Key Takeaways:
- Enhanced Scrutiny of MCO SIUs: All Medicaid Managed Care Organizations should reveal full compliance with Texas’ SIU staffing and investigative exercise necessities. Count on speedy verification efforts.
- Focused Critiques Are Imminent: HHSC and the OIG will prioritize excessive danger service areas, with autism companies being the primary goal below a June 2026 reporting deadline.
- Accelerated Enforcement Timelines: With a March 15, 2026 progress report because of the Governor, companies are probably already initiating evaluations, audits, and outreach to MCOs and suppliers.
On January 16, 2026, Governor Greg Abbott issued a directive to the Texas Well being and Human Companies Fee (HHSC) and HHSC’s Workplace of Inspector Common (OIG) to extend efforts to fight Medicaid fraud. This initiative displays federal priorities recognized by the Trump Administration relating to systematic fraud in Medicaid-funded packages.
Given the Governor’s particular deal with Managed Care Organizations (MCOs) and several other high-risk service areas, listed below are 5 key takeaways and motion objects to your organizations to contemplate instantly:
1. Guarantee SIU Staffing and Compliance
Governor Abbott has explicitly directed the HHSC to make sure that all Medicaid MCOs keep totally staffed Particular Investigations Items (SIUs). Past mere staffing, MCOs should reveal they’re finishing all investigative actions required by legislation.
What You Can Do Now: Conduct an instantaneous inner audit of your SIU’s staffing ranges and documentation to verify that investigative workflows meet statutory benchmarks.
2. Put together for Focused Coverage and Utilization Critiques
The OIG and HHSC have been tasked with performing focused evaluations of MCO insurance policies, particularly specializing in companies thought of most vulnerable to fraud, waste, and abuse.
What You Can Do Now: Re-evaluate inner insurance policies and utilization administration protocols for high-risk service strains to make sure they’re ready for heightened regulatory scrutiny.
3. Speedy Deal with Autism Companies
The Governor has ordered a focused utilization overview of autism companies, with a proper report due by June 2026. This means that suppliers and MCOs concerned within the supply or reimbursement of autism-related care will probably be below a microscope within the coming months.
What You Can Do Now: Suppliers and insurers working within the autism service area ought to proactively overview their billing patterns and utilization information for any outliers or potential compliance gaps.
4. Count on Elevated Audits and “Enhanced” SIU Coaching
The OIG will probably be reallocating its assets to analyze suspected fraudulent exercise extra aggressively utilizing its broad authority below Chapter 544 of the Texas Authorities Code. Moreover, the state plans to offer extra coaching to MCO SIUs to strengthen their capability to forestall, detect, and remove fraud.
What You Can Do Now: Put together your compliance groups for elevated interplay with the OIG. Be certain that your workers is ready for state-led coaching classes and that your inner reporting programs are prepared for extra frequent audits and inspections.
5. Aggressive Timeline for Progress Stories
The Governor has set a deadline for the OIG and HHSC to offer his workplace with a progress report by March 15, 2026. This quick deadline means that the companies will probably be searching for quick outcomes and should start their outreach and investigations nearly instantly.
What You Can Do Now: Don’t watch for a proper discover of audit. Given the March deadline, the state’s “proactive steps” are probably already underway.
Trying Forward
The Governor’s directive reinforces the duty of state companies to take “proactive steps to forestall fraud… to recoup inappropriately paid funds, and to carry these accountable that violate the legislation.” MCOs and suppliers ought to act now to overview compliance infrastructure, strengthen investigative protocols, and put together for elevated state engagement. Ought to you will have any questions, please contact a member of Foley’s Texas Authorities Options Group.
About Foley’s Texas Authorities Options Group
Foley & Lardner’s Texas Authorities Options group supplies shoppers unparalleled authorized and legislative illustration and counseling. The attorneys and lobbyists handle legislative and regulatory proposals on the Texas Capitol and earlier than state companies. The group counsels shoppers relating to key governmental processes and areas of legislation primarily based upon a long time of collective authorized or governmental expertise. Our Austin workplace can also be residence to a novel federal, state, and native authorities enforcement protection and investigations (GEDI) and litigation protection group, in addition to a number of members of Foley’s nationwide State Attorneys Common observe.