reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.536 - The Hearing Record and Decision

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Household members or the representative may inspect the hearing record during
				  work hours. They may also copy it at their own expense.
(b) The hearing officer sends written
				  notification of the decision to the household or to the appropriate Texas
				  Department of Human Services (DHS) staff as indicated in § 79.1918 of this
				  title (relating to Notification of Hearing Decision and Effect on Remaining
				  Household Members). The hearing officer's decision:
(1) specifies the reasons for the decision.
				  If the case is dismissed because advance notice requirements were not met, the
				  hearing officer specifies that the case is dismissed without
				  prejudice;
(2) identifies the
				  supporting evidence and regulations;
(3) responds to reasoned arguments of the
				  household member or his representative.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.537 - Effect of an Administrative Determination of Intentional Program Violation

Current through Reg. 49, No. 28; July 12, 2024
(a) If a hearing officer finds that a
				  household member committed an intentional program violation, the household
				  member is disqualified from the Food Stamp and/or Temporary Assistance for
				  Needy Families (TANF) programs for the following periods.
(1) TANF. If the intentional program
				  violation occurred on or after September 1, 2003, the person is disqualified:
(A) 12 months for the first intentional
				  program violation determination; and
(B) permanently for the second intentional
				  program violation determination.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.538 - Notification of Hearing Decision and the Effect on Remaining Household Members

Current through Reg. 49, No. 28; July 12, 2024
(a) The hearing
				  officer notifies the household member of his decision in writing.
(b) Within 15 calendar days of a hearing
				  officer's written decision to disqualify the household member, the Texas
				  Department of Human Services' (DHS's) Central Disqualification Unit notifies
				  the household member of the effect of the hearing officer's decision. In
				  dismissed or nondetermination of intentional program violation cases, the
				  hearing decision is the final notification sent to the household member. If the
				  hearing officer dismisses the case, he sends copies of the decision to the
				  investigator only.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.539 - Court Actions in Relation to Administrative Disqualification

Current through Reg. 49, No. 28; July 12, 2024
(a) The temporary assistance for needy
				  families (TANF) and food stamp federal regulations provide for a court of
				  appropriate jurisdiction to order an individual disqualified from participating
				  in the program for the time periods described in § 79.1917 of this title
				  (relating to Effect of an Administrative Determination of Intentional Program
				  Violation).
(b) The state, a
				  political subdivision of the state, or the United States may serve as
				  prosecutor or plaintiff.
(c) If the
				  court fails to impose a disqualification period on a household member who
				  committed an intentional program violation, the Texas Department of Human
				  Services (DHS) imposes one of the penalties described in § 79.1917 of this
				  title (relating to Effect of an Administrative Determination of Intentional
				  Program Violation). DHS imposes the appropriate penalty unless the court order
				  prohibits the penalty.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.540 - Presentation of the Texas Department of Human Services' (DHS's) Case

Current through Reg. 49, No. 28; July 12, 2024
The DHS representative is responsible for presenting the
					 department's case in the administrative disqualification hearing. The DHS
					 representative may choose to present the case in person or by the use of
					 teleconference equipment. If either the hearing officer or the household member
					 requests, the DHS representative must attend the hearing in person. Such a
					 request, however, must be made 10 days before the hearing.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.541 - Effect of Nondetermination of Intentional Program Violation

Current through Reg. 49, No. 28; July 12, 2024
If a hearing officer finds that the household member did
					 not commit an intentional program violation, the hearing officer determines
					 whether or not there was an overissuance and determines that the case involved
					 either:
(1) client error or
				  misunderstanding; or
(2) agency
				  error.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter K - ADMINISTRATIVE FRAUD DISQUALIFICATION HEARINGS › Section 357.542 - Consolidation of Administrative Disqualification Hearings and Fair Hearings

Current through Reg. 49, No. 28; July 12, 2024
(a) The hearing officer may combine a fair
				  hearing and an administrative disqualification hearing to settle the amount of
				  the claim at the same time as determining whether or not an intentional program
				  violation has occurred. To do this, the following conditions must exist:
(1) the factual issues arise out of the same,
				  or related, circumstances and the household receives advance notice that the
				  hearings will be combined; and
(2)
				  disqualification hearing procedures are adhered to.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter L - FRAUD INVOLVING RECIPIENTS › Section 357.561 - Terms and General Policy

