Rolling Audit And Inspections Plan - Texas
Rolling Audit andInspections PlanSeptember 2020
TABLE OF CONTENTSINTRODUCTION . 3AUDIT AND INSPECTIONS AUTHORITY . 4AUDIT AND INSPECTIONS UNIVERSE . 5RISK ASSESSMENT . 8TYPES OF AUDITS AND INSPECTIONS . 10CARRY-OVER AUDITS IN PROGRESS . 11CARRY-OVER INSPECTIONS IN PROGRESS . 14FISCAL YEAR 2021 AUDIT PLAN . 16FISCAL YEAR 2021 INSPECTIONS PLAN . 21FISCAL YEAR 2020 AUDIT AND INSPECTIONS REPORTS ISSUED . 23OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 2
INTRODUCTIONRole of OIGIn 2003, the 78th Texas Legislature created the Office of Inspector General (OIG) to strengthenthe Health and Human Services Commission’s (HHSC) capacity to combat fraud, waste, andabuse in publicly funded state-run Health and Human Services (HHS) programs.OIG’s mission, as prescribed by statute, is the “prevention, detection, audit, inspection, review,and investigation of fraud, waste, and abuse in the provision and delivery of all health and humanservices in the state, including services through any state-administered health or human servicesprogram that is wholly or partly federally funded, or services provided by the Department ofFamily and Protective Services (DFPS) and the enforcement of state law relating to the provisionof these services.”OIG’s primary tools for detecting, deterring, and preventing fraud, waste, and abuse are audits(conducted under the Generally Accepted Government Auditing Standards, “Yellow Book”standard); investigations (conducted pursuant to generally accepted investigative policies);inspections (conducted under the federal “Silver Book” standard); and reviews (conducted underthe Principles and Standards for Offices of Inspector General developed by the Association ofInspectors General, also known as the Green Book).OIG PrinciplesVisionPromoting the health and safety of Texans by protecting the integrity of state health and humanservices delivery.ValuesAccountability. Integrity. Collaboration. Excellence.MissionPrevent, detect, audit, inspect, review, and investigate fraud, waste, and abuse in the provisionand delivery of all state health and human services, and enforce state law related to the provisionof those services.OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 3
AUDIT AND INSPECTIONS AUTHORITYTexas Government Code Section 531.102 created OIG in 2003 and gives OIG the responsibilityto audit fraud, waste, and abuse in the provision and delivery of all health and human services inthe state, including services through any state-administered health or human services programthat is wholly or partly federally funded or services provided by DFPS. 1Section 531.102(h)(4) permits OIG to audit the use and effectiveness of state and federal funds,including contract and grant funds, administered by a person or state agency receiving the fundsfrom a health and human services agency. 2Section 531.1025(a) permits OIG to conduct a performance audit of any program or projectadministered or agreement entered into by the commission or a health and human servicesagency. 3Section 531.113(d-1) mandates that OIG investigate, including by means of regular audits,possible fraud, waste, and abuse by managed care organizations. 4 Section 531.102(s) alsoestablishes OIG’s authority to utilize a peer-reviewed sampling and extrapolation process whenauditing provider records. 51Tex. Gov. Code § 531.102(a) (Sept. 1, 2017).Tex. Gov. Code § 531.102(h)(4) (Sept. 1, 2015).3Tex. Gov. Code § 531.1025(a) (Sept. 1, 2015).4Tex. Gov. Code § 531.113(d-1) (Sept. 1, 2015).5Tex. Gov. Code § 531.102(s) (Sept. 1, 2015); See also 1 Tex. Admin. Code § 371.35 (May 15, 2016) wherein OIGadopted RAT/STATS, statistical software available from the United States Department of Health and HumanServices Office of Inspector General and policies and procedures consistent with the mathematical processes forsampling and overpayment estimation described in the Centers for Medicaid and Medicare Services MedicareProgram Integrity Manual.2OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 4
AUDIT AND INSPECTIONS UNIVERSEThe audit and inspections universe represents an inventory of all potential areas that can beaudited and inspected. The OIG Audit and Inspections Division defines its audit and inspectionsuniverse as the departments, programs, functions, and processes within the HHS System andDFPS, including services delivered through managed care and services delivered throughproviders and contractors.Health and Human Services SystemAdministrative Services Financial Services Information Technology Internal Audit Legal Ombudsman Policy and Performance Procurement and Contracting Services System Support ServicesDivisions Health and Specialty Care System Regulatory Services Access and Eligibility Services Health, Developmental and Independence Services Intellectual and Developmental Disabilities and Behavioral Health Services Medicaid and CHIP Services Department of State Health Services (DSHS)o Community Health Improvemento Consumer Protectiono Laboratory and Infectious Disease Serviceso Program Operationso Regional and Local Health OperationsDepartment of Family and Protective Services Administrative ServicesAdult Protective ServicesChild Protective ServicesInvestigationsPrevention and Early InterventionStatewide IntakeOIG Rolling Audit and Inspections Plan: September 2020September 2020Page 5
