| (a) The OIG may grant an award to a person who reports
activity that constitutes fraud, waste, or abuse of funds in the Medicaid
program or reports overcharges in the program if the OIG determines
that the disclosure results in the recovery of a damage or penalty
imposed under §32.039, Texas Human Resources Code, and described
in this subchapter. Unless the person is the original source of the
information as defined in §36.113(b), Texas Human Resources Code,
the OIG may not grant an award to a person in connection with a report
if:
(1) The OIG or the OAG had independent knowledge of
the activity;
(2) The OIG or the OAG had an open complaint or investigation
on the provider or person;
(3) the state or any agent of the state was a party
to civil or criminal proceedings in which the allegations were disclosed;
(4) the allegations were disclosed in a legislative
or administrative report, hearing, audit, or investigation; or
(5) the allegations were disclosed by the news media.
(b) A person who brings an action under Chapter 36,
Subchapter C, Texas Human Resources Code is not eligible for an award
under this section.
(c) A person who makes a report under this section
must make known at the time of the report of the complaint that they
are reporting the potential fraud, waste, or abuse in accordance with
this section.
(d) The OIG determines, at its discretion, the amount
of an award. The award may not exceed five percent of the amount of
the administrative damage or penalty collected under this subchapter
that resulted from the person's disclosure. In determining the amount
of the award, the OIG considers how important the disclosure was in
ensuring the fiscal integrity of the program. The OIG may also consider
whether the individual participated in the fraud, waste, abuse, or
overcharge.
(e) The OIG pays an award made under this section only
after collecting the funds to be awarded. Recovery of funds, including
overpayments, damages and penalties, and any other collections from
the provider or person committing the fraud, waste, or abuse, is applied
in the following order:
(1) the overpayment;
(2) refund of the federal share of any overpayment,
damages, or penalties;
(3) the OIG's method of finance from the collected
damages and penalties;
(4) the OIG's investigative costs from the collected
damages and penalties;
(5) other costs of recovery from the collected damages
and penalties;
(6) an award from the collected damages and penalties;
and
(7) any other accounts receivable against the person
or provider.
(f) The priority of application and distribution of
the collected funds under subsection (e) of this section may be altered,
at the discretion of the OIG, due to state or federal statute or other
policy determinations.
(g) The OIG calculates awards based on the collected
state general revenue portion of the penalties and damages. If HHSC
enters into global or national settlements where the federal government
or other agencies receive a portion of the amount of damages or penalties,
the award is calculated only on the remaining state general revenue
share collected.
(h) The OIG does not award a distribution unless the
OIG has met its method of finance threshold for the biennium, as defined
in the General Appropriations Act, from damages and penalties collected
under this subchapter.
(i) The person reporting a complaint has no discretion
or authority over the OIG decision to allow a payment plan or to decide
the terms of the payment plan.
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