Current through Reg. 49, No. 28; July 12, 2024
(a) Food stamp,
				  medical assistance, and financial assistance are indicated when the term
				  "assistance" is used in this subchapter. Medical assistance, Temporary
				  Assistance for Needy Families (TANF), and food stamp intentional program
				  violations are not given special treatment except if specific procedural
				  distinctions are noted.
(b) A
				  household member has committed a food stamp intentional program violation if he
				  has intentionally:
(1) made a false and
				  misleading statement;
(2)
				  misrepresented, concealed, or withheld facts; or
(3) violated any provision of the Food Stamp
				  Act, the Food Stamp Program regulations, or related state statutes in order to
				  use, present, transfer, acquire, receive, or possess food stamp coupons or food
				  stamp authorizations to participate (ATPs).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter L - FRAUD INVOLVING RECIPIENTS › Section 357.562 - Determination and Disposition of Intentional Program Violations

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas Department of Human Services
				  (DHS) determines the existence of intentional program violations; refers cases
				  for investigation, administrative hearings, and prosecution; takes collection
				  action and ensures clients' rights according to applicable Texas criminal
				  statutes and the following:
(1) Temporary
				  Assistance for Needy Families (TANF)--as provided in:
(A) Personal Responsibility and Work
				  Opportunity Act (RSA 601 et.
				  seq.);
(B) Human Resources Code,
				  Chapter 31; and
(C) Government
				  Code, §
												RSA
				  531.114;
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter L - FRAUD INVOLVING RECIPIENTS › Section 357.563 - Eligibility during Investigation

Current through Reg. 49, No. 28; July 12, 2024
Investigation for potential intentional program violation
					 is not to be used as a punitive action to deprive the recipient of assistance
					 or services. Food stamps, assistance, or services are continued if current
					 eligibility is established during the time that the alleged fraudulent acts are
					 under review and during any period of prosecution or appeal.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter L - FRAUD INVOLVING RECIPIENTS › Section 357.564 - Appeals

Current through Reg. 49, No. 28; July 12, 2024
The right to appeal and all applicable procedures for
					 appeal are described in Subchapter L of this chapter (relating to Fair
					 Hearings), Subchapter M of this chapter (relating to Appeals Process), and
					 Subchapter N of this chapter (relating to Hearing Procedure). Administrative
					 decisions to investigate a recipient's case for fraud and to refer such a case
					 to local law enforcement officials are not subject to appeal.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter L - FRAUD INVOLVING RECIPIENTS › Section 357.565 - Referral of Food Stamp and Temporary Assistance for Needy Families (TANF) Intentional Program Violation Claims to Administrative Disqualification Hearing Officer

Current through Reg. 49, No. 28; July 12, 2024
(a) If the
				  investigator has documented evidence to substantiate that an individual in a
				  food stamp or TANF household has committed an intentional program violation, an
				  administrative disqualification hearing may be held.
(b) The Texas Department of Human Services
				  (DHS) may refer to the hearing officer only three types of cases that have
				  first been referred to the prosecutor:
(1)
				  cases that were forwarded to the prosecutor but that he declined to prosecute;
				  or
(2) cases that were forwarded to
				  the prosecutor in which no action was taken within a reasonable amount of time
				  and the cases were formally withdrawn by DHS; or
(3) cases dismissed by the prosecutor after
				  charges were filed that do not reflect a lack of evidence to
				  prosecute.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter L - FRAUD INVOLVING RECIPIENTS › Section 357.566 - Collection Action on Food Stamp and Temporary Assistance for Needy Families (TANF) Intentional Program Violation Claims

Current through Reg. 49, No. 28; July 12, 2024
(a) The investigator must send the person
				  determined to have committed an intentional program violation a repayment
				  agreement. The investigator must send a repayment agreement even if the
				  household already received a nonintentional program violation demand
				  letter.
(b) The Texas Department of
				  Human Services (DHS) must begin collection action on intentional program
				  violation claims, unless:
(1) the household
				  has already repaid the overissuance because of a nonintentional program
				  violation claim; or
(2) the
				  investigator documents that the household cannot be located.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.581 - Department Responsibility

