December 2, 2014 -- A Texas appeals court has invalidated several rules related to payment holds imposed during Medicaid fraud investigations, saying they violate due process rights.
The Third Court of Appeals invalidated rules that authorized the Texas Office of Inspector General (OIG) to impose payment holds on Medicaid funds when a provider is being investigated for fraud, according to the November 25 ruling. The decision sides with plaintiffs Harlingen Family Dentistry and Trueblood Dental Associates and also reverses a trial court's ruling on the matter.
The Texas Health and Human Services Commission (HHSC) and the OIG have withheld more than $1.5 million in Medicaid payments from Harlingen Family Dentistry, said attorney Jason Ray, who represented Harlingen in the appeals case.
"This couldn't be a bigger win for Harlingen Family Dentistry," Ray told DrBicuspid.com. "Harlingen should receive all of the money that the state has withheld, and the state should stop withholding any money from Harlingen going forward."
“This couldn't be a bigger win for Harlingen Family Dentistry.”
— Jason Ray, attorney representing Harlingen Family Dentistry
On October 30, a state appeals court ordered the state to repay $1.3 million it has been withholding from Harlingen Family Dentistry, which it had accused of Medicaid fraud, continuing a winning streak for accused dentists and orthodontists as officials have settled cases for pennies on the dollar.
"A month ago, the court of appeals said the state had to give back 91% of what had been withheld from Harlingen, and this ruling requires that they have to give back the other 9%," Ray added.
HHSC spokeswoman Linda Edwards Gockel emailed this response to DrBicuspid.com: "We are still reviewing the court decision to determine the next steps."
The latest court ruling is another setback for the antifraud units embroiled in a high-stakes blame game over the responsibility for nearly a billion dollars in alleged abuse in the state's Medicaid dental and orthodontia program.
In August, Texas health officials accepted a $39,211 settlement from Trueblood Dental Associates, an Austin dental practice that had been charged with improperly billing more than $16 million in orthodontic Medicaid claims.
Trueblood was originally charged with Medicaid overpayments over a five-year period, from September 2007 to June 2012. In January 2013, Trueblood was placed on a 100% payment hold.
In August, a federal report laid the responsibility for hundreds of millions of dollars spent on dental and orthodontic procedures that may have been medically unnecessary squarely on HHSC, the agency that oversaw the program.
The OIG has been criticized for collecting only $5.5 million in the last year following a Texas Sunset Commission report that cited hundreds of millions of dollars of Medicaid fraud.
The HHSC is finalizing a $90 million contract for Medicaid fraud detection software with 21CT, an Austin-based federal defense contractor. The company had no experience with Medicaid before 2012, when the company was asked to use its Torch software to analyze a massive amount of data associated with $28.3 billion in Medicaid spending.
The Sunset Commission report found that Torch software had identified only $41 million in Medicaid fraud for 2014, according to the Texas Dentists for Medicaid Reform.
Texas has been rocked by allegations of fraud by dentists and orthodontists accused of bilking the state Medicaid program out of tens of millions of dollars. An OIG investigation found $6 billion in fraud and waste within Medicaid from 2004 to 2011.
Copyright © 2014 DrBicuspid.com
Last Updated hh 12/3/2014 11:26:40 AM
8 comments so far ...
12/2/2014 11:40:35 AM
MWDavisDDS
MWDavisDDS
"The Sunset Commission report found that Torch software had identified only $41 million in Medicaid fraud for 2014, according to the Texas Dentists for Medicaid Reform."
In the interests of full disclosure, Texas Dentists for Medicaid Reform is a group headed by Dr Juan Villarreal, owner of Harlingen Family Dentistry, one of the alleged Medicaid fraudsters.
Secondly, this gives you an idea of just how out-of-control dental Medicaid fraud is in Texas. When the alleged violators claim the number at ONLY $41milliin, one should realize it's a VERY serious problem.
Finally, since dental Medicaid is joinly funded by the state & feds, this cheating takes a bite out of every citizen's wallet, & not just in TX. Every American taxpayer gets hosed.
Michael W Davis, DDS
Santa Fe, NM
In the interests of full disclosure, Texas Dentists for Medicaid Reform is a group headed by Dr Juan Villarreal, owner of Harlingen Family Dentistry, one of the alleged Medicaid fraudsters.
Secondly, this gives you an idea of just how out-of-control dental Medicaid fraud is in Texas. When the alleged violators claim the number at ONLY $41milliin, one should realize it's a VERY serious problem.
