The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise. (1) Abuse--Provider practices that are inconsistent with sound fiscal, business, or medical practices and that result in unnecessary program cost or in reimbursement for services that are not medically necessary; do not meet professionally recognized standards for health care; or do not meet standards required by contract, statute, regulation, or previously sent interpretations to the provider of any of the items listed. (2) Act--The Medicare and Medicaid Patient and Program Protection Act of 1987 (Public Law 100-93). (3) Affiliates--Persons associated with one another so that any one of them directly or indirectly controls or has the power to control another in whole or in part. (4) Agent--Any person, company, firm, corporation, employee, independent contractor, or other entity or association acting for or in the place of the department or a provider under authority of the department or a provider. (5) Civil Monetary Penalty Law--Any state or federal law permitting or requiring assessment of penalties and/or damages against individuals or entities or both for conduct that includes a claim or request for payment under Titles XVIII, XIX, or XX; and that violates the federal and/or state statutes and regulations enacted pursuant to these titles. (6) Closed-end provider agreement--An agreement for a specific period of time. It must be renewed for the provider to continue to participate in the Medicaid Program. (7) Controlled substances--"Controlled substance" as defined by the Texas Controlled Substances Act (Texas Civil Statutes, Article 4476-15) or its successor and the Federal Controlled Substances Act (21 USCA §8.01 et seq.) or its successor. (8) Conviction or convicted--A person is considered to have been convicted of a criminal offense when: (A) a judgment of conviction has been entered against him by a federal, state, or local court, regardless of whether an appeal is pending or whether the judgment of conviction or other record relating to criminal conduct has been expunged; (B) he has been found guilty by a federal, state, or local court; (C) he has entered a plea of guilty or nolo contendere that has been accepted by a federal, state, or local court; or (D) he has entered a first offender or other program and judgement of conviction has been withheld. (9) Department--The Texas Department of Human Services (DHS). (10) Division administrator--The administrator for a division of the department administering a Title XIX or XX service. (11) Exclusion--The temporary barring or permanent exclusion of a person from participation in the Titles XIX and XX programs, which includes barring the person from providing, ordering or prescribing items or services for Titles XIX and XX recipients. This includes the termination of the provider contract/agreement with the excluded person. (12) False statement or misrepresentation--Any statement or representation that is inaccurate, incomplete, or not true. (13) Federal financial participation (FFP)--Federal dollar used for the administration of benefit programs. (14) Fraud--Any act that constitutes fraud under applicable federal or state law, including any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or some other person. (15) Fraud and Abuse Division--The division within the department charged with completing integrity reviews on potential Medicaid provider fraud or abuse cases and full investigations on provider abuse cases. (16) Inpatient institutional services--Inpatient services provided by hospitals and long term care facilities. (17) Licensing authority adverse action--Action by a state or federal licensing entity (including other similar authority) against conduct that adversely affects the status of the license. Action includes revocation or suspension of a license, reprimand, censure, or probation. (18) Open-end provider agreement--An agreement that has no specific termination date and continues in force as long as both parties agree. (19) Overpayment--The amount paid to a provider that exceeds the amount to which the provider is entitled for a particular service. Overpayments may result from any of the following, which are not intended to be all inclusive: a false statement or misrepresentation, an omission of pertinent information, or the lack of sufficient supporting documentation for the service. This does not include claims processing errors made by the department or its agents, although these are subject to recoupment. (20) Person--An individual, association, partnership, corporation, or other organization or legal entity that has or has had a contract or provider agreement with the department or has been or is an employee of a Title XVIII or any state's Title XIX, XX, or V provider. (21) Practitioner--A physician or other individual licensed under state law to practice his profession. (22) Provider--A person, firm, partnership, corporation, agency, association, institution, or other entity that was or is approved by the department to provide medical assistance under contract or provider agreement with the department. (23) Recipient--A person eligible for and covered by the Texas Medical Assistance program. (24) Recoupment of overpayment--A reduction or an adjustment of the amounts paid to a provider or collection of funds on previously submitted pending and subsequently submitted bills to offset overpayments previously made to the provider. (25) Restricted reimbursement--Denial of payment for specific procedures for a specified time period for services that the provider has abused or has billed inappropriately. (26) State Health Care program--Any program that has a state plan approved under Title XIX or any program that receives funds or allotments in any state under Title V or XX of the Social Security Act. (27) Suspension of payments (payment hold)--The withholding of all or any portion of payments due a provider until the matter in dispute between the provider and the department or agent is resolved. (28) Title XVIII--Title XVIII (Medicare) of the Social Security Act. (29) Title XIX--Title XIX (Medicaid) of the Social Security Act. (30) Title XX--Social Services Block Grant of the Social Security Act. (31) Unit--The Medicaid Fraud Control Unit within the attorney general's office that is responsible for investigating all potential Medicaid provider fraud cases and cases involving physical abuse of patients in institutional settings. |
| Source Note: The provisions of this §357.587 adopted to be effective July 1, 1986, 11 TexReg 2825; amended to be effective December 15, 1988, 13 TexReg 5828; transferred effective September 1, 2004, as published in the Texas Register September 17, 2004, 29 TexReg 9013 |