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
				  Department of Human Services is responsible for minimizing the opportunity for
				  provider fraud and abuse as well as recipient fraud and abuse and for
				  protecting recipients of federally funded health care programs from unsafe
				  practitioners. The department takes appropriate action to protect recipients
				  and the program when providers of services are suspected of committing fraud or
				  abuse.
(b) All actions resulting in
				  overpayment to a provider are not necessarily fraudulent. Some circumstances
				  could result in the referral of a provider to the Medicaid Fraud Control Unit
				  in the attorney general's office. Other circumstances would result in
				  administrative action rather than referral for judicial action or criminal
				  prosecution. These actions, or sanctions, range from a notice to the provider
				  explaining his error to exclusion from the Medicaid Program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.582 - Confidentiality of Fraud or Abuse Investigation Records

Current through Reg. 49, No. 28; July 12, 2024
Requests for disclosure or copies of information regarding
					 fraud or abuse investigations are treated as confidential, and records may not
					 be disclosed under the Open Records Act or otherwise without first coordinating
					 the requests with the office of the general counsel and the fraud and abuse
					 division.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.583 - Statutory Bases

Current through Reg. 49, No. 28; July 12, 2024
The statutory bases for Medicaid fraud and abuse
					 investigation and prosecution are Texas Human Resources Code, Chapter 32, and
					 RSA
					 1396b(q) and
					 RSA
					 1396h. State and federal officials may also
					 act under other statutes, including, but not limited to, the Deceptive Trade
					 Practices and Consumer Protection Act, the Texas Penal Code, the Civil Monetary
					 Penalties Law, and Public Law 100-93.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.584 - Department Responsibilities in Relation to Provider Fraud and Abuse

Current through Reg. 49, No. 28; July 12, 2024
The department's responsibilities in relation to provider
					 fraud and abuse include the following:
(1) establishing criteria for identifying
				  cases of possible fraud or abuse;
(2) establishing the methods for referring
				  suspected fraud cases for investigation;
(3) cooperating with the Medicaid Fraud
				  Control Unit, Office of the Attorney General, by furnishing information and
				  data and serving as witnesses, when requested;
(4) recouping all overpayments and taking
				  other administrative sanctions and actions; and
(5) investigating cases of possible
				  abuse.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.586 - Administrative Sanctions/Actions, Restitution, and Recoupment

Current through Reg. 49, No. 28; July 12, 2024
The department exercises authority for recoupment and
					 restitution of overpayments to providers in all medical programs. The
					 department, its agents can collect the money involved. The department also has
					 the authority to impose administrative sanctions and actions against a provider
					 when violations, as listed in this subchapter, and other applicable sections
					 have occurred. For purposes of the sections in this subchapter and in
					 §§ 79.2301-79.2305 of this title (relating Recovery of Benefits
					 Wrongfully Received), the provider is responsible for his own actions as well
					 as the actions of the provider's agents.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.587 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings, unless the context clearly
					 indicates otherwise.
(1)
				  Abuse--Provider practices that are inconsistent with sound fiscal, business, or
				  medical practices and that result in unnecessary program cost or in
				  reimbursement for services that are not medically necessary; do not meet
				  professionally recognized standards for health care; or do not meet standards
				  required by contract, statute, regulation, or previously sent interpretations
				  to the provider of any of the items listed.
(2) Act--The Medicare and Medicaid Patient
				  and Program Protection Act of 1987 (Public Law 100-93).
(3) Affiliates--Persons associated with one
				  another so that any one of them directly or indirectly controls or has the
				  power to control another in whole or in part.
(4) Agent--Any person, company, firm,
				  corporation, employee, independent contractor, or other entity or association
				  acting for or in the place of the department or a provider under authority of
				  the department or a provider.
(5)
				  Civil Monetary Penalty Law--Any state or federal law permitting or requiring
				  assessment of penalties and/or damages against individuals or entities or both
				  for conduct that includes a claim or request for payment under Titles XVIII,
				  XIX, or XX; and that violates the federal and/or state statutes and regulations
				  enacted pursuant to these titles.
(6) Closed-end provider agreement--An
				  agreement for a specific period of time. It must be renewed for the provider to
				  continue to participate in the Medicaid Program.
(7) Controlled substances--"Controlled
				  substance" as defined by the Texas Controlled Substances Act (Texas Civil
				  Statutes, Article 4476-15) or its successor and the Federal Controlled
				  Substances Act (21 USCA §8.01 et seq.) or its successor.
(8) Conviction or convicted--A person is
				  considered to have been convicted of a criminal offense when:
(A) a judgment of conviction has been entered
				  against him by a federal, state, or local court, regardless of whether an
				  appeal is pending or whether the judgment of conviction or other record
				  relating to criminal conduct has been expunged;
(B) he has been found guilty by a federal,
				  state, or local court;
(C) he has
				  entered a plea of guilty or nolo contendere that has been accepted by a
				  federal, state, or local court; or
(D) he has entered a first offender or other
				  program and judgement of conviction has been withheld.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.588 - Administrative Sanctions and Actions

