Inspector General Stuart Bowen, Jr., Inspector General I NSPECTOR G ENERAL Texas Health and Human Services Commission Page 1
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Mission, vision, and values Mission (Govt. Code Section 531.102(a)) The Office of Inspector General is responsible for the prevention, detection, audit, inspection , review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state, including services through any state-administered health or human services program that is wholly or partly federally funded, and the enforcement of state law relating to the provision of those services. Page 3
DEPUTY IG FOR INSPECTIONS & EVALUATIONS DAVID HOLMGREN U.S. Air Force: 1971-2000 Inspector General for the Office of Naval Intelligence Inspector General for the Navy Installations Command Deputy Inspector General of the Marine Corps: 2006 Deputy Inspector General for Inspections & Evaluations for the Treasury Inspector General for Tax Administration (TIGTA): 2008-2014 (responsible for oversight of major IRS activities and programs) Page 4
DEPUTY IG FOR POLICY & EXTERNAL RELATIONS REBECCA KOMKOV JD from UT Law (law review): 1984 30 years of healthcare law practice Assistant General Counsel for HHSC: 1997-1998 Fulbright & Jaworski: 7 years Director of Compliance for Seton Healthcare System: 4 years Private law practice: 5 years Page 5
DEPUTY IG FOR INVESTIGATIONS JAY CROWLEY Postal Inspector: 1971-1980 U.S. Dept. of Agriculture-OIG: 1980-2004 Special Agent (Houston) Special Agent-in-Charge (Southwest Region) SIGIR: 2007-2013 Special Agent-in-Charge (Western Region) Deputy Assistant IG for Investigations Page 6
DEPUTY IG FOR AUDIT DAVID GRIFFITH M.A. in Administration, Central Michigan University U. S. Air Force: 21 years Texas State Auditor's Office Director, San Antonio Office of Internal Review Auditor, Federal Railroad Retirement Board-OIG Internal Audit Director, HHSC: 10 years Director, HHSC Risk & Compliance Management Page 7
CHIEF OF STAFF QUINT ARNOLD West Point Graduate: 1989 U.S. Army: 1989-2014 4 tours of duty in Iraq 1 tour of duty in Afghanistan Executive Officer to Commanding General Deputy Brigade Commander Battalion Commander Command Inspector General Director, Maneuver Test Directorate Retired, Colonel Page 8
SENIOR ADVISOR & CHIEF ANALYTICS OFFICER SYLVIA KAUFFMAN Senior Advisor & Chief Analytics Officer Stanford (B.S. Computer Science) Harvard (M.S. Public Policy) IT Project Manager, Exxon (Houston) Senior Policy Analyst, Strategic Planning Unit in the IT Division at the Commonwealth of Massachusetts (design, develop & implement www.mass.gov) HHSC: 3 years Senior Policy Advisor for Medicaid Health Information Technology Director for the Office of e-Health Coordination Special Advisor for Strategic Infrastructure Page 9
April 1, 2015 Page 10
June 21,2015 Page 11
CAF/Payment Holds SB 207 New Standard of Proof at hearings OIG must show: 1. Probable cause that the credible allegation of fraud…has an indicia of reliability; 2. Continuing to pay the provider represents an ongoing significant financial risk to the state; and 3. Continuing to pay the provider represents a threat to the integrity of Medicaid. Page 12
QUARTERLY REPORT SB 207 The QR must report on: 1. the office's activities; 2. the office's performance measures….; 3. fraud trends identified by the office; and 4. any recommendations for changes in policy to prevent…fraud, waste, and abuse… Page 13
NEW IG WEBSITE SB 207 requires that the QR be published on the IG website. Current IG website = user unfriendly New IG website (live this month?) = user friendly and useful Page 14
Sec. 531.1023. COMPLIANCE WITH FEDERAL CODING GUIDELINES. The commission's office of inspector general, including office staff and any third party with which the office contracts to perform coding services, shall comply with federal coding guidelines, including guidelines for diagnosis-related group (DRG) validation and related audits. Sec. 531.1024. HOSPITAL UTILIZATION REVIEWS AND AUDITS: PROVIDER EDUCATION PROCESS. The executive commissioner, in consultation with the office, shall by rule develop a process for the commission's office of inspector general, including office staff and any third party with which the office contracts to perform coding services, to communicate with and educate providers about the diagnosis-related group (DRG) validation criteria that the office uses in conducting hospital utilization reviews and audits. Page 15
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77984 Insufficient documentation to support the requirement of clinical evaluation, therapeutic treatment, diagnostic procedures, extended length of hospital stay or increased nursing care/monitoring, or in the case of newborns, conditions the provider deems to have implication for future health care needs. Page 17
QUESTIONS? Page 18
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