| (a) The OIG recovers overpayments made to providers
within the Medicaid or other HHS programs, whether the overpayment
resulted from error by the provider, the claims administrator, or
an operating agency, misunderstanding, or a program violation.
(b) Application. The OIG may recoup from any person
if it determines that the person committed an act for which a person
is subject to administrative actions or sanctions, including the following:
(1) commits a program violation that leads to the payment
of an overpayment;
(2) has failed to pay a debt owed to Medicare or to
any Medicaid program as the result of fraudulent or abusive actions
by a person participating in such program;
(3) is affiliated with a person who commits a program
violation that leads to the payment of an overpayment;
(4) commits an act for which sanctions, damages, penalties,
or liability could be or are assessed by the OIG; or
(5) who causes or receives an overpayment.
(c) Notice includes:
(1) the specific basis for the overpayment or debt;
(2) a description of facts and supporting evidence;
(3) a representative sample of any documents that form
the basis for the overpayment or debt;
(4) the extrapolation methodology, information relating
to the extrapolation methodology used as part of the investigation,
and the methods used to determine the overpayment or debt in sufficient
detail so that the extrapolation results may be demonstrated to be
statistically valid and are fully reproducible;
(5) the calculation of the overpayment or debt amount;
(6) the amount of damages and penalties, if applicable;
and
(7) a description of administrative and judicial due
process remedies, including the provider's option to seek informal
resolution, the provider's right to seek a formal administrative appeal
hearing, or the provider's option to seek both.
(d) The person who is the subject of a recoupment of
overpayment or recoupment of a debt is responsible for payment of
all overpayment amounts or debts assessed.
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| Source Note: The provisions of this §371.1711 adopted to be effective October 14, 2012, 37 TexReg 7989; amended to be effective April 15, 2014, 39 TexReg 2833; amended to be effective October 1, 2015, 40 TexReg 6585; amended to be effective May 1, 2016, 41 TexReg 2941 |
