Search Results for: Special Investigations Unit

Texas HHSC-OIG is Ramping-Up its Investigations of Medicaid Pediatric Telemedicine Claims

(June 27, 2023): In the State of Texas, Medicaid plays a significant role in providing healthcare services to a large portion of the population. With more than 5.9 million[1] Texans (approximately 18.9% of the current population[2]) enrolled in Medicaid, it is an essential program for qualifying low-income citizens. In Texas, Medicaid costs taxpayers over $40 […]

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Medicare Advantage SIU Audits and Investigations are More Prevalent Than Ever

Author: Ashley Morgan, Annabella Denzel (April 5, 2023): In the sphere of healthcare compliance, providers must manage audits coming from every possible authority whether it be from public agencies, a private payor, or other third-party authorities. CMS has announced that the FY 2022 fee-for-service improper payment rate was 7.46%.[1] While this is a slight increase

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Amniotic Fluid / Amniotic Membrane Tissue Audits, Investigations and Prosecutions are Continuing to Climb in 2022

(August 4, 2022): Over the past year, we have seen a significant increase in the number of Medicare administrative audits, False Claims Act investigations and criminal prosecutions by the Department of Justice (DOJ), related to the billing of allogeneic (harvested from someone else) stem cell products. Medicare and Medicaid claims stemming from amniotic liquid and

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VA Acupuncture Audits of Non-VA, Community Providers are Increasing

(May 20, 2022): Acupuncture audits and investigations by federal, state and private payors have greatly expanded in recent years. One of the most active players conducting acupuncture audits today is the U.S. Department of Veterans Affairs. (VA). It is worth noting that long before traditional Medicare even considered covering acupuncture services,[1] the VA made these

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United Concordia Dental and its SIU are Actively Auditing Dentists Around the Country.

(September 15, 2020): There are approximately 1.4 million active duty service members in our country. These active duty service members have approximately 1.9 million dependents. Our military also consists of almost a million reserve and national guard participants. Depending on an individual’s status, these active duty service members, their dependents, and reservists are likely eligible

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Recent Developments in Personal Care & Community-Based Services in Medicaid and Medicare

(March 23, 2020): Until recently, personal care services, such as home health aides, were not covered under the Medicare program unless they were part of a skilled service where the beneficiary was homebound.  However, beginning with calendar year 2019, the Medicare program has expanded the ability of plans that participate in the Medicare Advantage program

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Overview of Dental Claims Audits and Investigations by Medicaid and Private Payors in 2019

(March 4, 2020): Many dentists and dental practices around the country are glad that 2019 is behind us.  Last year was a banner year for law enforcement investigators and administrative auditors of dental claims.  Federal and State prosecutors around the country actively pursued both civil and criminal cases against individual dentists for a variety of

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Investigations of Medicaid Dental Fraud in Texas

(July 1, 2014): Law enforcement authorities are actively investigating and prosecuting health care providers for crimes based upon allegations of Medicaid dental fraud in Texas. When looking for fake billing to the Medicaid program, investigators have historically targeted hospitals and doctors, but increasingly dentists have come under watch. In Texas, new measures have been adopted

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Personal Care Service Agencies and Personal Care Service Attendants are Increasingly Targeted in Medicaid Fraud Investigations

(September 15, 2023): Medicaid funding for personal care services allows those that need help for activities of daily living to remain in their homes and receive care from qualified individuals rather than have to live in institutional settings.[1] This is also a benefit to Medicaid, as it reduces the demand and costs for institutional and

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