In fact, Mr. Bowen met with TMA leaders during the legislative session, ad-
dressed members at TexMed 2015 last spring, and also planned to address the Border Health Caucus at the TMA Fall Conference in late September. Sen. Juan “Chuy” Hinojosa’s Senate Bill 207, which took effect Sept. 1, man-
“[Treating errors as fraud] shouldn’t have happened. I’m interested in pursuing actual fraudsters.”
dated the new quarterly reports, but the law does much more to address physi- cians’ concerns with OIG investigations. 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. If OIG needs more time than that to complete its investiga- tion, it must notify the subject of the investigation of the reason why, except in cases in which doing so would jeopardize the investigation. Senator Hinojosa (D-McAllen) says investigators at the “dysfunctional” OIG
were previously focusing on technical mistakes, rather than real fraud. TMA Practice Consulting can help physicians and their staff members take concrete steps to avoid billing and coding problems, including Medicaid billing. (See “Billing and Coding Help From TMA,” opposite page.) “The cases would take, on the average, three years, and some as long as 10
years,” he said. “I don’t know if any health care provider can last three years of an investigation, much less 10 years, with holds being placed on them, without giving them reasons why the hold was placed. [OIG was] coming into their of- fices with gestapo-type tactics. They were rude and pushy and took all the files within a very short, unreasonable time period. So now we have a fresh start.” TMA pushed hard for passage of SB 207 during the 2015 Texas Legislature.
See TMA’s testimony to the House Human Services Committee at tma.tips/Mis takesArentFraud. Mr. Bowen says SB 207 supports the mission of the revamped OIG, and it’s unfortunate that the agency previously treated an unintentional error as fraud. “[Treating errors as fraud] shouldn’t have happened,” he said. “I’m interested in pursuing actual fraudsters.”
WINNING BACK DOCTORS? As positive as Dr. Holcomb is about the changes at OIG, he says he doesn’t think a better audit and investigative approach would lead to a reversal of the state’s Medicaid participation trend. TMA’s biennial Survey of Texas Physicians has shown a sharp decline in Medicaid participation since 2000, when 67 percent of survey participants reported taking all new Medicaid patients. The latest figure is a dismal 37 percent. (See “Physicians Pass on Medicaid,” page 31.) “When [physicians] leave a program like either Medicaid or Medicare, they
almost never go back, no matter what happens,” Dr. Holcomb said. “So once you lose them, we believe that you’ve lost them forever. The real question is, can you stem further loss? In other words, we’re already at [around] a third of the doc- tors seeing Medicaid patients; what would happen if you went down to only 20 percent of the doctors seeing them? “So I think … that the pay structure is a significant problem, and it’s presum-
ably affected by adding more money into the system. If you then throw on top of these low billings the risk of having your money confiscated without due process, it’s just not clear why anybody would want to participate.” Mary Dale Peterson, MD, the chief executive officer of Driscoll Health Plan,
an HMO serving South Texas, says her staff members who work with OIG al- ready have seen the office release a number of payment holds from old cases. Dr. Peterson, who’s a member of the Committee on Medicaid, CHIP and the
Uninsured, says in the past, when Driscoll would refer practitioners to OIG for investigation of possible waste, fraud, or abuse, OIG would take an extended amount of time to complete its probe. That cost Driscoll hundreds of thousands
32 TEXAS MEDICINE November 2015
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