The Health and Human Services Commission’s Office of Inspector General is being charged with poorly managing and being unfair in its investigations of medical and dental providers accused of Medicaid fraud. This conclusion is according to a report from the Sunset Advisory Commission, a state auditor.
Their report also found that the Office of Inspector General’s investigative tools, such as payment holds, used to stop Medicaid payments to providers, are used indiscriminately and inappropriately, which often results in financial hardship to the provider, even when only minor offenses were committed.
The Sunset Advisory Commission’s report goes on to detail the Office of Inspector General’s failure to distinguish providers’ serious misconduct from minor transgressions, their failure to close investigations in a timely manner, their difficulty of proving fraud and abuse in their cases, and their use of payment holds as unfair leverage to compel financial settlements. “Actual settlement amounts well below the identified overpayment are a likely indicator of an inconsistent and unfair process for providers,” as stated in the report. All of these aspects combined are a powerful sign that the Office of Inspector General’s investigators are not properly distinguishing minor paperwork violations from legitimate fraud. This report is also a promising sign to providers being investigated that changes will be made in the way their case is handled.
But how do we fix these issues? The Sunset Advisory Commission recommended that the Office of Inspector General not be run by a gubernatorial appointee as it is now, but instead by someone hired by the Health and Human Services executive commissioner, and that they also be evaluated every few years. A spokeswoman for the Health and Human Services Commission made a statement that the agency “will be conducting a management review of OIG to make sure policies and processes are fair and effective and clearly communicated to providers. We soon will be naming a special assistant to lead that review.”