Special Investigative Unit Wellpoint Texas

CHIP-specific data mining or investigations were not conducted; Wellpoint did not perform CHIP-focused data mining/analysis or investigations.

Wellpoint did not consistently document that all required elements of preliminary investigations were completed or that investigations were conducted within the required timelines (39 of 50 sampled preliminary investigations lacked supporting documentation; 11 with all elements completed, only 3 completed beyond the required timeline).

In extensive investigations, Wellpoint did not complete elements within the required timeframes in 17 of 23 cases (74 percent); one case lacked documentation showing the sample size met minimum requirements.

Wellpoint did not maintain supporting documentation for the sample size in one investigation.

There were inconsistencies between Wellpoint’s internal case management data and what was reported to OIG: Wellpoint’s CM system showed 418 investigations with $16.7 million identified overpayments, while the OIG-reporting showed 413 investigations with $11.65 million identified overpayments; recoveries differed ($428,069 vs $426,467).

Wellpoint reported 418 investigations in its system but 189 leads were not reported to OIG; some leads were not considered preliminary investigations, though documentation showed some activities.

Data elements in the case management system and OIG reports were missing or inaccurate, limiting the reliability of the data used for this audit.

Fraud, waste, and abuse training was not tailored to employees’ or subcontractors’ specific job functions.

Wellpoint must perform required SIU activities for CHIP including data mining, data analysis and fraud, waste, and abuse investigations.

For preliminary investigations, Wellpoint should improve processes and controls to (a) perform and document all required elements, and (b) complete investigations within required timeframes.

Wellpoint should strengthen processes to meet and document the following timelines: selection of provider claims samples within 15 working days of completing a preliminary investigation with suspicious indicators; requests for medical records and encounter data within 15 working days of sample selection; review of records within 45 working days of receipt; and ensure sample size requirements are met.

Wellpoint should improve processes and controls to capture all required data accurately in its case management system, report complete and accurate information on the MCO Open Case List Report, and provide feedback and request technical assistance from OIG promptly.

For personnel involved in data collection, provider enrollment or disenrollment, encounter data, claims processing, utilization review, quality assurance, and marketing for Medicaid or CHIP, Wellpoint must provide training tailored to their areas of responsibility.