| (a) The OIG begins a full investigation within 30 days
of completing the preliminary investigation if it determines that
a full investigation is warranted.
(b) The OIG may close a full investigation for one
or more of the following reasons, if the OIG determines that:
(1) the investigative research and evidence gathered
during the full investigation indicates that fraud, waste, or abuse
is not present;
(2) there is no violation of Medicaid policy;
(3) there is no overpayment to recover;
(4) the potential identified overpayment is not cost-effective
to pursue;
(5) the issues related to the complaint are outside
of OIG jurisdiction;
(6) a referral to the appropriate licensure or oversight
agency is deemed a more appropriate action;
(7) the case should be referred to another division
of OIG for action;
(8) the provider should receive education;
(9) the Medicaid provider is deceased or out of business;
or
(10) no administrative action, sanction, or overpayment
is appropriate after weighing the following factors:
(A) the seriousness of the allegations and potential
program violations;
(B) the investigative resources available to pursue
the full investigation; and
(C) the sufficiency and strength of evidence gathered
in the full investigation.
(c) A full investigation must be completed within 180
days unless the OIG determines that more time is needed to complete
the investigation.
(d) If the OIG determines that more time is needed
to complete the investigation, the OIG must notify the provider who
is the subject of the investigation indicating that the investigation
will exceed 180 days and specifying the reasons the OIG is unable
to complete the investigation within the 180-day time period. However,
the OIG is not required to notify the provider if the OIG determines
that notice would jeopardize the investigation.
(e) Within 30 days of completion of the preliminary
investigation, the OIG refers the case to the state's Medicaid fraud
control unit if a provider is suspected of fraud, waste, or abuse
involving criminal conduct or if the OIG learns or has reason to suspect
that a provider's records are being withheld, concealed, destroyed,
fabricated, or in any way falsified. This referral does not preclude
the OIG from continuing its investigation of the provider.
|
| Source Note: The provisions of this §371.1307 adopted to be effective April 15, 2014, 39 TexReg 2833; amended to be effective May 1, 2016, 41 TexReg 2941; amended to be effective July 23, 2019, 44 TexReg 3628 |