Medicaid Managed CareManaged Care Entities and Subcontractors Managed Care Organizations (MCO) Dental Maintenance Organizations Medical Transportation Organizations Behavioral Health Organizations Pharmacy Benefit Managers (PBM) Third Party AdministratorsManaged Care Programs Children’s Health Insurance Program (CHIP) Children’s Medicaid Dental Services CHIP Dental Texas Dual Eligible Integrated Care Project (Medicare-Medicaid Plans) State of Texas Access Reform (STAR) STAR PLUS STAR Kids STAR HealthServices Delivered Through Providers and ContractorsThe audit and inspections universe includes the services delivered through providers andcontractors that support the HHS System programs and managed care sections listed above.These services are categorized into two groups: (a) Medicaid and CHIP services and (b) otherservices.Medicaid and CHIP ServicesThe list of Medicaid and CHIP services was compiled by reviewing the Medicaid and CHIPexpenditures included in the U.S. Department of Health and Human Services Centers forMedicare and Medicaid Services (CMS) 64 reports and CMS 21 reports. Behavioral Health ServicesCase Management (Primary Care andTargeted)Clinic ServicesCritical Access Hospital ServicesDental ServicesDiagnostic Screening and PreventativeServicesEmergency Hospital ServicesEmergency Services forUndocumented AliensFamily PlanningOIG Rolling Audit and Inspections Plan: September 2020September 2020 Federally Qualified Health Center ServicesFreestanding Birth Center ServicesHealth Home for Enrollees with ChronicConditionsHealth Services InitiativesHome and Community-Based ServicesHome Health ServicesHospiceInpatient Hospital ServicesInpatient Mental Health Facility ServicesIntermediate Care Facility Services (Privateand Public)Page 6
Laboratory and Radiological ServicesMedical EquipmentMedical TransportationNon-Emergency MedicalTransportationNurse MidwifeNurse Practitioner ServicesNursing Facility ServicesOccupational TherapyOther Care ServicesOther Practitioners’ ServicesOutpatient Hospital ServicesOutpatient Mental Health FacilityServicesPersonal Care ServicesPhysical TherapyPhysician and Surgical ServicesPrescribed Drugs Private Duty NursingPrograms of All-Inclusive Care for theElderlyProsthetic Devices, Dentures, andEyeglassesRehabilitative Services (Non-School-Based)Rural Health Clinic Screening ServicesSchool-Based ServicesScreening Services Component of Early andPeriodic Screening, Diagnosis, andTreatment ServicesServices for Speech, Hearing, and LanguageSterilizationsTherapy ServicesTobacco Cessation for Pregnant WomenTranslation and InterpretationVision ServicesOther ServicesOther services include services provided by the HHS System and DFPS programs that aredelivered through providers and contractors for which there is no federal financial participationthrough Title XIX (Medicaid) or Title XXI (CHIP). Examples include: Adoption and Permanency ServicesAutism ProgramChild Advocacy ProgramsDeaf and Hard of Hearing ServicesEmergency Medical Services (EMS)Family Violence ServicesFoster CareGuardianshipHIV/STD Prevention ServicesPopulation-Based ServicesOIG Rolling Audit and Inspections Plan: September 2020September 2020 Prevention and Early Intervention ServicesPublic Health PreparednessSubstance Abuse, Prevention, Intervention,and TreatmentSupplemental Nutrition Assistance Program(SNAP)Temporary Assistance for Needy FamiliesWomen, Infants, and Children (WIC)Page 7
RISK ASSESSMENTThe OIG Audit and Inspections Division conducts a continuous risk assessment to identifypotential audit topics for inclusion in its Rolling Audit and Inspections Plan. Potential audit andinspections topics consist of programs, services, providers, and contractors with an elevatedpotential for fraud, waste, and abuse.We identify potential audit and inspections topics from a variety of methods, such as: Coordinating with:o HHS System Internal Audit Divisiono DFPS Internal Audit Division Reviewing past, current, and planned work performed by external organizations,including:o Texas State Auditor’s Office (SAO)o U.S. Department of Agriculture Office of Inspector General (USDA OIG)o U.S. Department of Health and Human Services Centers for Medicare andMedicaid Services (CMS)o U.S. Department of Health and Human Services Office of Inspector General(HHS OIG)o U.S. Government Accountability Office (GAO) Conducting interviews with HHS System and DFPS management and staff, and externalstakeholders. Coordinating with the OIG Inspections and Reviews Division. Reviewing the results of external reviews conducted on managed care organizations. Analyzing data of services delivered through providers and contractors. Monitoring relevant Texas House and Senate legislative committee hearings. Requesting referrals from within OIG, the HHS System, DFPS, and the public. 