Recently a large number of Speech Language Pathologists (SLP) in Texas have received notices from the Texas Health and Human Services Commission Office of Inspector General advising that a vendor hold (i.e., payment suspension) has been placed on their Medicaid payments from TMHP due to a "credible allegation of fraud." The effect of the vendor hold is to stop all Medicaid reimbursements to the Provider until such time as HHSC-OIG is convinced that fraud has not and is not occurring. HHSC-OIG grants providers due process rights to appeal and lift the suspension.
The first and most important step is to request an initial Informal Resolution Meeting (IRM). The IRM is the Provider's first and best opportunity to meet with representatives from HHSC-OIG to address, discuss and hopefully persuade the HHSC-OIG that no fraudulent activity is occurring and thus obtain a lifting of the vendor hold/ payment suspension. Generally speaking, the investigator and HHSC-OIG attorney assigned to the case, as well as the Deputy Inspector General, Jack Stick, attend the IRM. The Provider is permitted to attend the meeting and have their case presented by an attorney of their choice. The Provider is entitled to one additional IRM as well as an expedited administrative hearing at the State Office of Administrative Hearings (SOAH) should the first IRM prove unsuccessful.
The recent spate of vendor holds placed on SLP's appears to be related to recent data mining activities by investigators at HHSC-OIG who have identified SLP's submitting claims to TMHP for services totaling over 24 hours per day, per TPI number, for multiple dates. This issue appears to be the basis for HHSC-OIG determining that a credible "allegation of fraud" exists, thus mandating the imposition of a vendor hold under federal law.
What HHSC-OIG does not know or understand is that within the SLP profession, it is entirely acceptable for SLP's to supervise properly qualified and registered assistants (SLPAs) and to submit claims for services rendered by such assistants to TMHP for reimbursement. The challenge faced by SLP's in Texas is to quickly obtain an IRM with HHSC-OIG to request and provide evidence for lifting the payment suspension before irreversible financial harm occurs to the Provider.
The good news is this challenge is not insurmountable. The key to lifting the payment suspension is to closely observe the deadlines referred to in the Provider Due Process Rights memo that accompanies the letter advising of the vendor hold; to request and then schedule an IRM in short order; and finally, to organize and present persuasive evidence and logical arguments which support all of the Provider's billing practices-including evidence that all SLPA's were properly registered with the State and practicing within their permitted scope of practice. Provision of all the necessary documentation and evidence is essential to persuading the OIG that fraud has never occurred.