| (A) During the MDS assessment utilization review of
a facility, the OIG identifies each assessment error (e.g., overpayment
amount or underpayment amount of an MDS assessment claim) from the
population as that term is described in subsection (m) of this section.
(B) Following the unannounced on-site review of the
sampled MDS assessment claim forms, an assessment error rate is calculated
as follows:
Attached Graphic
(C) The OIG processes all RUG reclassifications identified
as a result of the unannounced on-site utilization review.
(i) The OIG recovers from the facility any overpayment(s)
associated with an MDS assessment claim. The recovered amount is a
debt owed by the facility to the Texas Medicaid program. The facility
is reimbursed for any underpayment(s) identified.
(ii) To calculate any overpayment, the OIG extrapolates
to the population and the extrapolation is applied only to the RUG
classifications found in error. An adjustment equal to the net value
of the identified overpayment(s) and underpayment(s) is made. Any
net overpayments constitute a debt owed by the facility/provider,
as applicable, to the Texas Medicaid program. Net underpayments are
reimbursed to the facility/provider, as applicable. The OIG Utilization
Review extrapolates to the population in all cases of overpayment,
and the extrapolation is applied only to the RUG classifications found
in error.
(iii) An error rate greater than 25 percent or suspected
program violation described in Subchapter G, Division 2, of this chapter,
results in a referral for investigation to the OIG Medicaid Program
Integrity Division. This referral is made part of the state's method
for identification, investigation and referral for fraud under Chapter
357, Subchapter M, of this title (relating to Fraud or Abuse Involving
Medical Providers) and Chapter 371, Subchapter G of this title (relating
to Administrative Actions and Sanctions).
(D) An assessment error is subject to reconsideration
in accordance with subsection (q) of this section.
(i) If the facility timely requests reconsideration
of the unannounced on-site review results, the assessment error rate
is based on the results of the reconsideration.
(ii) If the facility does not timely request reconsideration
of the unannounced on-site review, the assessment error rate is based
on the results of the unannounced on-site review.
(s) Suspected fraudulent documentation, such as medical
or clinical records that appear to have been altered, falsified, or
fabricated, results in a referral for investigation to the OIG Medicaid
Program Integrity Division. This referral is made part of the state's
method for identification, investigation, and referral for fraud under
Chapter 357, Subchapter M, of this title.
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| Source Note: The provisions of this §371.214 adopted to be effective October 9, 2008, 33 TexReg 8311; amended to be effective May 1, 2016, 41 TexReg 2941; amended to be effective January 1, 2019, 43 TexReg 8582 |