6 Considering impacts of emergency events or extenuating circumstances, such as theCOVID-19 pandemic.6Members of the public are encouraged to report suspected fraud, waste, or abuse by recipients or providers inTexas HHS programs by calling the OIG toll-free Integrity Line at 1-800-436-6184 or submitting a referral onlinevia ReportTexasFraud.com.OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 8
After compiling the list of potential audit and inspections topics, the OIG Audit and InspectionsDivision considers several factors to select audits for its Rolling Audit and Inspections Planincluding: Requests from the legislature and executive managementCurrent oversight activities, including internal and external auditsPublic interestAvailable resourcesPotential financial and client impactOIG Rolling Audit and Inspections Plan: September 2020September 2020Page 9
TYPES OF AUDITS AND INSPECTIONSThe OIG Audit and Inspections Division conducts risk-based performance audits related to(a) services delivered through medical providers and contractors and (b) programs, functions,processes, and systems within the HHS System and DFPS, to help identify and reduce fraud,waste, and abuse. While variations occur for which audit type is performed, those audit types aregenerally defined as follows: HHS and DFPS System Audits—Review the effectiveness and efficiency of HHS Systemand DFPS program performance and operations. Provider Audits—Assess medical service provider compliance with criteria contained instatute, rules, guidance, or contracts, and determine whether funds were used as intended. Contractor Audits—Evaluate contractor performance for compliance with contractrequirements and determine whether funds were used as intended. Information Technology Audits—Assess compliance with applicable informationtechnology requirements and examine the effectiveness of general and applicationcontrols for systems that support HHS System and DFPS programs or are used bycontractors or business partners who process and store information on behalf of HHS andDFPS programs. Inspections—Conducts inspections of HHS programs, systems, and functions, includinginspections of contractors, vendors, and providers.Audits and inspections may result in recommendations to improve the provision and delivery ofhealth and human services in the state. Recommendations may include options for how fundsmay be utilized in a more efficient and effective manner or for information technology controlimprovements to mitigate security vulnerabilities. They may also identify questioned orunsupported costs and include recoveries, liquidated damages, and penalties or other sanctions.OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 10
CARRY-OVER AUDITS IN PROGRESSThe following audit projects were initiated by OIG before September 2020 and were in progressas of August 31, 2020.HHS System AuditsTIERS Data Processing and IntegrityAn audit of a contractor’s compliance with certain performance measures is ongoing and wasinitiated in fiscal year 2020.ObjectiveTo determine whether the TIERS system and process controls are adequate to reasonably ensurethat Medicaid eligibility determinations are accurate based on selected eligibility requirements.Contractor AuditsProcessing of Outlier Nursing Facility STAR PLUS Claims and AdjustmentsAudits of two MCOs were initiated in fiscal year 2019 and fiscal year 2020. Both audits areongoing.ObjectiveTo determine whether selected STAR PLUS MCOs accurately and timely adjudicated qualifiednursing facility provider clean claims in compliance with selected criteria.Selected Substance Use Disorder ContractsTwo audits of selected contractors are ongoing and were initiated in fiscal year 2020. Theobjectives for these audits vary slightly.ObjectiveTo determine whether (a) contract funds were used as intended and (b) contractor billing andperformance was in accordance with federal or state rules and guidelines, and applicablecontractual requirements.OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 11
