| (i) Reconciliation. Beginning in the third year of
the waiver, data on the uncompensated-care physician application will
be used to reconcile actual costs incurred by the physician group
practice for a prior period with uncompensated-care payments, if any,
made to the physician group practice for the same period.
(1) If a physician group practice received payments
in excess of its actual costs, the overpaid amount will be recouped
from the physician group practice, as described in subsection (j)
of this section.
(2) If a physician group practice received payments
less than its actual costs, and if HHSC has available waiver funding
for the period in which the costs were accrued, the physician group
practice may receive reimbursement for some or all of those actual
documented unreimbursed costs.
(3) Transition payments are not subject to reconciliation
under this subsection.
(j) Recoupment.
(1) In the event of a disallowance by CMS of federal
financial participation related to a physician group practice's receipt
or use of payments under this section, HHSC may recoup an amount equivalent
to the amount of the overpayment or disallowance. The non-federal
share of any funds recouped from the physician group practice will
be returned to the entity that owns or is affiliated with the physician
group practice.
(2) Payments under this section may be subject to adjustment
for payments made in error, including, without limitation, adjustments
under §371.1711 of this title (relating to Recoupment of Overpayments
and Debts), 42 CFR Part 455, and Chapter 403, Texas Government Code.
HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid
payments as follows:
(A) HHSC will recoup from the physician group practice
against which any disallowance was directed or to which an overpayment
was made.
(B) If, within 30 days of the physician group practice's
receipt of HHSC's written notice of recoupment, the physician group
practice has not paid the full amount of the recoupment or entered
into a written agreement with HHSC to do so, HHSC may withhold any
or all future Medicaid payments from the physician group practice
until HHSC has recovered an amount equal to the amount overpaid or
disallowed.
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| Source Note: The provisions of this §355.8202 adopted to be effective July 1, 2012, 37 TexReg 4581; amended to be effective June 13, 2013, 38 TexReg 3526; amended to be effective June 12, 2014, 39 TexReg 4419; amended to be effective September 1, 2014, 39 TexReg 6407; amended to be effective January 10, 2019, 44 TexReg 230 |