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  The following sanctions may be imposed against providers for any reason
				  specified in § 79.2105 of this title (relating to Grounds for Fraud
				  Referral and Administrative Sanction):
(1)
				  exclusion from participation in the Titles XIX and XX programs for a specified
				  period of time;
(2) suspension of
				  payments (payment hold) to a provider;
(3) recoupment of overpayments;
(4) recoupment of overpayments projected from
				  a sampling process; and
(5)
				  restricted reimbursement from the Titles XIX and XX programs for a specified
				  period of time.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.590 - Imposing a Sanction

Current through Reg. 49, No. 28; July 12, 2024
The decision to impose a sanction or make a fraud referral
					 is at the discretion of the deputy commissioner or designee responsible for the
					 program area affected by the violation. In determining the sanction to be
					 imposed, the decision-maker may consider the seriousness of the program
					 violation, the extent of the violation, prior imposition of sanctions,
					 willingness to comply with program rules, recommendations of peer review
					 groups, or any other pertinent information.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.591 - Notice of Adverse Action

Current through Reg. 49, No. 28; July 12, 2024
(a) Except in
				  the following circumstances, the department sends the provider prior written
				  notification about its intent to impose an exclusion sanction and includes a
				  time frame for the provider to take action necessary to correct the problem
				  areas:
(1) any criminal conduct;
(2) any action by the federal government that
				  would preclude federal financial participation (FFP);
(3) any conduct or omission of conduct that
				  presents a significant health, safety, or security hazard to a recipient
				  receiving services from the provider;
(4) any conduct or omission of conduct that
				  causes financial loss to a recipient receiving services from the provider, if
				  the financial loss is caused by a violation of the requirements of the Texas
				  Medicaid Program;
(5) any conduct
				  or omission of conduct by the provider that indicates a pattern of repeated
				  violations of the Texas Medicaid Program;
(6) any conduct or omission of conduct by the
				  provider that causes a significant loss of department funds paid for services
				  not provided or not provided according to the requirements of the Texas Medical
				  Assistance Program;
(7) any conduct
				  or omission of conduct by the provider that would preclude the department or
				  its authorized agents, representatives of the department of health and human
				  services, or the attorney general's Medicaid Fraud Control Unit from obtaining,
				  upon request, access to or copies of records of services provided to Medicaid
				  recipients and payments made for those services including, but not limited to,
				  documents related to diagnosis, treatment, service, lab results, and
				  x-rays.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.592 - Informing Other Interested Parties

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  When a provider has been excluded, the department notifies, as appropriate, the
				  applicable professional society, board of registration or licensure, and
				  federal or state agencies about the findings made and the actions imposed
				  according to federal requirements of the Act.
(b) The department also notifies providers,
				  recipients, and the public about providers being excluded, through procedures
				  established by the department.
(c)
				  All department offices that maintain provider lists are promptly
				  notified.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.593 - Provider Education

Current through Reg. 49, No. 28; July 12, 2024
Except when an exclusion is imposed, each person who is
					 sanctioned or is seeking reinstatement may be asked to participate in a
					 provider education program. These educational meetings are arranged by the
					 division administrator or designee and are held at a location designated by the
					 department.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.594 - Request for Reinstatement

