Current through Reg. 49, No. 38; September 20, 2024
(a) In
this section, "provider" means an individual, firm, partnership, corporation,
agency, association, institution, or other entity that is or was approved by
HHSC to provide Medicaid under contract or provider agreement with
HHSC.
(b) This section does not
apply to a computerized audit conducted using the Medicaid Fraud Detection
Audit System or an audit or investigation conducted by the Medicaid Fraud
Control Unit of the Office of the Attorney General, the Office of the State
Auditor, the Office of Inspector General, or the Office of Inspector General in
the United States Department of Health and Human Services.
(c) Except as described in subsection (b) of
this section, an agency auditing division or entity must:
(1) Notify the provider, and the provider's
corporate headquarters, if the provider is a pharmacy that is incorporated, of
the impending audit not later than the seventh day before the date the field
audit portion of the audit begins;
(2) Limit the period covered by an audit to
three years;
(3) Accommodate the
provider's schedule to the greatest extent possible when scheduling the field
audit portion of the audit;
(4)
Conduct an entrance interview before beginning the field audit portion of the
audit;
(5) Audit all providers of
the same type under the same standards and parameters;
(6) Conduct the audit in accordance with
generally accepted government auditing standards issued by the Comptroller
General of the United States or other appropriate standards;
(7) Conduct an exit interview at the close of
the field audit portion of the audit with the provider to review the agency's
initial findings;
(8) At the exit
interview, allow the provider to:
(A) Respond
to questions by the agency;
(B)
Comment, if the provider desires, on the initial findings of the agency;
and
(C) Submit additional
supporting documentation, for consideration, that meets the auditing standards
required by paragraph (6) of this subsection, to correct a questioned cost, if
there is no indication that the error or omission that resulted in the
questioned cost demonstrates intent to commit fraud;
(9) Provide to the provider a preliminary
audit report and a copy of any document used to support a proposed adjustment
to the provider's cost report;
(10)
Permit the provider to produce, for consideration, documentation to address any
exception found during an audit not later than the 10th day after the date the
field audit portion of the audit is completed;
(11) Deliver a draft audit report to the
provider not later than the 60th day after the date the field audit portion of
the audit is completed;
(12) Permit
the provider to submit, for consideration, a written management response to the
draft audit report or to informally appeal the findings in the draft audit
report not later than the 30th day after the date the draft audit report is
delivered to the provider. The informal appeal will consist of a desk review by
the auditing division or entity; and
(13) Deliver the final audit report to the
provider not later than the 180th day after the date the field audit portion of
the audit is completed or the date on which a final decision is issued on an
appeal made under subsection (d) of this section, whichever is later.
(d) Upon receipt of the final
audit report specified in subsection (c)(13) of this section, the provider may
request an informal, early review of a final audit report or an unfavorable
audit finding by an HHSC ad hoc review panel without the need to obtain legal
counsel. All recommendations of the ad hoc review panel are advisory in nature
and are not binding on HHSC.
