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Medicare Audits in Houston, TX

In this new feature, we focus on particular Medicare audits and appeals information for various ZPIC audit and RAC audit hotspots around the country. Check back in for information about Medicare audits and appeals in your city.

Medicare Audits in Houston, TX

At-a-Glance Information:

Houston Population: 2,145,146 (2011 Census)
Medicare Administrative Contractor (MAC) (Parts A/B): Novitas Solutions LLC (a/k/a Highmark)
DME MAC (Region C): CIGNA Government Services Administrators LLC
Zone Program Integrity Contractor (ZPIC): Health Integrity LLC
Recovery Audit Contractor (RAC):  Connolly Consulting Associates, Inc.
Medicaid Contractors: Affiliated Computer Services (ACS) provides Medicaid claims processing services; Health Management Systems, Inc.  (HMS) provides Medicaid Recovery Audit Contractor services
State Healthcare Investigative Service: Texas Health and Human Services Commission

Medicare Audits and Enforcement in Houston, TX

Medicare audits in Houston, Tx

Houston, TX Skyline (courtesy Hequals2henry)

Houston, TX has been known to be a hotbed of Medicare fraud, waste, and abuse. The Office of Inspector General (OIG), the Department of Justice (DOJ), and their joint HEAT teams have been very active in Houston since the inception of the HEAT teams around 2009-2010. Recently, 9 residents of the Houston area were charged in a $16.4 million Medicare fraud scheme, when Federal HEAT teams swarmed throughout the country making nearly 100 arrests in one day. Moreover, OIG and the state’s HHSC-OIG have been very active in both Medicare and Medicaid reviews over the past few years.

While Houston has been a prime target for criminal healthcare fraud enforcement, both Medicaid and Medicare overpayment audits in Houston, TX have also been pronounced. Originally, TriCenturion served as the Program Safeguard Contractor (PSC) for the Houston area, performing audits and other program integrity functions. When the Centers for Medicare & Medicaid Services (CMS) switched to the ZPIC program, the new ZPIC contract for Houston, Texas and several surrounding states was awarded to Health Integrity. As the ZPIC, Health Integrity has been extraordinarily aggressive in auditing Houston providers, as well as providers throughout South Texas, in areas such as Laredo, Brownsville, and McAllen. To be fair, much of Health Integrity’s criticism of provider billing and coding practices  has been right on target. Few small to medium healthcare providers in Houston have implemented an effective compliance plan.

In any regard, whether a ZPIC, RAC, or a federal or state law enforcement agency is involved, providers in Houston, TX should be sure to retain experienced and qualified legal counsel to assist them with Medicare audits and appeals. Having qualified legal counsel by your side can ensure that all of your rights are preserved and that your responsibilities to the government are timely and adequately met. Equally important, if you do not currently have an effective compliance plan in place, now is the time to develop and implement this important preventative tool.

Robert LilesRobert Liles represents providers in Medicare post-payment audits and appeals, and similar appeals under Medicaid. In addition, Robert counsels clients on regulatory compliance issues, performs gap analyses and internal reviews, and trains healthcare professionals on various legal issues. He has extensive experience developing and implementing effective compliance plans. For a free consultation, call Robert today at 1-800-475-1906.

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  1. […] some of the Medicaid contractors for various “hot-spot” cities, such as Baton Rouge and Houston, and you might find it interesting to note that a lot of Medicaid claims processing contractors or […]



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