Current through Reg. 49, No. 28; July 12, 2024
After the exclusion period specified by the department, the
					 provider or entity may request reinstatement as specified in the notification
					 letter. The department determines the need for individual provider
					 participation or reinstatement. The request for reinstatement could result in a
					 denial by the department. This determination is based on the following
					 criteria:
(1) accessibility of other
				  health care to the recipient population; and
(2) the provider's previous conduct,
				  including conduct during participation in the Titles XVIII, XIX, XX, and V
				  programs in any state, or any conduct or action for which a sanction could have
				  been taken, as described in these sections or § 79.2105 of this title
				  (relating to Grounds for Fraud Referral and Administrative Sanctions) or §
				  79.2402 of this title (relating to Liability).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter M - FRAUD OR ABUSE INVOLVING MEDICAL PROVIDERS › Section 357.595 - Obligation of Health Care Practitioners and Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) Each provider is responsible for ensuring
				  that items or services furnished personally by, at the medical direction of, or
				  on the prescription or order of an excluded physician are not billed to the
				  Titles XIX and XX programs after dates specified in this subchapter.
(b) Providers must not bill recipients for
				  services or items specified in subsection (a) unless:
(1) the recipient is informed, before
				  delivery of the item or service, that those services are not reimbursed by the
				  department; and
(2) the provider
				  obtains and retains before delivery of the item or service, a signed consent
				  from the recipient indicating that the recipient understands he is responsible
				  for the payment of these services and that he still requests the
				  service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter N - FRAUD OR ABUSE INVOLVING PROVIDERS (EXCEPT MEDICAL) › Section 357.601 - Responsibilities of the Department In Relation to Provider Fraud

Current through Reg. 49, No. 28; July 12, 2024
DHS' responsibilities in relation to provider fraud
					 include:
(1) setting criteria for
				  identifying cases of possible fraud or abuse;
(2) establishing the methods of referral for
				  investigating those case in which fraud is suspected;
(3) keeping appropriate records and making
				  periodic reports of suspected fraudulent cases;
(4) collecting all overpayments.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter N - FRAUD OR ABUSE INVOLVING PROVIDERS (EXCEPT MEDICAL) › Section 357.602 - Statutory Bases for Prosecution

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  For all services for which DHS provides remuneration, DHS is in effect, the
				  legal owner of the funds used to pay for the goods or services. DHS has the
				  right and responsibility to seek legal redress for any overpayments that may
				  occur as a result of a provider's actions.
(b) The most common form of criminal sanction
				  would take place under the Texas Penal Code, §§ 31.032,
				  RSA
				  7.23, and
				  RSA
				  37.10.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter O - RECOVERY OF BENEFITS WRONGFULLY RECEIVED › Section 357.621 - Department Responsibility

Current through Reg. 49, No. 28; July 12, 2024
(a) The
				  department or its agents are responsible for recovering from providers all
				  payments made for services delivered or provided under fraudulent or abusive
				  circumstances or through error or misunderstanding. At the department's
				  discretion, overpayments may be collected in a lump sum or in installments. If
				  collection is made through installments, the provider must comply with the
				  payment plan established by the department for a reasonable length of time not
				  to exceed 12 months.
(b) The
				  department determines the need for individual provider participation or
				  reinstatement. This determination is based on the following criteria:
(1) accessibility of other health care to the
				  recipient population; and
(2)
				  previous conduct of the provider during participation in the Medicare or
				  Medicaid program in any state or any conduct or action for which a sanction as
				  described in these sections could have been taken.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter O - RECOVERY OF BENEFITS WRONGFULLY RECEIVED › Section 357.622 - Recovery from Providers

Current through Reg. 49, No. 28; July 12, 2024
(a) Overpayments
				  involving possible fraud are referred to the Attorney General's Fraud Control
				  Unit. If intent to defraud is not determined or cannot be proven, the
				  department or its agents may take an administrative sanction to recoup
				  overpayments. Recovery of the overpayments from a provider who made a false
				  statement or misrepresentation, or who omitted pertinent facts may include the
				  cumulative dollar amount due. The following situations are not intended to be
				  all inclusive.
(1) An ordering provider
				  causes an overpayment to be made to himself or to another provider as a result
				  of a false statement, misrepresentation, or omission of pertinent facts on a
				  claim, attachments to a claim, medical records, or any other documentation used
				  to adjudicate a claim for payment; any documentation submitted or maintained by
				  the provider to support payment on individual claims or to support
				  representations made on cost reports; or other documents used to establish
				  fees, daily payment rates, or vendor payments.
(2) A provider makes a false statement, a
				  misrepresentation, or omits pertinent facts on a provider agreement or any
				  documents required as a prerequisite for Medicaid participation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter O - RECOVERY OF BENEFITS WRONGFULLY RECEIVED › Section 357.623 - Recovery When Fraud Is Involved