Finally, since dental Medicaid is joinly funded by the state & feds, this cheating takes a bite out of every citizen's wallet, & not just in TX. Every American taxpayer gets hosed.
Michael W Davis, DDS
Santa Fe, NM
12/3/2014 12:39:40 PM
DentalLover
DentalLover
I agree with Dr. Davis. Fraud is a crime and any dentist who participates in fraudulent activity deserves to be fined and the practice tagged with a requirement to be removed from the medicaid system and to provide records for a financial audit for a period of at least 5 years. This last penalty would provide a protection to nonmedicaid dental insurance companies that the DDS did not continue in fraudulent billing. The DDS should pay an annual penalty to cover the cost of this audit.
12/3/2014 12:53:03 PM
Dr. Thomas J. Greany
Dr. Thomas J. Greany
It's ironic that a $90 Million contract was awarded to develop "Medicaid Fraud Detection" software, when a viable solution already existed. A Web-based dental claims evaluation and processing system was developed with private funds at a fraction of that cost, and used to manage employer-funded, non-insured dental plans in Colorado for eight years (2005-2012) with great success. Employers saved well over 30% (against a PPO control). Plans provided subscribers and beneficiaries with coverage for any dentoalveolar procedure, while reducing out-of-pocket costs significantly (mainly due to elimination of cost-shifting mechanisms). Dentists could not (and didn't attempt to) abuse the system. Claims were evaluated autonomously using Symbyos's proprietary software, developed in accordance with the American Dental Association's Principles of Ethics in billing. If benefits were not available, none were paid. Pre-determined payment rules established by plan sponsors provided the framework for determining benefits eligibility and claims payment levels. A $90 Million "solution" was not needed, as it already existed. It is a travesty that a contract of that magnitude, funded with additional public dollars was awarded without reasonable due diligence. For more information about Symbyos system, read the 62-page report at http://dentalstudy.toothiq.com/cover/
12/3/2014 4:18:05 PM
AZTooth
AZTooth
More complex solutions are right around the corner. The move to digital with the assistance of EHR funds will ensure all providers supporting Medicaid/Medicare are digital. Once information is digital the amazing power of big data can be applied to that information to very quickly identify suspicious claims and swift action can be taken. Digitization although painful and expensive in the short term will be very beneficial to the taxpayer and the ethical providers.
12/4/2014 10:36:55 AM
eatatjoes
eatatjoes
I've gotta take issue with you AZTooth - the AMAZING powers of big data have yet to be proven - RAND published a study in 2013 stating that the EHR has essentially failed to deliver cost savings or fraud reduction as of yet.
The medical community has had lots to say about the inability of the EHR to do anything besides raise the costs for everyone (except those selling EHR's who have profitted quite nicely). See the link from the AAOS (orthopedic surgeons) on EHR's which include the qote below.
http://www.aaos.org/news/aaosnow/mar13/advocacy1.asp
"Furthermore, EHRs have made it easier to overbill for services. For example, clicking yes-boxes or coding for keywords multiple times—a process called “cloning”—replicates procedures unnecessarily. “Upcoding” the intensity of care or the severity of patients’ conditions boosts charges without improving the quality of care.
According to a 2010 analysis by the Office of the Inspector General, claims for lower reimbursement categories have dropped since 2001, but higher-paid levels of care have increased across all visits—especially for Level 5 emergency department visits. Although these costly trends should, in part, be attributed to EHRs, the administration is calling for stronger Medicaid/Medicare oversight to avoid fraud and false documentation in the future
The medical community has had lots to say about the inability of the EHR to do anything besides raise the costs for everyone (except those selling EHR's who have profitted quite nicely). See the link from the AAOS (orthopedic surgeons) on EHR's which include the qote below.
http://www.aaos.org/news/aaosnow/mar13/advocacy1.asp
"Furthermore, EHRs have made it easier to overbill for services. For example, clicking yes-boxes or coding for keywords multiple times—a process called “cloning”—replicates procedures unnecessarily. “Upcoding” the intensity of care or the severity of patients’ conditions boosts charges without improving the quality of care.
According to a 2010 analysis by the Office of the Inspector General, claims for lower reimbursement categories have dropped since 2001, but higher-paid levels of care have increased across all visits—especially for Level 5 emergency department visits. Although these costly trends should, in part, be attributed to EHRs, the administration is calling for stronger Medicaid/Medicare oversight to avoid fraud and false documentation in the future