| (a) The Office of Inspector General (OIG) plans and
conducts regular audits of Managed Care Organizations (MCOs) participating
in Medicaid. OIG audits of MCOs are conducted independent of the Health
and Human Services Commission (HHSC), but rely on the coordination
described in this section.
(b) For purposes of this rule, "MCO" includes any entity
with which an MCO contracts.
(c) OIG's roles and responsibilities for audits of
MCOs include:
(1) coordinating with the HHSC Medicaid and CHIP Services
Division (MCSD) and Health and Human Services (HHS) Internal Audit
Division in the development of audit plans to minimize duplication
of activities relating to audits of MCOs;
(2) conferring with MCSD on potential OIG MCO audits;
(3) considering input from MCSD, including input into
the development of risk assessment methodologies;
(4) considering audit requests by HHS System executive
management;
(5) performing risk assessments to select MCOs or MCO
activities for audit;
(6) considering previous audit and review findings
of MCOs by MCSD, HHS Internal Audit Division, and HHSC audit contractors;
(7) submitting to the HHS Executive Commissioner, at
least annually, a draft audit plan identifying the OIG's planned audits
of MCOs;
(8) considering and responding to any comments, or
alternative or additional audit topics, submitted to the OIG by the
HHS Executive Commissioner, or the HHS Executive Commissioner's designee,
on the OIG's draft audit plan before finalizing the annual audit plan;
(9) consulting with MCSD management, consulting with
subject matter experts, and, when necessary, obtaining specialized
training, to ensure the OIG has sufficient knowledge and understanding
of managed care-related policies and contract requirements to effectively
conduct audits of MCOs;
(10) communicating preliminary results of MCO audits
to MCSD for review and comment;
(11) considering MCSD comments before finalizing MCO
audit report recommendations; and
(12) sharing proposed audit findings with MCSD before
issuing a final report to an MCO or to MCSD.
(d) Notwithstanding subsections (a), (b), and (c) of
this section, the OIG may conduct unplanned audits of allegations
of suspected fraud, waste, or abuse by MCOs. Such unplanned audits
need not be part of any OIG audit plan or part of the usual processes
described in this section and the OIG may, after sharing proposed
audit findings with MCSD, issue audit reports directly to MCOs.
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