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Decision to recover funds.
(1) Recovery of
				  funds which are obtained through fraudulent means by a provider may be
				  recommended by the prosecuting attorney or by an administrative determination
				  by program staff.
(2) After a case
				  is referred to the Fraud and Abuse Division, department staff may not attempt
				  to recover funds without prior approval from the Fraud and Abuse Division.
				  Vendor payments may be withheld to coincide with the investigation according to
				  program procedures. If fraud cannot be determined or if the prosecuting
				  attorney declines the case, the attorney general's unit returns the case to the
				  department for administrative sanction or action.
(3) When provider fraud is suspected, the
				  department makes no agreements for restitution. The decision regarding
				  acceptance of restitution is left to the prosecuting attorney.
(4) The prosecuting attorney may decide to
				  accept restitution payments before or after an indictment, or a court may order
				  a repayment schedule upon conviction. Whether restitution is made instead of a
				  prosecution or following a court order, all cashier's checks or money orders
				  are made payable to the Texas Department of Human Services.
(5) The department or its agents are
				  responsible for recoupment when referred cases do not result in prosecution.
				  These cases are returned to the department's Fraud and Abuse Division to send
				  to the appropriate division administrator for administrative action.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.641 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, shall have the following meanings, unless the context clearly
					 indicates otherwise.
(1) Claim--An
				  application for payment of health care services under Title XIX of the Social
				  Security Act that is submitted by a person who is under a contract or provider
				  agreement with DHS.
(2) Contract or
				  provider agreement--Any written document (or series of documents) that
				  obligates DHS or its health insuring agent to pay a person money under Title
				  XIX of the Social Security Act in exchange for his goods or services. Included
				  are claims for payment that a licensed practitioner (as defined by federal law)
				  submits for services provided to Medicaid recipients.
(3) Commissioner--The commissioner of the
				  Texas Department of Human Services.
(4) Days--Calendar days, unless otherwise
				  specified.
(5) Department--The
				  Texas Department of Human Services.
(6) Health insuring agent--An organization
				  legally operating in the state that:
(A) pays
				  providers of certain Title XIX medical services and supplies in exchange for
				  premiums paid by DHS; and
(B)
				  assumes an underwriting risk.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.642 - Liability

Current through Reg. 49, No. 28; July 12, 2024
DHS may assess a civil monetary penalty against a person
					 who submits a claim, or causes a claim to be submitted, to DHS or its health
					 insuring agent that contains a statement or representation that the person knew
					 was false.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.643 - Maximum Amount

Current through Reg. 49, No. 28; July 12, 2024
The maximum amount of the civil monetary penalty is:
(1) the amount that DHS or its health
				  insuring agent pays because of the false claim and the interest on that amount
				  determined at the rate provided by law for legal judgments (Texas Civil
				  Statutes, Article 5069-1.05) accruing from the date on which the payment was
				  made; plus
(2) twice the amount
				  that DHS or its health insuring agent pays because of the false claim;
				  plus
(3) $2,000 or less for each
				  item or service for which payment was claimed.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.644 - Exemptions

Current through Reg. 49, No. 28; July 12, 2024
(a) The requirements of § 79.2402 of
				  this title (relating to Liability) do not apply to a claim based on a voucher
				  if DHS calculated and printed the claim amount on the voucher and submitted it
				  for the provider's signature unless:
(1) the
				  provider gave DHS information to use in preparing the voucher that he knew, or
				  should have known, was false; or
(2) the provider failed to correct
				  information he knew, or should have known, was false when given the opportunity
				  to do so.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.645 - Determining the Amount

