“Every day, I worry about the mail. What’s going to come in the mail today?”
PAYMENT HOLD LIMITS
In addition to explicitly stating clerical, technical, and administrative errors do not qualify as fraud, the new law strongly limits OIG’s ability to place payment holds in non-fraud cases and limits OIG probes to 180 days.
Dr. Mims said. “The biggest fear is that the person passing judgment on me is not going to know what they’re doing. They’re not going to have any expertise whatsoever.” Dr. Mims says OIG most likely audited him because he works in a narrow subspecialty in a part of South Texas where Medicaid patients don’t have many other options for his particular services. He says his Medicaid billing volume makes him a statistical outlier, ripe for ensnarement. “If every provider in my specialty … who is in a small group or solo private
practice knew what the Medicaid OIG has the capacity to do to them, they would say, ‘I am going to figure out a way to see fewer and eventually no new Medicaid patients.’ It’s that big of a problem,” he said.
NEW LEADERSHIP, NEW APPROACH Stories of physician problems with OIG’s Medicaid audits have circulated for years. The agency gained a reputation for sometimes taking years to finish a case; using a maligned extrapolation method for determining overpayments that ballooned a physician’s bill well beyond the amount the audit discovered; and placing holds on doctors’ Medicaid payments while an investigation continued. Through it all, doctors who dealt with OIG’s attempts to recoup overpay-
ments often said the agency wasn’t at all transparent about exactly what OIG was investigating and/or its method of calculating overpayments and penal- ties. One such case involved San Antonio pediatric radiologist Milissa Aldridge, MD, whom OIG flagged in 2009 for involvement in 35 percent of her group’s Medicaid billing. After Dr. Aldridge tried and failed to obtain the full story on why she was under scrutiny, OIG sent her a letter with a proposed settlement agreement in which she would pay more than $830,000. (See “Dr. Aldridge’s Nightmare,” July 2009 Texas Medicine, pages 29–34, or visit
www.texmed.org/ AldridgeNightmare.) In 2014, the Texas Sunset Advisory Commission released a scathing report on OIG that found:
• The agency’s fraud prevention and educational efforts were significantly lacking.
• Its issuing of payment holds had “gone beyond the law’s intent for use as an enforcement tool.”
• OIG took an average of more than three years to solve cases. • OIG recouped only $5.5 million of the $1.1 billion in alleged Medicaid over- payments the office identified in 2012 and 2013.
The report says OIG lacked the “structure, guidelines, and measurement of
data” required to improve its investigations. TMA commented on the report following its release, writing to Sen. Jane
Nelson (R-Flower Mound), chair of the commission. In the comment letter, Dr. Holcomb wrote Medicaid regulations should be clear so physicians can focus on patient care, not “administrative hassles, burdensome audits, and fear of fraud and abuse accusations.” Dr. Holcomb also expressed TMA’s belief that the best way to promote com- pliance and prevent improper payments is through education and outreach. “Physicians must be afforded adequate notice of the alleged issues or viola-
tions, calculation of overpayments (including extrapolation methodology), and proposed sanctions or penalties, and the right to offer a meaningful response,” he wrote. More trouble for the agency quickly followed the sunset report. Numerous
30 TEXAS MEDICINE November 2015
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