Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 11 - GENERAL ADMINISTRATION › Section 354.1157 - Potential Fraud, Program Abuse, and Other Misutilization

Current through Reg. 49, No. 28; July 12, 2024
(a) The health insuring agent and the
					 department develop and mutually agree to procedures and safeguards reasonably
					 necessary to prevent and control fraud, program abuse, and other misutilization
					 by eligible recipients, eligible providers, and others.
(b) The health insuring agent in accordance
					 with procedures approved by the Texas Department of Health (department) may, or
					 if required by the department will, withhold future payments to eligible
					 providers involved in or suspected of being involved in potential fraud,
					 program abuse, or other misutilization.
(c) In the event fraud, other violations of
					 law of the State of Texas or the United States, program abuse, or other
					 misutilizations are suspected, the health insuring agent promptly advises the
					 department that such a situation appears to exist and that it has conducted an
					 internal investigation and has determined that said situation is not the result
					 of computer or human error. The health insuring agent in accordance with prior
					 approval by the department independently or in conjunction with the department
					 conducts an initial investigation to acquire and evaluate such facts as are
					 necessary to determine if any offense, violation, program abuse, or other
					 misutilization in fact exists.
(d)
					 The health insuring agent assists the department in the furnishing of any
					 reports or other documentation necessary for the department to acquire and
					 evaluate facts necessary to determine if any offense, violation, program abuse,
					 or other misutilization exists. The department refers cases to the appropriate
					 state agencies and law enforcement agency, if the seriousness of an offense,
					 violation, program abuse, or other misutilization warrants the
					 referral.
(e) The health insuring
					 agent, with prior approval of the department on a case-by-case basis, and in
					 accordance with guidelines mutually agreed upon by the health insuring agent
					 and the department, pursues and seeks to recover, with or without legal action,
					 any amounts paid as the result of program abuse or other misutilization. The
					 health insuring agent, with prior approval of the department on a case-by-case
					 basis compromises, settles, and executes appropriate releases in accordance
					 with generally accepted insurance practice.
(f) Any sums recovered under this section by
					 the health insuring agent or the department, less court costs, attorney's fees,
					 and other costs of litigation, if any, are applied against the claims
					 involved.
(g) If an eligible
					 provider delivers health care to an individual having a bona fide Medical Care
					 Identification Card, the eligible provider is paid as usual for such services
					 even though it may be determined that the card was obtained by fraudulent means
					 unknown to the provider.