| (a) If a managed care organization (MCO) suspects fraud
or abuse in the Medicaid or CHIP program, based on information, data,
or facts obtained by the MCO, it must:
(1) immediately notify the Health and Human Services
Commission-Office of Inspector General (HHSC-OIG) and the Office of
the Attorney General (OAG);
(2) following the completion of ordinary due diligence
regarding a suspected overpayment, begin payment recovery efforts
subject to subsection (b) of this section; and
(3) ensure that any payment recovery efforts in which
the MCO engages are in accordance with this subchapter.
(b) If the amount to be recovered exceeds $100,000,
the MCO may not engage in payment recovery efforts if it receives
a notice from the HHSC-OIG or the OAG indicating that the MCO is not
authorized to proceed with recovery effort. Such notice must be supplied
no later than the tenth business day after the MCO notifies the HHSC-OIG
and OAG of the suspected fraud or abuse.
(c) If the HHSC-OIG or the OAG has assumed responsibility
for completion of the investigation and final disposition of any administrative,
civil, or criminal action taken by the state or federal government,
the HHSC-OIG or the OAG will determine and direct the collection of
any overpayment.
(d) An MCO may retain any money recovered by the MCO.
(e) The HHSC-OIG will distribute any amounts collected
to the MCO, less any costs of investigation and collection proceedings.
(f) An MCO must submit a quarterly report to the HHSC-OIG
detailing the amount of money recovered.
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