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“I want doctors to know that as we develop this, it is not about catching those small errors and prosecuting them. It’s about correcting small errors before they become high-dollar amounts.”


sophisticated software techniques to pick up on the small error that over time can be a big error. Those same software pro- grams can let you look at certain things that clearly identify overuse and outright fraud, and that’s where you get into the real trouble. I want doctors to know that as we develop this, it is not about catch- ing those small errors and prosecuting them. It’s about correcting small errors before they become high-dollar amounts. But it’s also about watching for outright fraud and abuse.


Texas Medicine: Physicians worry that when an investigation starts, payments stop while everything is sorted out be- hind the scenes, and yet business must carry on. Could this scenario be avoided in the process you just described?


ing. It’s primarily related to rates, but there is a hassle factor involved. To turn that ship around is going to take some time and some money. Mostly it’s going to take spending the money we have wisely. And that would include things like not spending money on things that end up being fraudulent further down the road. We’re making an effort on all fronts. We look at rates to providers of all stripes constantly. Periodically, on a set schedule, we look at and revise those rates as we think is warranted. Again, I want to create a system where excel- lent providers, providers of quality, are able to come into the system, and that incentivizes other doctors to say, “Gosh, I want to be part of the system.”


Texas Medicine: There’s no question there are abuses. But the physicians are concerned the new antifraud rules may make legitimate, unintentional errors a target for prosecution. (See “Guilty Until Proven Innocent,” December 2012 Texas Medicine, pages 16–22.) Are doctors rightly concerned this may be a back- wards approach, a “guilty-until-proven innocent-approach,” and why not spell out the difference between an error, or what is not fraud and what is?


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30 TEXAS MEDICINE January 2013


Dr. Janek: One thing we can do is to look at and monitor payments as they go through the system. Using sophisticated software techniques, if you start to see an outlier, you call it to the doctor’s at- tention early on. If [the physician] can show [auditors] that there’s a legitimate, clinical reason [for the billing pattern] early on, no harm no foul. If [the physi- cian] can’t, it’s better to catch that when it’s a less expensive error to the taxpay- ers than to wait 18 months to two years. So we want to monitor payments as they go along, and it is possible now using


Dr. Janek: The process would be this: If [the OIG finds] a credible allegation of fraud, we have the ability to put a provider payment on hold. That means they would continue to accumulate. You investigate that allegation. And then if we found there’s nothing, we’ll release the money. The important thing for doc- tors is this should not drag out for two months, or three months, while they are waiting for payment. They’ve got cash flow needs to meet to keep their office going. We’re asking for more attorneys in the OIG. I can almost hear the gasps among your readers that [these attor- neys] will have to have something to do and find allegations of fraud and the like. The purpose of these extra employees is to cut that time down. From the time an allegation is made, and a hold is in place, [the OIG’s goal] is that we get this all resolved in a four-week period of time. I want there to be a good, strong dia- logue with TMA and other physicians as we go forward. Help us develop that system that works without forcing you to either quit taking new Medicaid patients or shut down your practice.


Texas Medicine: Your agency recently proposed a 1-percent across-the-board cut in Medicaid and CHIP payments in its 2014–15 budget request. How do you justify that proposal given the low par- ticipation rates we just discussed?


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