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 G - ADMINISTRATIVE ACTIONS AND SANCTIONS
Division 3 - ADMINISTRATIVE ACTIONS AND SANCTIONS
Section 371.1719 - Recoupment of Overpayments Identified by Audit

(1) An audit conducted by the OIG or its contractor must:

(2) If an exit conference is conducted after the site visit, the auditor must allow the person to:

(1) Point of contact. A person may designate a specific address and individual point of contact to receive all correspondence related to the audit by sending the designated individual's contact information to the auditor and to the OIG Sanctions unit. The OIG begins sending all notices and correspondence to the designated point of contact within 30 calendar days after receiving the designation.

(2) Draft audit report. After the field work is completed, the OIG or its auditor delivers written notice of a draft audit report in accordance with § RSA 371.1609 of this subchapter (relating to Notice and Service).

(3) Revised draft audit report and additional revisions. The auditor may elect whether to issue a revised draft audit report or to issue a final report. The auditor may revise the draft audit report as needed to incorporate the management responses and reconsideration of any initial findings. A revised draft audit report is delivered to the person in accordance with § RSA 371.1609 of this subchapter.

(4) Notice of final audit report. The OIG or its auditor delivers written notice of a final audit report in accordance with § RSA 371.1609 of this subchapter. The final audit report must include:

(5) Notice of appeal results. After the conclusion of any appeal hearing, the OIG delivers written notice of the appeal results in accordance with § RSA 371.1609 of this subchapter. The written notice identifies the final overpayment amount.

(1) Draft audit report. A person who is the subject of a draft audit report may request an informal appeal, may make a written management response, or both. The OIG or its auditor, as designated in the notice letter, must receive a written request for the informal appeal or written management response no later than the 30th calendar day after the date the person receives the draft audit report, or by the date specified by the auditor, whichever is earlier. The informal appeal, if requested, consists of a desk review by the auditing division or entity at the OIG or its auditor.

(2) Revised draft audit report. If the person is the subject of a revised draft audit report that modifies the basis or rationale for determining that an overpayment exists or that increases the overpayment amount, the person may request an informal appeal, may make a written management response, or both. The OIG or its auditor, as designated in the notice letter, must receive a written request for the informal appeal or written management response no later than the 30th calendar day after the date the person receives the revised draft audit report, or by the date specified by the auditor, whichever is earlier. The informal appeal, if requested, consists of a desk review by the auditing division or entity at the OIG or its auditor.

(3) Response to final audit report. A person who receives a final audit report must respond in one of the following ways:

(4) Request for a hearing to appeal. Upon timely receipt of a proper written request for appeal, the OIG notifies the HHSC Appeals Division of the provider's hearing request. The appeal then proceeds pursuant to Chapter 357, Subchapter I of this title (relating to Hearings Under the Administrative Procedure Act).

(1) The effect of a final overpayment identified in an audit is to create a final debt in favor of the State of Texas.

(2) A final audit report becomes final and unappealable if a written request for an appeal is not received by the OIG within 15 calendar days after the person's receipt of the final audit report.

(3) If a duly requested final payment plan agreement is not executed by all parties or full restitution is not received within 60 calendar days after receipt by the person of an unappealed final audit report or final disposition of an administrative appeal, one or more vendor holds may be placed on the person's payment claims and account; however, the OIG may agree to toll the imposition of any vendor holds pending negotiations of payment plan terms. The OIG sends written notice to the person of any decision to toll the imposition of any vendor holds.

(4) If the person has duly requested an appeal, the contested amount of the overpayment becomes final 30 days after the person receives written notice of the appeal results. Recoupment of any overpayments at issue on appeal is not initiated until the appeal has been finally determined.

(1) For purposes of refunding the federal share of any questioned costs, the final audit report constitutes the State's written notice of the identified overpayment amount. The date of the written notice of overpayment accompanying a final audit report constitutes the date of discovery.

(2) If a person appeals a final audit report, the State issues a written notice of the identified overpayment amount at the conclusion of the appeal, and the date of that notice of final audit report constitutes the date of discovery.