ObjectiveTo evaluate whether the contractor’s treatment services (a) were provided in accordance with thecontractual requirements; (b) were provided by qualified staff; and (c) supported the paymentreceived.Selected MCO Financial DataAn audit of a selected MCO is ongoing and was initiated in fiscal year 2020.ObjectiveTo determine whether the MCO accurately reported selected administrative expenses to HHSC.Selected MCO’s Delivery of Pharmacy Benefit Services Through a PBM Focused onSpread PricingAn audit of a MCO’s pharmacy benefit services is ongoing and was initiated in fiscal year 2020.ObjectiveTo determine whether selected MCOs and their subcontracted PBM have processes and controlsin place to ensure that MCO reimbursements to PBMs are based on actual amounts paid topharmacies and comply with the UMCM and other applicable requirements related toreimbursement methods and spread pricing.Selected Family Planning Grant Program and Healthy Texas Women’s Grant ProgramContractorsAn audit of a selected contractor is ongoing and was initiated in fiscal year 2020.ObjectivesTo determine whether: Expenses paid to subcontractors were allowable under the terms of the grantsExpenses, payroll, and fringe benefits were apportioned properly under the terms of thecontractsExpenses charged were within the contract funding periodAll charges were made within the scope of the contractSubcontractor contracts existed for service deliveryOIG Rolling Audit and Inspections Plan: September 2020September 2020Page 12
Selected Third Party Administrators’ Compliance with Affiliate Reporting ExceptionRequirementsAn audit of a selected contractor is ongoing and was initiated in fiscal year 2020.ObjectivesTo determine whether the: Affiliate reporting exception met state and contractual requirementsMCO's affiliate third-party administrator expenses were accurately reported to HHSC andallowableProvider AuditsSelected Durable Medical Equipment (DME) ProvidersAn audit of a selected provider is ongoing and was initiated in fiscal year 2020.ObjectiveTo determine whether documentation to support the authorization and delivery of fee-for-serviceDME and supplies associated with Medicaid claims submitted by and paid to the providerexisted and were completed in accordance with state laws, rules, and guidelines.OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 13
CARRY-OVER INSPECTIONS IN PROGRESSMental Health Targeted Case Management (MHTCM) and Rehabilitative Services (MHR)ObjectiveTo determine if certain eligible Medicaid members receive MHTCM and MHR Services inaccordance with requirements.TelemonitoringObjectiveTo determine if prior authorizations for telemonitoring claims meet Texas Administrative Coderequirements.State Supported Living Centers (Series I and II)ObjectiveTo review the processes used by State Supported Living Centers (SSLCs) for hiring and trainingdirect support professionals.Children and Adolescent Needs and Strengths (CANS) 2.0 AssessmentObjectivesTo understand: If the provider conducts CANS 2.0 assessments for children in community-based care asrequired by the DFPS. If the provider delivers services to children in community-based care consistent with theCANS 2.0 assessment.Overlap of Certain Home and Health Claims During Hospital StaysObjectivesTo determine: Whether MCOs have effective processes to identify overlapping claims for MedicaidmembersHow MCOs recoup and report identified overlapping claims for Medicaid membersOIG Rolling Audit and Inspections Plan: September 2020September 2020Page 14
Local Mental Health AuthoritiesObjectiveTo determine whether Local Mental Health Authorities complied with selected TexasAdministrative Code requirements and the Texas Resilience and Recovery UtilizationManagement Guidelines (TRRUMG).OIG Rolling Audit and Inspections Plan: September 2020September 2020Page 15
FISCAL YEAR 2021 AUDIT PLANThe HHS System has over 41,000 employees responsible for managing approximately 44.9 billion each year, 7 and DFPS has over 12,000 employees responsible for managingapproximately 2.2 billion each year. 8 Collectively, the HHS System and DFPS have over200 programs providing needed services to millions of Texans. These programs are subject to(a) federal and state regulations, statutes, and rules and (b) agency and program policies. Theprograms, and the administrative and technical support that enables them to function, are subjectto funding constraints, policy changes, and changing priorities. As a result, risks associated withfunctions within the HHS System and DFPS are constantly changing.In an effort to be responsive to continuously changing risks and an evolving environment andaccommodate requests for audit services, the audit projects listed in the section titled “FiscalYear 2021 Audit Plan” will be updated periodically. Audit projects will be planned and initiatedbased on current priorities and availability of audit staff members needed to form audit teams.The audit projects that OIG plan
FISCAL YEAR 2021 AUDIT PLAN . 16 FISCAL YEAR 2021 INSPECTIONS PLAN. 21 FISCAL YEAR 2020 AUDIT AND INSPECTIONS REPORTS ISSUED . 23. OIG Rolling Audit and Inspections Plan: September 2020 Page 3 . Processing of Outlier Nursing Facility STAR PLUS Claims and Adjustments . September 2020 . September 2020 .
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