Public audit ledger
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23 reports
Molina did not consistently submit dental value-added services encounters with the correct financial arrangement code, which may affect the accuracy of FSR data and the computation of capitation rates and potential experience rebates.
Wellpoint did not consistently submit dental value-added services encounters with the correct financial arrangement code.
Superior HealthPlan, Inc. did not consistently submit dental value-added services encounters with the correct financial arrangement code.
The Blue Cross and Blue Shield of Texas Special Investigative Unit did not operate an effective SIU program and did not comply with requirements related to preventing, detecting, and investigating fraud, waste, and abuse, and reporting accurate information on SIU activities, r…
Based on our assessment, Encore Pharmacy #1 fully resolved all reported audit issues. As a result, OIG Audit did not reissue any recommendations from the previous audit.
AES had processes and controls to prevent and detect the creation of multiple IDs and associated overpayments, but improvements can be made to further limit the creation of multiple IDs for Texas Medicaid and CHIP members.
The Wellpoint Texas SIU did not consistently comply with state and contractual requirements related to preventing, detecting, and investigating fraud, waste, and abuse and reporting reliable information on SIU activities, results, and recoveries to the Texas Health and Human S…
Based on our assessment, Cook Children’s Home Health did not fully resolve some reported audit issues and the agency must repay $1,064.92 to the state of Texas for overpayments identified during this assessment; two recommendations from the previous audit were reissued and mod…
UnitedHealthcare Dental had a process for preparing and reviewing FSRs; however, internal controls were not always effective and allowed for reporting errors, which resulted in overstating reported expenses by $799,351.
While all five providers complied with some of the requirements tested, each had at least one finding of noncompliance.
CaremarkPCS Health, LLC (Caremark) and Aetna Better Health of Texas Inc. (Aetna) employed unallowable pricing models to reduce prescription expenses, and Aetna incorrectly reported expenses on its financial statistical reports to HHSC.
The Texas OIG found that the involved entities employed unallowable pricing practices to reduce prescription expenses, and Wellpoint incorrectly reported expenses on FSRs, with scope limitations due to Caremark's restricted access. The report concludes that these practices, in…
Omnicare Pharmacy (Omnicare) filled and dispensed prescriptions for Texas Medicaid members; however, Omnicare did not consistently comply with certain requirements for dispensing medication, confirming medication delivery, providing instructions for use, and accurately submitt…
Meadowbrook Pharmacy filled and dispensed prescriptions for Texas Medicaid and CHIP members; however, Meadowbrook did not consistently comply with certain requirements for dispensing refills, accurately submitting claims, providing instructions for use, and maintaining support…
Cook Children’s Health Plan (CCHP) had a process for preparing financial statistical reports (FSRs), which included controls related to removing unallowable expenses and identifying the appropriate FSR sections for reporting allowable expenses. However, CCHP did not always suf…
The FY 2024 Texas Medicaid managed care capitation rates are actuarially sound overall, with no material program-wide under- or over-funding detected. Milliman identifies several recommendations to strengthen the rate-setting process and reduce future risk, and notes that CMS…
Milliman concluded that FY2023 capitation rates were actuarially sound, with no program-wide pattern of under- or over-funding, though improvements were recommended in several rate-setting and governance processes.
ReCept Pharmacy #1 properly billed for paid claims and complied with applicable contractual, Texas Administrative Code, and federal requirements for most claims tested; however, ReCept did not consistently comply with requirements for accurate claims submissions and dispensing…
Cook Children’s Health Plan accurately reported STAR Kids medical and pharmacy expenses in FY 2020 and complied with eligibility requirements for medical and pharmacy claims. However, improvements are needed in reporting shared administrative expenses, particularly those alloc…
The audit identified strengths in some areas but also significant weaknesses that could affect the program's integrity and compliance. The Commission has committed to implementing recommended improvements.
The audit found that while the Health Plan accurately reported medical, administrative, and quality improvement expenses, its pharmacy expense reporting was flawed due to unallowable practices by the Pharmacy Benefit Manager, which could impact Medicaid costs and program integ…
The audit found that the Health and Human Services Commission has made significant progress in establishing processes and controls related to Medicaid managed care contract management, in compliance with Senate Bill 894. However, some planned improvements are still in progress…
The Commission has made significant progress in establishing processes and controls for Medicaid managed care contract management, aligning with Senate Bill 894 requirements. However, further efforts are needed to fully implement planned audits, monitoring activities, and IT c…