Current through Reg. 49, No. 38; September 20, 2024
(a) The Health and Human Services Commission
(HHSC), through the Medicaid and CHIP Services Division, the Office of
Inspector General (OIG), and Health and Human Services (HHS) Internal Audit
Division, is responsible for audits of MCOs and any entity with which an MCO
contracts.
(b) For purposes of this
rule, "MCO" includes any entity with which an MCO contracts.
(c) HHSC conducts audits of MCOs, including
financial audits, performance audits, compliance audits, and agreed upon
procedures:
(1) with the scope and frequency
necessary to provide information to allow for the effective oversight and
control of the MCOs; and
(2) as
necessary to comply with all federal and state laws.
(d) Medicaid and CHIP Services Division's
roles and responsibilities for audits of MCOs include:
(1) determining, based on coordination with
OIG about MCO audits, which audits to assign to contracted audit firms in order
to eliminate duplication of audit effort and reduce the impact of potentially
duplicative audits on the MCOs;
(2)
coordinating with HHS Internal Audit Division to obtain delegated authority,
from the State Auditor's Office (SAO), to procure audit services as required by
Texas Government Code §
RSA
321.020;
(3) facilitating and determining the extent
of work to be performed in agreed upon procedures and audits of MCOs, through
the use of contracted audit firms as part of the integrated business processes
used to oversee and monitor MCOs;
(4) providing final reports of agreed upon
procedures and audits to OIG, along with other information relevant to
quantifying MCO performance under the contract with HHSC, including results of
on-site monitoring visits, and other relevant MCO-related performance
information;
(5) providing all
deliverables, such as contracts, contract amendments, and audit reports, for
contracted audit related engagements to HHS Internal Audit Division for
delivery to the SAO; and
(6)
ensuring actions planned to address audit recommendations are implemented,
including actions planned by the Medicaid and CHIP Services Division or by an
MCO.
(e) The OIG's roles
and responsibilities, related to performing audits of MCOs, are as outlined in
§
RSA
371.37 of this title (relating to Audit of
Managed Care Organizations).
(f)
HHS Internal Audit Division's roles and responsibilities, related to audits of
MCOs, are:
(1) auditing the Medicaid and CHIP
Services Division and OIG, as part of its established audit authority and
risk-based audit coverage, including auditing the effectiveness of coordination
between the Medicaid and CHIP Services Division and OIG on the performance of
MCO audits;
(2) notifying and
conferring with the Medicaid and CHIP Services Division and OIG before
initiating an audit of an MCO contained in the audit plan approved by the HHS
Executive Commissioner;
(3)
coordinating with Medicaid and CHIP Services Division when audit services need
to be procured to ensure HHSC obtains the appropriate authority to procure
audit services from the SAO; and
(4) coordinating with Medicaid and CHIP
Services Division to ensure that all appropriate documents related to
contracted audit services are obtained and provided to the SAO. These documents
include executed contracts, contract amendments, and audit reports.