Current through Reg. 49, No. 28; July 12, 2024
To determine the amount of a civil monetary penalty, DHS
					 considers the following:
(1) the
				  seriousness of the violation;
(2)
				  the person's history in submitting claims; and
(3) the amount necessary to deter the person
				  from submitting false claims in the future.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.646 - Assessment of a Civil Monetary Penalty

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Preliminary report. If after examining the facts the deputy commissioner or
				  designee responsible for the program area affected by the violation concludes
				  that the claim is false, the deputy commissioner or designee issues a
				  preliminary report. The report includes the facts upon which the recommendation
				  to assess a penalty were based and the amount of the recommended
				  penalty.
(b) Notice of intent to
				  assess a penalty.
(1) DHS must give the
				  person charged with submitting a false claim a written notice of the
				  preliminary report and DHS' intent to assess a civil monetary penalty. The
				  notice must include the following information:
(A) a brief summary of the facts;
(B) the amount of the recommended penalty;
				  and
(C) a statement of the person's
				  right to an informal review of the false claim charge or penalty amount or
				  both.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.647 - Payment of a Civil Monetary Penalty

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Within 30 days of receiving the notice of assessment specified in §
				  79.2406 of this title (relating to Assessment of Civil Monetary Penalty), the
				  person must submit the full amount in a manner and format specified by DHS. If
				  the person requests a judicial review of the false claim or penalty amount
				  ordered under § 79.2406 of this title (relating to Assessment of Civil
				  Monetary Penalty), he shall forward the amount of the penalty to DHS or submit
				  to DHS a supersedeas bond, in a form approved by DHS, for the full amount. The
				  bond is effective until all judicial review of the order or decision is
				  final.
(b) If the person pays for
				  the penalty but the penalty is later reduced, withdrawn, or not assessed, DHS
				  remits the appropriate amount plus the interest accrued between the date that
				  the penalty was paid and the date that the amount is remitted. Interest accrues
				  at the rate provided by law for legal judgments.
(c) If the person has submitted a supersedeas
				  bond as specified in subsection (a) of this section but the penalty is later
				  withdrawn or not assessed, DHS releases the bond. If the person has submitted a
				  supersedeas bond but the penalty is later reduced, DHS releases the bond when
				  it receives an acceptable substitute bond or payment for the reduced amount.
				  The deputy commissioner or designee responsible for the program area affected
				  by the violation releases the bond.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter P - CIVIL MONETARY PENALTIES › Section 357.648 - Prohibited Use of Civil Monetary Penalties in Cost Reports or Claims

Current through Reg. 49, No. 28; July 12, 2024
Civil monetary penalties and costs a person incurs as a
					 result of a penalty are not allowable expenses for cost reports or claims that
					 providers submit to determine rates or payments under the Texas Medical
					 Assistance Program.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter Q - REIMBURSEMENT RATES FOR PROSECUTION OF INTENTIONAL PROGRAM VIOLATIONS › Section 357.661 - Rates of Reimbursement

Current through Reg. 49, No. 28; July 12, 2024
The Texas Department of Human Services (DHS) contracts with
					 county commissioners for prosecuting Aid to Families with Dependent Children
					 (AFDC) and Food Stamp intentional program violations. As approved by the Texas
					 Board of Human Services, DHS passes to the local prosecutors the federal share
					 of the cost per case, and the local prosecutors supply the state match. The
					 Budget Deficit Reduction Act of 1993 reduces the federal participation rate
					 from 75% to 50% for fraud control activities, effective July 1, 1995. DHS is
					 required to reduce the rate in effect before July 1, 1995, by 25% from:
(1) $420 to $280 for uncontested cases;
				  and;
(2) $1,017 to $678 for
				  contested cases.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter R - JUDICIAL AND ADMINISTRATIVE REVIEW OF HEARINGS › Section 357.701 - Purpose and Application

