Current through Reg. 49, No. 38; September 20, 2024
(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
(2)
jurisdiction.
(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 § 531.1021(g) and subject to Texas Government Code
§ 531.1021(h).
