OIG and HHSC Under the Gun!

Texas Dentists:

As you may have heard, the HHSC is under sunset review in Texas this year and it is not going very well for them.

About Sunset Review in Texas:

In government, the term “sunset” means that a particular agency, program, policy, or law will expire on a particular date, unless it is reauthorized by the legislature.  In other words, anything with a “sunset” date will cease to exist after a set period of time unless the legislature reauthorizes it.

During the 1970s, many states enacted “sunset” laws to address the escalation of government budgets and the perception that government bureaucracy was not accountable.  Sunset provisions differ greatly, but share the common belief that it is useful to deal with the tendency of government agencies and programs to be self-perpetuating by requiring their periodic review.

(from: https://www.sunset.texas.gov/about-us/frequently-asked-questions)

This year the HHSC is under Sunset Review and have faced a rocky road mostly due to the Medicaid Scandal and the OIG handling of this scandal.

One BIG Problem: with OIG:

After listening to many calls from Dentists under an OIG investigation, it has become quite clear. The data mining done by the OIG is not optimum for the Dentist.

Here is how it works: (in basic terms)

Step 1: OIG collects about 100 records from the provider under investigation or review or whatever they call it so it sounds not so scary- even though it is very scary.

Step 2: OIG reviews those records and creates an error rate.

Step 3: OIG then applies this error rate to ALL of your records! (For example: If they decide you have an 80% error rate on the 100 records they pulled, then they ASSUME you have an error rate of 80% on ALL your records)

Step 4: The accountants at OIG get their calculators out and start them whirring! They figure your bill based on that error rate. That means that 80% is considered an overpayment and you have to pay back 80% of all money collected.

Step 5: You get a collection letter from the OIG (we have seen these letters with the amount due in the millions!) or a visit from the OAG with a criminal compliant!

I am not a mathematician, but I can tell you 100 examples is not a statistically significant data set. The Sunset Committee agrees. Sunset staff found OIG lacked an effective tool to collect and analyze key data to monitor cases at every stage of the investigation, needed to make its policies and procedures more available for providers, and should clearly define its criteria for opening and prioritizing cases.  So they are bringing in a private company to review their data mining process!

Want to get involved? The next SUNSET meetings are: