Current through Reg. 50, No. 13; March 28, 2025
(a) The OIG may
receive and investigate complaints related to fraud, waste, or abuse within
HHSC or an HHS agency. The OIG prioritizes complaints for purposes of
determining the order in which complaints are investigated, taking into account
the seriousness of the allegations made in a complaint. The OIG may consider
the following factors when opening cases and prioritizing cases for the
efficient management of the OIG's workload:
(1) the highest potential for recovery or
risk to the State;
(2) the history
of noncompliance with applicable law and regulations;
(3) identified fraud trends;
(4) internal affairs investigations according
to the seriousness of the threat to recipient or public safety or the risk to
program integrity in terms of the amount or scope of fraud, waste, or abuse
posed by the allegation that is the subject of the investigation;
(5) acts or the failure to act that
potentially threatens the public health or may result in physical harm to the
public; and
(6) the potential for
or actual physical destruction of state property, including the loss, theft and
destruction of State assets, property, benefits, or
equipment.
(b) The OIG
assesses complaints received by the OIG from any source to determine within 30
days of receipt whether it has:
(1) sufficient
indicators of fraud, waste, or abuse; and
(c) If the OIG has jurisdiction and
sufficient information to justify an investigation, the OIG completes a
preliminary investigation within 45 days of receipt of the complaint to
determine whether there is sufficient basis to warrant a full investigation.
The OIG may also collaborate with federal or other state authorities in
conducting audits or investigations and in taking enforcement measures in
response to program violations.
(1) After
completing its preliminary investigation, the OIG may, at its discretion,
initiate settlement discussions of an administrative case with the person who
is the subject of the investigation. If the matter cannot reasonably be settled
or if the OIG determines that further investigation is required before the
propriety of settlement or other enforcement can be evaluated, the OIG may
conduct a full investigation.
(2)
If, at any point during its investigation, the OIG determines that an
overpayment resulted without wrongdoing, the OIG may refer the matter for
routine payment correction by HHSC's fiscal agent or an operating agency or may
offer a payment plan.
(d) The OIG may also consider the following
factors in determining whether to open a full investigation:
(1) the nature of the program
violation;
(2) evidence of
knowledge and intent;
(3) the
seriousness of the program violation;
(4) the extent of the violation;
(5) prior noncompliance issues;
(6) prior imposition of sanctions, damages,
or penalties;
(7) willingness to
comply with program rules;
(8)
efforts to interfere with an investigation or witnesses;
(9) recommendations of peer review
groups;
(10) program violations
within Medicaid, Medicare, Titles V, XIX, XX, CHIP, and other HHS
programs;
(11) pertinent affiliate
relationships;
(12) past and
present compliance with licensure and certification requirements;
(13) history of criminal, civil, or
administrative liability; and
(14)
any other relevant information or analysis the OIG deems
appropriate.
(e) In
addition to the factors listed in subsection (d) of this section, the OIG may
also consider the following factors in determining whether to close a
preliminary investigation:
(1) the complainant
is unavailable or unwilling to cooperate;
(2) information or evidence to substantiate
the complaint is unavailable or unobtainable;
(3) the complaint is resolved after it is
filed with the OIG;
(4) data
regarding the subject of the complaint, such as claims or encounter data, does
not support the allegations raised in the complaint;
(5) an investigation, audit, inspection, or
other review regarding the complaint already exists;
(6) an analysis of the provider's billing
patterns does not show that the provider's billing patterns vary significantly
from those of comparable providers; or
(7) any other relevant information or
analysis the OIG deems appropriate.
(f) Once the preliminary investigation is
completed, the OIG reviews the allegations of fraud, waste, abuse, or
questionable practices, and all facts and evidence relating to the allegation
and prepares a preliminary report before the allegation of fraud or abuse
proceeds to a full investigation. The preliminary report documents the
following:
(1) the allegation that is the
basis of the report;
(2) the
evidence reviewed;
(3) the
procedures used to conduct the preliminary investigation;
(4) the findings of the preliminary
investigation; and
(5) whether a
full investigation is warranted.
(g) The OIG maintains a record of all
allegations of fraud, waste, or abuse against a provider containing the date
each allegation was received or identified and the source of the allegation, if
available. This record is confidential under Texas Government Code §
544.0259(e)
and subject to Texas Government Code §
544.0259(f).
