| (a) Each managed care organization (MCO) subject to
this section must develop a plan to prevent and reduce waste, abuse,
and fraud and submit that plan annually to the Health and Human Services
Commission (HHSC), Office of Inspector General (OIG) for approval.
(b) The MCO is responsible for investigating possible
acts of waste, abuse, or fraud for all services, including those that
the MCO subcontracts to outside entities.
(c) The plan submitted to the HHSC-OIG must include
the following information to be considered for approval.
(1) A description of the MCO's procedures for detecting
possible acts of waste, abuse, and fraud by providers. The description
must address each of the following requirements:
(A) use of audits to monitor compliance and assist
in detecting and identifying CHIP program violations and possible
waste, abuse, and fraud overpayments through data matching, analysis,
trending, and statistical activities;
(B) monitoring of service patterns for providers, subcontractors,
and recipients;
(C) use of a hotline or another mechanism to report
potential or suspected violations;
(D) use of random payment review of claims submitted
by providers for reimbursement to detect potential waste, abuse, or
fraud;
(E) use of edits or other evaluation techniques to
prevent payment for fraudulent or abusive claims;
(F) use of routine validation of MCO data; and
(G) verification that MCO members actually received
services that were billed.
(2) A description of the MCO's procedures for investigating
possible acts of waste, abuse, and fraud by providers. The procedures
must satisfy the requirements in subparagraphs (A) - (C) of this paragraph.
(A) The MCO must conduct a preliminary investigation
within 15 working days of the identification or reporting of suspected
or potential waste, abuse, or fraud.
(B) The preliminary investigation must include the
following:
(i) Determining if the MCO has received any previous
reports of incidences of suspected waste, abuse, or fraud or conducted
any previous investigations of the provider in question. If so, the
investigation should include a review of all materials related to
the previous investigations, the outcome of the previous investigations,
and a determination of whether the new allegations are the same or
relate to the previous investigation.
(ii) Determining if the service provider has received
any educational training from the MCO in regard to the allegation.
(iii) Conducting a review of the provider's billing
pattern to determine if there are any suspicious indicators.
(iv) Reviewing the provider's payment history for the
past three years, if available, to determine if there are any suspicious
indicators.
(v) Reviewing the policies and procedures for the program
type in question to determine if what has been alleged is a violation.
(C) If it is determined that suspicious indicators
of possible waste, abuse, or fraud exist, within 15 working days from
the conclusion of subparagraphs (A) and (B) of this paragraph, the
MCO must select a sample for further review. The sample must consist
of a minimum of 50 recipients or 15% of a provider's claims related
to the suspected waste, abuse, and fraud; provided, however, that
if the MCO selects a sample based upon 15% of the claims, the sample
must include claims relating to at least 50 recipients. The MCO must:
(i) within 15 working days of the selection of the
sample, request medical or dental records and encounter data for the
sample recipients.
(ii) review the requested medical or dental records
and encounter data within 45 working days of receipt of the records
to:
(I) validate the sufficiency of service delivery data
and to assess utilization and quality of care;
(II) ensure that the encounter data submitted by the
provider is accurate; and
(III) evaluate if the review of other pertinent records
is necessary to determine if waste, abuse, or fraud has occurred.
If the review of additional records is necessary then conduct such
review.
(3) A description of the MCO's procedures for detecting
possible acts of waste, abuse, and fraud by recipients. The description
must address the following:
(A) Review of claims when waste, abuse, or fraud is
suspected or reported to determine if:
(i) Treatment(s) and/or medication(s) prescribed by
more than one provider appears to be duplicative, excessive, or contraindicated;
(ii) Recipients are using more than one provider to
obtain similar treatments and /or medications;
(iii) Providers other than the assigned Primary Care
Provider (PCP) are treating the recipient, and there is no evidence
that the recipient was treated by the assigned PCP for a similar or
related condition; and
(iv) The recipient has a high volume of emergency room
visits with a non-emergent diagnosis.
(B) Review medical or dental records for the recipients
in question if claims review does not clearly determine if waste,
abuse, or fraud has occurred.
(C) For health care MCOs, use of edits or other evaluation
techniques to identify possible overuse or abuse of psychotropic or
controlled medications by recipients who are allegedly treated at
least monthly by two or more physicians. A physician includes: psychiatrists,
pain management specialists, anesthesiologists, and physical medicine
and rehabilitation specialists.
(4) A description of the MCO's procedures for investigating
possible acts of waste, abuse, and fraud by recipients. The procedures
must satisfy the requirements in subparagraphs (A) - (B) of this paragraph,
as applicable.
(A) An MCO must conduct a preliminary investigation
within 15 working days of the identification or reporting of suspected
or potential waste, abuse, or fraud.
(B) For a health care MCO, a preliminary investigation
must include the following:
(i) Review of acute care and emergency room claims
submitted by providers for the recipient suspected of waste, abuse,
or fraud.
(ii) Analysis of pharmacy claim data submitted by providers
for the recipient suspected of waste, abuse, or fraud to determine
possible abuse of controlled or non-controlled medications. If the
MCO does not have the data necessary to conduct the pharmacy claims
review, the MCO must request the data within 15 working days of the
initial identification or reporting of the suspected or potential
waste, abuse, or fraud.
(iii) Analysis of claims submitted by providers to
determine if the diagnosis is appropriate for the medications prescribed.
(5) A description of the MCO's internal procedures
for referring possible acts of waste, abuse, or fraud to the MCO's
Special Investigative Unit (SIU) and the mandatory reporting of possible
acts of waste, abuse, or fraud by providers or recipients to the HHSC-OIG.
The procedures must satisfy the requirements in subparagraphs (A)
- (E) of this paragraph.
(A) Assign an officer or director the responsibility
and authority for reporting all investigations resulting in a finding
of possible acts of waste, abuse, or fraud to the OIG. An officer
could be but is not limited to a Compliance Officer, a Manager of
Government Programs, or a Regulatory Compliance Analyst.
(B) Provide specific and detailed internal procedures
for officers, directors, managers, and employees to report possible
acts of waste, abuse, and fraud to the MCO's SIU. The procedures must
include but are not limited to:
(i) Guidance regarding what information must be reported
to the MCO's SIU.
(ii) A requirement that information must be reported
to the MCO's SIU within 24 hours of identification or reporting of
suspected waste, abuse, and fraud.
(C) Provide specific and detailed internal procedures
for the SIU to report investigations resulting in a finding of waste,
abuse, or fraud to the assigned officer or director. The procedures
must include but are not limited to:
(i) Guidance regarding what information must be reported
to the assigned officer or director.
(ii) A requirement that possible acts of waste, abuse,
or fraud be reported to the assigned officer or director must occur
within 15 working days of making the determination.
(D) Utilizing the HHSC-OIG fraud referral form, the
assigned officer or director must report and refer all possible acts
of waste, abuse or fraud to the HHSC-OIG within 30 working days of
receiving the reports of possible acts of waste, abuse or fraud from
the SIU. The report and referral must include an investigative report
identifying the allegation, statutes/regulations violated or considered,
and the results of the investigation; copies of program rules and
regulations violated for the time period in question; the Cont'd... |