Current through Reg. 49, No. 28; July 12, 2024
The purpose of this subchapter is to address the process
					 for requesting administrative and judicial review of hearings. This subchapter
					 applies to those hearings provided in this chapter that are related to benefits
					 provided under the public assistance programs of Chapters 31 (TANF), 32
					 (Medicaid) and 33 (Nutrition Assistance Programs) Human Resources
					 Code.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter R - JUDICIAL AND ADMINISTRATIVE REVIEW OF HEARINGS › Section 357.702 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings, unless the context clearly indicates
					 otherwise.
(1) Administrative
				  Review--A desk review performed by an HHS System attorney of a hearing decision
				  related to benefits provided under the public assistance programs of Chapters
				  31, 32 and 33, Human Resources Code and is limited to the hearing record that
				  was considered by the hearings officer.
(2) Appellant--An applicant or client who
				  requests a hearing or requests an administrative review of the hearing decision
				  either personally or through a representative.
(3) Commission--The Texas Health and Human
				  Services Commission.
(4) Date of
				  Notice of Hearings Officer's Decision--The date on the written notice that
				  contains the hearings officer's decision.
(5) Day--A calendar day, unless otherwise
				  specified.
(6) Health and Human
				  Services (HHS) System Agencies--The following five state agencies that are
				  responsible for health and human services functions:
(A) Texas Health and Human Services
				  Commission (HHSC);
(B) Department
				  of Aging and Disability Services (DADS);
(C) Department of Assistive and
				  Rehabilitative Services (DARS);
(D)
				  Department of Family and Protective Services (DFPS); and
(E) Department of State Health Services
				  (DSHS).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 357 - HEARINGS › Subchapter R - JUDICIAL AND ADMINISTRATIVE REVIEW OF HEARINGS › Section 357.703 - Process and Timeframes

Current through Reg. 49, No. 28; July 12, 2024
(a) The hearing
				  officer makes the final administrative decision in a hearing for the HHS System
				  agency and its designees, unless, in those instances related to benefits
				  provided under the public assistance programs of Chapters 31, 32 and 33, Human
				  Resources Code, the appellant or the appellant's representative files a request
				  for an administrative review of the hearing decision.
(b) The following provisions establish the
				  process and timelines for an administrative review under this subchapter.
(1) An appellant or the appellant's
				  representative may make a timely request for an administrative review of a
				  hearing officer's decision.
(2) To
				  be timely, a request for an administrative review of the hearing officer's
				  decision must be postmarked not later than the 30th day after the date of the
				  notice of the decision and must be addressed to the hearings administrator. A
				  request for administrative review will be considered timely if filed after 30
				  days, where Appellant demonstrates good cause. Exception: The 30 days does not
				  begin until a new decision is issued if the appellant or appellant's
				  representative is working with the hearing officer to reopen or reschedule the
				  hearing.
(3) Within 10 days of
				  receipt of the request for administrative review, the Commission designates a
				  HHS System attorney to handle the administrative review of the hearing decision
				  on behalf of the HHS System Agency. The assigned attorney reviews the hearing
				  decision and the hearings record upon which it is based for errors of law and
				  errors of fact using the "preponderance of evidence" standard. This standard
				  means that the evidence as a whole shows that the fact sought to be proved is
				  more probable than not.
(4) The
				  attorney completes the administrative review and notifies the appellant in
				  writing of the results not later than the 15th business day after the date the
				  attorney receives the request for review.
(5) When an administrative review is
				  conducted, the attorney makes the final decision for the HHS system agency and
				  its designees.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 358 - MEDICAID ELIGIBILITY FOR THE ELDERLY AND PEOPLE WITH DISABILITIES › Subchapter A - GENERAL INFORMATION › Section 358.101 - Purpose and Scope

Current through Reg. 49, No. 28; July 12, 2024
(a) This chapter
				  establishes the Medicaid eligibility criteria for Medicaid-funded programs for
				  the elderly and people with disabilities (MEPD) in Texas, which provide medical
				  assistance to eligible persons as described in this chapter and in:
(1) Title XVI of the Social Security Act
				  (RSA 1382
				  et seq.);
(2) Title XIX of the
				  Social Security Act (RSA
				  1396a et seq.);
(3) 20 CFR Part 416, Supplemental security
				  income for the aged, blind, and disabled;
(4) 42 CFR Part 435, Eligibility in the
				  States, District of Columbia, the Northern Mariana Islands, and American
				  Samoa;
(5) 42 U.S.C. Chapter 7,
				  Social Security; and
(6) the Texas
				  State Plan for Medical Assistance (Medicaid).