Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 371 - MEDICAID AND OTHER HEALTH AND HUMAN SERVICES FRAUD AND ABUSE PROGRAM INTEGRITY
Subchapter B - OFFICE OF INSPECTOR GENERAL
Section 371.11 - Scope

Universal Citation: 1 TX Admin Code § 371.11

Current through Reg. 50, No. 13; March 28, 2025

(a) The OIG is responsible for preventing, detecting, auditing, inspecting, reviewing, and investigating fraud, waste, and abuse in the provision of HHS in Medicaid and other HHS programs. As part of its authority, the OIG may impose sanctions upon a finding by the OIG of fraud, waste, or abuse in Medicaid. The OIG is also responsible for enforcing state law relating to the provision of HHS in Medicaid and other HHS programs. As a result, the OIG may also investigate a suspected regulatory violation in a non-Medicaid, HHS program and, upon a finding of a violation, may recommend the HHS program take appropriate enforcement action to the extent of the HHS program's regulatory authority. The OIG administers program integrity and enforces program violations to the extent of applicable law governing Medicaid and the provision of other HHS. This includes pursuing Medicaid and other HHS fraud, abuse, overpayment, or waste. To accomplish the objectives of this chapter, the OIG implements review processes to distinguish payment discrepancies that can be corrected through routine payment adjustments from those suspected to result from program violations requiring investigation and possible administrative enforcement or judicial action.

(b) The Inspector General establishes objectives and priorities for the OIG that emphasize:

(1) coordinating investigative efforts to aggressively recover funds;

(2) allocating resources to cases that have the strongest supportive evidence and the greatest potential for recovery of money; and

(3) maximizing opportunities for referral of cases to the OAG.

(c) In addition to performing functions and duties otherwise provided by law, the OIG may:

(1) assess administrative penalties otherwise authorized by law on behalf of HHSC;

(2) request that the OAG obtain an injunction to prevent a person from disposing of an asset identified by the OIG as potentially subject to recovery by the OIG due to the person's fraud, waste, or abuse;

(3) provide for coordination between the OIG and SIUs or entities with which managed care organizations contract to identify and investigate fraudulent claims and other types of program abuse by recipients and providers, and approve the plan of the SIUs to prevent and reduce fraud, waste, or abuse;

(4) audit the use and effectiveness of state or federal funds, including contract and grant funds, administered by a person or state agency receiving the funds from an HHS agency;

(5) conduct investigations relating to the funds described in paragraph (4) of this subsection; and

(6) recommend policies promoting economical and efficient administration of the funds described in paragraph (4) of this subsection and the prevention and detection of fraud, waste, or abuse in the administration of those funds.

(d) The OIG may require employees of HHS agencies to provide assistance to the OIG in connection with its duties relating to the review, inspection, investigation, or audit of fraud, waste, abuse, or overpayment in the provision of HHS.

(e) The OIG is entitled to access to any information maintained by an HHS agency, including internal records, relevant to the functions of the OIG. This chapter sets forth the types of activities performed by the OIG to ensure program integrity.

(f) HHSC may obtain any information or technology necessary to enable the OIG to meet its responsibilities as mandated by state statute or other law.

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