TX-State violated federal reimbursement rules, imm health

State violated federal reimbursement rules for immigrant health services, audit finds
Posted Monday, Sep. 14, 2009
By DARREN BARBEE

dbarbee@star-telegram.com

Illegal and legal immigrants in Texas received taxpayer-subsidized healthcare services and thousands of prescriptions for nonemergency conditions in violation of the law, according to a federal watchdog agency.

At fault, an audit says, is the Texas Health and Human Services Commission, which provided lax oversight in restricting immigrants to emergency services, such as childbirth, for which the state can seek federal reimbursement. The audit found that more than 20 percent of the cases it reviewed weren’t for emergency situations.

The state also provided prescription drugs in cases that weren’t true emergencies and overrode controls aimed at preventing immigrants from receiving family planning services, the audit says.

The report, released Monday, comes amid a furor over whether healthcare reform proposals will allow immigrants to get taxpayer-funded healthcare.

Stephanie Goodman, a spokeswoman for the state health commission, said the federal reimbursement rules are stringent. For instance, an emergency appendectomy is covered under the rules, but a follow-up prescription for antibiotics isn’t because "we don’t know if it would be life-saving."

"I think they went pretty hard-core on their definition of an emergency," Goodman said.

The federal government is asking Texas to refund $286,427 for the federal share of medical and prescription services not eligible for emergency Medicaid coverage, the report shows.

Goodman added that the primary issue in the audit seems to be coverage of tests for services provided in conjunction with emergency care.

"Part of the treatment didn’t meet the standards for emergency care," she said. "An example listed in the audit was . . . a person . . . getting chemotherapy and being treated for convulsions. Emergency Medicaid can cover the treatment for convulsions but not the chemotherapy."

Goodman said the commission will work with the federal Centers for Medicare and Medicaid Services to review standards for emergency care and make changes if necessary.

Anne Dunkelberg, associate director of the Center for Public Policy Priorities in Austin, said the audit is "not any big deal."

"Texas Medicaid paid for $18 billion in medical care in [fiscal year] 2008," she said. "This is routine federal oversight, followed by a request for corrective action, which the state agreed to."

Illegal immigrants qualify only for emergency care. Immigrants granted temporary resident status are restricted to emergency services for their first five years in the country.

Audit findings

The U.S. Health and Human Services Department’s Office of the Inspector General reviewed 854 medical claims. Of those, 193 claims totaling $262,366 — with a federal match of $159,702 — did not meet the criteria for an emergency. The state agency also did not have medical documents to determine whether services billed on 32 other claims worth $5,903 were for emergency care.


Other findings include:

The commission wants reimbursement for 170 medical claims for nonemergency services totaling $165,494 — roughly $100,000 in federal matching payments.

It seeks $58,966 in federal reimbursement for 23 claims for nonemergency services totaling $96,872. The claims were initially denied but, after an appeal, were paid.

The commission sought federal reimbursement for 7,114 claims for prescription drugs totaling $147,805 that did not meet the state’s own definition of emergency care. The federal match was about $90,000.

In response, the commission said that before the audit, it did not realize that outpatient pharmacy drugs that are not part of emergency treatment are not eligible for federal reimbursement.

The commission said it will work with the federal government to review claims for allowable prescription drugs and identify any additional federal funds paid for prescriptions filed before and after the audit period.

Additionally, the audit found that the state’s system to prevent payment of family planning services for immigrants didn’t always operate correctly — or was manually overridden — to allow services to be claimed. Those are paid at an enhanced federal medical assistance rate of 90 percent. Many immigrants are not eligible for family planning services or the enhanced rate that is paid for these services.

The commission claimed enhanced matching for $126,178 to bring in $113,560 in federal money for 350 claims. As a result, the commission claimed overpayments totaling at least $36,756 from the federal government, the report says.

The report also details some claims improperly filed for reimbursement.

In one case, a patient who had a history of convulsions, hypertension, asthma and circulatory disease, and who had previously had a colostomy, went to a hospital complaining of abdominal pain. She stayed in the hospital for three days and received scans of her abdomen and pelvis. When her pain subsided, she was discharged.

Only the abdominal pain was an emergency; the other diagnoses were not. The state claimed $2,323 ($1,414 federal share) for the nonemergency medical services.

The audit period was from Oct. 1, 2004 to Sept. 30, 2005. The state processed 303,266 claims, or about $314.2 million, of which $191.2 million was federal match, for emergency medical services provided to illegal immigrants. Prescription drugs cost $148,000, $90,000 of which was picked up by the federal government. Of the $314.2 million total, about $218.3 million, or 70 percent, was for labor and delivery.



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What’s an emergency? Texas maintains a list of 3,987 diagnoses considered to be emergency medical situations, such as abdominal pain, shortness of breath, chest pains, normal labor and delivery, and altered mental status. The condition must have a "sudden onset."
Federal law states that an emergency medical condition has acute symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in:

Placing the patient’s health in serious jeopardy.

Serious impairment to bodily functions

Serious dysfunction of any body part or organ.



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