1 Tex. Admin. Code § 353.505 - Recovery of Funds
(a) If a managed
care organization (MCO) discovers fraud or abuse has occurred in the Medicaid
or CHIP program, based on information, data, or facts obtained by the MCO, it
must:
(1) notify the Health and Human
Services Commission-Office of Inspector General (HHSC-OIG) and the Office of
the Attorney General (OAG) through a referral as described in §
353.502 of this subchapter
(relating to Managed Care Organization's Plans and Responsibilities in
Preventing and Reducing Waste, Abuse, and Fraud) that includes a detailed
description of the fraud or abuse and each payment made to a provider as a
result of the fraud or abuse;
(2)
subject to subsection (b) of this section, begin payment recovery efforts;
and
(3) ensure that any payment
recovery efforts in which the MCO engages are in accordance with this
subchapter.
(b) If the
amount sought to be recovered under subsection (a)(2) of this section exceeds
$100,000, the MCO may not engage in payment recovery efforts if, not later than
the 10th business day after the date the MCO notified HHSC-OIG and the OAG
under subsection (a)(1) of this section, the MCO receives a notice from either
office indicating that the MCO is not authorized to proceed with recovery
efforts.
(c) To the extent allowed
by federal law, an MCO may retain one-half of any money recovered under
subsection (a)(2) of this section by the MCO. The MCO shall remit the remaining
money recovered under subsection (a)(2) of this section to the OIG.
(d) If the OIG notifies an MCO under
subsection (b) of this section, the OIG proceeds with recovery efforts, and the
OIG recovers all or part of the payments the MCO identified as required by
subsection (a)(1) of this section, the MCO is entitled to one-half of the
amount recovered for each payment the MCO identified after any applicable
federal share is deducted. The MCO may not receive more than one-half of the
total amount of money recovered after any applicable federal share is
deducted.
(e) An MCO shall submit a
quarterly report to the HHSC-OIG detailing the amount of money recovered under
subsection (a)(2) of this section.
(f) Notwithstanding any provision of this
section, if the OIG discovers waste, abuse, or fraud in Medicaid or CHIP in the
performance of its duties, the OIG may recover payments made to a provider as a
result of the waste, abuse, or fraud. All payments recovered by the OIG shall
be deposited to the credit of the general revenue fund.
(g) The OIG shall coordinate with MCOs to
ensure that the OIG and the MCOs do not both begin payment recovery efforts
under this rule for the same case of waste, abuse, or fraud.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.