| (a) The health insuring agent and the department develop and
mutually agree to procedures and safeguards reasonably necessary to prevent
and control fraud, program abuse, and other misutilization by eligible recipients,
eligible providers, and others.
(b) The health insuring agent in accordance with procedures
approved by the Texas Department of Health (department) may, or if required
by the department will, withhold future payments to eligible providers involved
in or suspected of being involved in potential fraud, program abuse, or other
misutilization.
(c) In the event fraud, other violations of law of the State
of Texas or the United States, program abuse, or other misutilizations are
suspected, the health insuring agent promptly advises the department that
such a situation appears to exist and that it has conducted an internal investigation
and has determined that said situation is not the result of computer or human
error. The health insuring agent in accordance with prior approval by the
department independently or in conjunction with the department conducts an
initial investigation to acquire and evaluate such facts as are necessary
to determine if any offense, violation, program abuse, or other misutilization
in fact exists.
(d) The health insuring agent assists the department in the
furnishing of any reports or other documentation necessary for the department
to acquire and evaluate facts necessary to determine if any offense, violation,
program abuse, or other misutilization exists. The department refers cases
to the appropriate state agencies and law enforcement agency, if the seriousness
of an offense, violation, program abuse, or other misutilization warrants
the referral.
(e) The health insuring agent, with prior approval of the department
on a case-by-case basis, and in accordance with guidelines mutually agreed
upon by the health insuring agent and the department, pursues and seeks to
recover, with or without legal action, any amounts paid as the result of program
abuse or other misutilization. The health insuring agent, with prior approval
of the department on a case-by-case basis compromises, settles, and executes
appropriate releases in accordance with generally accepted insurance practice.
(f) Any sums recovered under this section by the health insuring
agent or the department, less court costs, attorney's fees, and other costs
of litigation, if any, are applied against the claims involved.
(g) If an eligible provider delivers health care to an individual
having a bona fide Medical Care Identification Card, the eligible provider
is paid as usual for such services even though it may be determined that the
card was obtained by fraudulent means unknown to the provider.
|
| Source Note: The provisions of this §354.1157 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective April 18, 1984, 9 TexReg 1965; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561 |
