 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

  1. 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.

Fiscal Impact

These recommendations can be implemented within these agency's current appropriations.