| (B) a person obtains through embezzlement, misuse,
misapplication, improper withholding, conversion, or misappropriation
of funds that had been obtained by virtue of participation in Medicaid.
(49) Medical assistance--Includes all of the health
care and related services and benefits authorized or provided under
state or federal law for eligible individuals of this state.
(50) Member of household--An individual who is sharing
a common abode as part of a single-family unit, including domestic
employees, partners, and others who live together as a family unit.
(51) OAG--Office of the Attorney General of Texas or
its successor.
(52) OIG--HHSC Office of the Inspector General, its
successor, or designee.
(53) OIG's method of finance--The sources and amounts
authorized for financing certain expenditures or appropriations made
in the General Appropriations Act.
(54) Operating agency--A state agency that operates
any part of the Medicaid or other HHS program.
(55) Overpayment--The amount paid by Medicaid or other
HHS program or the amount collected or received by a person by virtue
of the provider's participation in Medicaid or other HHS program that
exceeds the amount to which the provider or person is entitled under
§1902 of the Social Security Act or other state or federal statutes
for a service or item furnished within the Medicaid or other HHS programs.
This includes:
(A) any funds collected or received in excess of the
amount to which the provider is entitled, whether obtained through
error, misunderstanding, abuse, misapplication, misuse, embezzlement,
improper retention, or fraud;
(B) recipient trust funds and funds collected by a
person from recipients if collection was not allowed by Medicaid or
other HHS program policy; or
(C) questioned costs identified in a final audit report
that found that claims or cost reports submitted in error resulted
in money paid in excess of what the provider is entitled to under
an HHS program, contract, or grant.
(56) Ownership interest--A direct or indirect ownership
interest (or any combination thereof) of five percent or more in the
equity in the capital, stock, profits, or other assets of a person
or any mortgage, deed, trust, note, or other obligation secured in
whole or in part by the person's property or assets.
(57) Payment hold (suspension of payments)--An administrative
sanction that withholds all or any portion of payments due a provider
until the matter in dispute, including all investigation and legal
proceedings, between the provider and HHSC or an operating agency
are resolved. This is a temporary denial of reimbursement under Medicaid
for items or services furnished by a specified provider.
(58) Person--Any legally cognizable entity, including
an individual, firm, association, partnership, limited partnership,
corporation, agency, institution, MCO, Special Investigative Unit,
CHIP participant, trust, non-profit organization, special-purpose
corporation, limited liability company, professional entity, professional
association, professional corporation, accountable care organization,
or other organization or legal entity.
(59) Person with a disability--An individual with a
mental, physical, or developmental disability that substantially impairs
the individual's ability to provide adequately for the person's care
or his or her own protection, and:
(A) who is 18 years of age or older; or
(B) who is under 18 years of age and who has had the
disabilities of minority removed.
(60) Physician--An individual licensed to practice
medicine in this state, a professional association composed solely
of physicians, a partnership composed solely of physicians, a single
legal entity authorized to practice medicine owned by two or more
physicians, or a nonprofit health corporation certified by the Texas
Medical Board under Chapter 162, Texas Occupations Code.
(61) Practitioner--An individual licensed or certified
under state law to practice the individual's profession.
(62) Preliminary investigation--A review by the OIG
undertaken to verify the merits of a complaint/allegation of fraud,
waste, or abuse from any source. The preliminary investigation determines
whether there is sufficient basis to warrant a full investigation.
(63) Prima facie--Sufficient to establish a fact or
raise a presumption unless disproved.
(64) Professionally recognized standards of health
care--Statewide or national standards of care, whether in writing
or not, that professional peers of the individual or entity whose
provision of care is an issue, recognize as applying to those peers
practicing or providing care within the state of Texas.
(65) Program violation--A failure to comply with a
Medicaid or other HHS provider contract or agreement, the Texas Medicaid
Provider Procedures Manual or other official program publications,
or any state or federal statute, rule, or regulation applicable to
the Medicaid or other HHS program, including any action that constitutes
grounds for enforcement as delineated in this subchapter.
(66) Provider--Any person, including an MCO and its
subcontractors, that:
(A) is furnishing Medicaid or other HHS services under
a provider agreement or contract with a Medicaid or other HHS operating
agency;
(B) has a provider or contract number issued by HHSC
or by any HHS agency or program or its designee to provide medical
assistance, Medicaid, or any other HHS service in any HHS program,
including CHIP, under contract or provider agreement with HHSC or
an HHS agency; or
(C) provides third-party billing services under a contract
or provider agreement with HHSC.
(67) Provider agreement--A contract, including any
and all amendments and updates, with Medicaid or other HHS program
to subcontract services, or with an MCO to provide services.
(68) Provider screening process--The process in which
a person participates to become eligible to participate and enroll
as a provider in Medicaid or other HHS program. This process includes
enrollment under this chapter or Chapter 352 of this title (relating
to Medicaid and Children's Health Insurance Program Provider Enrollment),
42 C.F.R Part 1001, or other processes delineated by statute, rule,
or regulation.
(69) Reasonable request--Request for access, records,
documentation, or other items deemed necessary or appropriate by the
OIG or a requesting agency to perform an official function, and made
by a properly identified agent of the OIG or a requesting agency during
hours that a person, business, or premises is open for business.
(70) Recipient--A person eligible for and covered by
the Medicaid or any other HHS program.
(71) Records and documentation--Records and documents
in any form, including electronic form, which include:
(A) medical records, charting, other records pertaining
to a patient, radiographs, laboratory and test results, molds, models,
photographs, hospital and surgical records, prescriptions, patient
or client assessment forms, and other documents related to diagnosis,
treatment, or service of patients;
(B) billing and claims records, supporting documentation
such as Title XIX forms, delivery receipts, and any other records
of services provided to recipients and payments made for those services;
(C) cost reports and documentation supporting cost
reports;
(D) managed care encounter data and financial data
necessary to demonstrate solvency of risk-bearing providers;
(E) ownership disclosure statements, articles of incorporation,
bylaws, corporate minutes, and other documentation demonstrating ownership
of corporate entities;
(F) business and accounting records and support documentation;
(G) statistical documentation, computer records, and
data;
(H) clinical practice records, including patient sign-in
sheets, employee sign-in sheets, office calendars, daily or other
periodic logs, employment records, and payroll documentation related
to items or services rendered under an HHS program; and
(I) records affidavits, business records affidavits,
evidence receipts, and schedules.
(72) Recoupment of overpayment--A sanction imposed
to recover funds paid to a provider or person to which the provider
or person was not entitled.
(73) Requesting agency--The OIG; the OAG’s Medicaid
Fraud Control Unit or Civil Medicaid Fraud Division; any other state
or federal agency authorized to conduct compliance, regulatory, or
program integrity functions on a provider, a person, or the services
rendered by the provider or person.
Cont'd... |
